By K. Sobota. Walla Walla University. 2018.
Royal was Assistant Professor of Pediatrics and Director of the GenEthics Unit in the National Human Genome Center at Howard University 20 mg vardenafil mastercard. She serves on the: Bioethics Advisory Committee of the March of Dimes Foundation generic vardenafil 10mg with amex; Social Issues Committee of the American Society of Human Genetics; Editorial Board of the American Journal of Bioethics; and various other professional Committees and boards. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease 90 ethnicity, and identity. Her specific interests include genetic variation and the (re)conceptualization of race, use of race and ancestry in research and clinical practice, gene- environment interactions in health and health disparities, genetic ancestry inference, involvement of historically marginalized and underrepresented groups in genetic and genomic research, and genomics and global health. She has taught, presented, published, and received funding in these and other related areas. A key objective of her research program is to advance a more holistic and ethical approach to understanding and improving human health and well-being through increased integration of genetic and genomic research with behavioral, social science, and humanities research. Yamamoto’s research is focused on signaling and transcriptional regulation by intracellular receptors, which mediate the actions of several classes of essential hormones and cellular signals; he uses both mechanistic and systems approaches to pursue these problems in pure molecules, cells and whole organisms. Yamamoto was a founding editor of Molecular Biology of the Cell, and serves on numerous editorial boards and scientific advisory boards, and national Committees focused on public and scientific policy, public understanding and support of biological research, and science education; he chairs the Coalition for the Life Sciences (formerly the Joint Steering Committee for Public Policy) and for the National Academy of Sciences, he chairs the Board on Life Sciences. Yamamoto was elected as a member of the American Academy of Arts and Sciences in 1988, the National Academy of Sciences in 1989, the Institute of Medicine in 2003, and as a fellow of the American Association for the Advancement of Sciences in 2002. Hook-Barnard is a program officer with the Board on Life Sciences of the National Research Council. She came to the National Academies from the National Institutes of Health where she was a Postdoctoral Research Fellow from 2003 to 2008. Her graduate research examined translational regulation and ribosome binding in Escherichia coli. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease ͻͳ she contributes to projects in a variety of topic areas. Much of her current work is related to issues of molecular biology, microbiology, biosecurity and genomics. She was study director for the 2010 report Sequence-Based Classification of Select Agents: A Brighter Line, and continues to direct the U. How would a New Taxonomy of human disease enable more cost effective and rapid development of new, effective and safe drugs in the pharma/biotech setting? How would a New Taxonomy of human disease promote integration of clinical and research cultures in the pharma/biotech industry? How would a New Taxonomy of human disease promote public/private partnerships between industry and academia? What are key factors that would limit the implementation of a New Taxonomy of human disease in the pharma/biotech setting? Such studies involve testing hundreds of thousands of genetic variants called single nucleotide polymorphisms throughout the genome in people with and without a condition of interest. In addition, the consortium includes a focus on social and ethical issues such as privacy, confidentiality, and interactions with the broader community. Data Sharing Guiding Principles: All data sharing will adhere to 1) the terms of consent agreed to by research participants; 2) applicable laws and regulations, and; 3) the principle that individual sites within the network have final authority regarding whether their site’s data will be used or shared, on a per-project basis. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease 100 administered by the National Institutes of Health. In addition each Member agrees to report in writing to the other Members any use or disclosure of any portion of the data of which it becomes aware that is not permitted by this Agreement including disclosures that are required by law. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease 101 Appendix E: Glossary Biobank – A bank of biological specimens for biomedical research. Biomarker : a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention. Because of its location, the gene is suspected of causing the disease or other phenotype. Clinical utility the ability of a screening or diagnostic test to prevent or ameliorate adverse health outcomes such as mortality, morbidity, or disability through the adoption of efficacious treatments conditioned on test results (Khoury 2003). The polymer that encodes genetic material and therefore the structures of proteins and many animal traits. EpigenomeThe epigenome consists of chemical compounds that modify, or mark, the genome in a way that tells it what to do, where to do it, and when to do it. Exposome characterization of both exogenous and endogenous exposures that can have differential effects at various stages during a person’s lifetime (Wild 2005; Rappaport 2011). Gel Electrophoresis: electrophoresis in which molecules (as proteins and nucleic acids) migrate through a gel and especially a polyacrylamide gel and separate into bands according to size (Merriam-Webster 2007). Genbank –The GenBank sequence database is an annotated collection of all publicly available nucleotide sequences and their protein translations (Mizrachi 2002). Gene-environment interactions an influence on the expression of a trait that results from the interplay between genes and the environment. Some traits are strongly influenced by genes, while other traits are strongly influenced by the environment. Gene expression is the process by which the information encoded in a gene is used to direct the assembly of a protein molecule. Gene-expression profile Gene expression profiling is the measurement of the activity of thousands of genes at once, to create a global picture of cellular function. These profiles can, for example, distinguish between cells that are actively dividing, or show how the cells react to a particular treatment.
Sympathectomy: This is the surgical division of symphysis pubis cheap 20 mg vardenafil mastercard; the joint connecting the pubic bones in the front of the pelvis order vardenafil 20 mg fast delivery. There is risk of serious damage to the urethra and bladder with this procedure if not done correctly and these are cut during the attempt. It can be life saving for the baby but has the potential to cause chronic joint pain in the mother and risk of infection. If you have an obstructed labour or mal-positioned baby, and/or the baby is dead, and there are no facilities to perform a caesarean section then as unpalatable as it sounds, delivering the baby in pieces may be the only option to save the mother. If the labour is prolonged with the head deeply embedded in the pelvis, pressure injuries can occur in the mother’s pelvic floor, causing a fistula between the vagina and the bladder or bowel to occur – these are very common in third world countries and very disabling. This is extremely unpleasant but can be done with a sterile wire saw and scissors. This is rarely required and is a last ditched solution to save the mother, as in a major disaster situation with no conceivable access to health care. If not done in a sterile manner infection will be introduced and will likely prove fatal to the mother “A Book for Midwives” by Susan Kline, Hesperian Foundation 1995 is the best single source of info on delivery, problems, and newborn care in an austere environment. If it is something you feel uncomfortable with then please skip to the next section. Unfortunately abortion has been a fact of life for centuries and merits discussion. Prior to legal abortion in the 1970s emergency departments on a daily basis saw young women with septic abortion and even tetanus from illegal abortion. Historically a wide range of plants have been used to induce abortion on most continents and in most cultures. They have varying efficacy but most do work to a - 115 - Survival and Austere Medicine: An Introduction degree. If this is interest to you most reputable herbal medicine texts cover this topic in varying detail. In the first trimester, psychological issues aside, surgical abortion is a very safe relatively minor procedure with a low complication rate. Infection and perforation of the uterus are potentially life threatening and were very common in backstreet abortion. One point of view is that in an austere situation with limited access to medical care a first trimester termination, provided it is done in a sterile manner with appropriate instruments is safer than carrying the pregnancy to term. This is not the case, however, with second and third trimester terminations which if performed in an austere situation are likely to prove fatal to the mother. Breasting feeding is the Gold standard by a considerable distance for nutrition for children in the first 6 months of life. It is also the ideal survival food requiring no space or rotation and is readily portable. The most reliable method of ensuring the baby is getting sufficient milk is their general contentment and steady weight gain. While there are many causes for irritable babies, when combined with poor weight gain it suggests inadequate nutrition. A common cause is insufficient breast milk although other nutritional problems can present in a similar fashion. In the event that the mother’s milk supply is insufficient or falling off there are several options. This was very common practice until the advent of commercial infant formula in the last century. If the mother had insufficient milk for the baby then another lactating woman fed the baby. There were women who did this as a career, and in upper class England this was common so the aristocratic woman could “preserve” her figure. In an austere situation this is only an option if there is another breast-feeding mother in your group either with enough spare milk or an older child who can be weened. Nipple stimulation to simulate sucking 3-4 times per day can lead to the onset of milk production after 7-10 days. This is more likely to be successful and to occur earlier in women who have previous had children and had breast-fed for longer periods. This is usually done using a manual or electric pump, however, it is possible to milk the human breasts in a similar fashion to milking cows! It can be given to the baby via a bottle and teat or from a cup – even newborn babies are able to sip from a cup although this may take a little practice. The baby sucks on your finger and sucks milk up the tube – commonly used sizes are 6 or 8 French. If you have infants or plan on having children it is important that you give some consideration to what you would do if you were unable to breast feed the infant. The unfortunate fact is that storing and rotating 6 months worth of infant formula may be prohibitively expensive for most and this is a risk you may need to live with. In a truly austere situation it is possible to make infant formula from stored food although this is clearly sub-optimal. The following table contains several recipes for using stored food components to manufacture baby formula – please accept the caution that this is only for a life-threatening situation where there are no alternatives and the baby will otherwise die. This is basic overview and further references should be consulted for more detailed information. There are three subsections under each heading category: Prevention, Equipment, and Medical preparations.
The responsibility for the interpretation and use of the material lies with the reader order vardenafil 10 mg mastercard. In no event shall the World Health Organization be liable for damages arising from its use discount vardenafil 20mg without prescription. This report was produced under the overall direction of Catherine Le Galès-Camus (Assistant Director-General, Noncommunicable Diseases and Mental Health), Robert Beaglehole (Editor-in-Chief) and JoAnne Epping-Jordan (Managing Editor). The core contributors were Dele Abegunde, Robert Beaglehole, Stéfanie Durivage, JoAnne Epping-Jordan, Colin Mathers, Bakuti Shengelia, Kate Strong, Colin Tukuitonga and Nigel Unwin. Guidance was offered throughout the production of the report by an Advisory Group: Catherine Le Galès-Camus, Andres de Francisco, Stephen Matlin, Jane McElligott, Christine McNab, Isabel Mortara, Margaret Peden, Thomson Prentice, Laura Sminkey, Ian Smith, Nigel Unwin and Janet Voûte. External expert review was provided by: Olusoji Adeyi, Julien Bogousslavsky, Debbie Bradshaw, Jonathan Betz Brown, Robert Burton, Catherine Coleman, Ronald Dahl, Michael Engelgau, Majid Ezzati, Valentin Fuster, Pablo Gottret, Kei Kawabata, Steven Leeder, Pierre Lefèbvre, Karen Lock, James Mann, Mario Maranhão, Stephen Matlin, Martin McKee, Isabel Mortara, Thomas Pearson, Maryse Pierre-Louis, G. Ramana, Anthony Rodgers, Inés Salas, George Schieber, Linda Siminerio, Colin Sindall, Krisela Steyn, Boyd Swinburn, Michael Thiede, Theo Vos, Janet Voûte, Derek Yach and Ping Zhang. Report development and production were coordinated by Robert Beaglehole, JoAnne Epping-Jordan, Stéfanie Durivage, Amanda Marlin, Karen McCaffrey, Alexandra Munro, Caroline Savitzky, Kristin Thompson, with the administrative and secretarial support of Elmira Adenova, Virgie Largado-Ferri and Rachel Pedersen. The web site and other electronic media were organized by Elmira Adenova, Catherine Needham and Andy Pattison. Four out of ﬁve chronic disease deaths today are in low and middle income countries. People in these countries tend to develop diseases at younger ages, suffer longer – often with preventable complications – and die sooner than those in high income countries. Globally, of the 58 million deaths in 2005, approximately 35 million will be as a result of chronic diseases. They are currently the major cause of death among adults in almost all countries and the toll is projected to increase by a further 17% in the next 10 years. At the same time, child overweight and obesity are increasing worldwide, and incidence of type 2 diabetes is growing. This is a very serious situation, both for public health and for the societies and economies affected. Until recently, the impact and proﬁle of chronic disease has generally been insuf- ﬁciently appreciated. This ground-breaking report presents the most recent data, making clear the actual scale and severity of the problem and the urgent need for action. The means of preventing and controlling most chronic diseases are already well- established. It is vital that countries review and implement the interventions described, taking a comprehensive and integrated public health approach. Through investing in vigorous and well- targeted prevention and control now, there is a real opportunity to make signiﬁcant progress and improve the lives of populations across the globe. I have looked at the facts contained in this report and I can see that to meet these challenges I will have to address chronic diseases. But it is less well understood that diseases such as heart disease, stroke, cancer and diabetes already have a signiﬁcant impact and that, by 2015, chronic diseases will be a leading cause of death in Nigeria. In the majority of cases these are preventable, premature deaths and they are undermining our efforts to increase life expectancy and the economic growth of our country. If we wait even 10 years, we will ﬁnd that the problem is even larger and more expensive to address. Prosperity is bringing to our nation many beneﬁts, but there are some changes that are not positive. As our diets and hab- its are changing, so are our waist- viii Supporting statements lines. Already, more than 35% of women in Nigeria are overweight; by 2010 this number will rise to 44%. We do not need to say, “we are a poor nation, we cannot afford to deal with chronic diseases”. As this report points out, there are low-cost, effective measures that any country can take. Governments have a responsibility to support their citizens in their pursuit of a healthy, long life. It is not enough to say, “we have told them not to smoke, we have told them to eat fruit and vegetables, we have told them to take regular exercise”. We must create com- munities, schools, workplaces and markets that make these healthy choices possible. I believe, and the evidence supports me, that there are clear links between health, economic development and poverty alleviation. If my government and I are to build a strong Nigeria, and if my brothers and sisters throughout Africa are to create a strong continent, then we must include chronic diseases in our thinking. If we take action now, it could be that the predictions outlined in these analyses never come true. I will join with the World Health Organization to implement the changes necessary in Nigeria, in the hope that we, too, can contribute towards achieving the global goal of reducing chronic disease death rates by 2% per year over the next 10 years, saving 36 million lives by 2015. However, we now have major public health issues due to chronic diseases that need to be addressed with equal energy and focus. This World Health Organization report, Preventing chronic diseases: a vital investment, is of relevance to me, as Indian Minister for Health, as my country tackles the increasing number of issues relating to chronic disease. The scale of the problem we face is clear with the projected number of deaths attributable to x Supporting statements chronic diseases rising from 3.
For the purpose of minimizing radiation exposure purchase 10mg vardenafil, the criteria for the image quality necessary to achieve the diagnostic task in paediatric radiology may differ from adults purchase vardenafil 10 mg line, and noisier images, if sufficient for radiological diagnosis, should be accepted. The advice of medical physicists should be sought, if possible, to assist with installation, setting imaging protocols and optimization. Exposure parameters that control radiation dose should be carefully tailored for children and every examination should be optimized with regard to radiological protection. Apart from image quality, attention should also be paid to optimizing study quality. Acceptable quality also depends on the structure and organ being examined and the clinical indication for the study. Additional training in radiation protection is recommended for paediatric interventional procedures, which should be performed by experienced paediatric interventional staff due to the potential for high patient radiation dose exposure. Public protection: Release of patients after therapy with unsealed radionuclides A major concern for public protection related to medicine is the release of patients after therapy with unsealed radionuclides. After some therapeutic nuclear medicine procedures with unsealed radionuclides, precautions may be needed to limit doses to other people. Iodine-131 results in the largest dose to medical staff, the public, caregivers and relatives. Young children and infants, as well as visitors not engaged in direct care or comforting, should be treated as members of the public (i. The modes of exposure to other people are external exposure, internal exposure due to contamination, and environmental pathways. Contamination of infants and children with saliva from a patient could result in significant doses to the child’s thyroid. Many types of therapy with unsealed radionuclides are contraindicated in pregnant females. The second largest 131 discharges, I, can be detected in the environment after medical uses. Radionuclides released into modern sewage systems are likely to result in doses to sewer workers and the public that are well below public dose limits. The decision to hospitalize or release a patient should be determined on an individual basis. In addition to residual activity in the patient, the decision should take many other factors into account. Hospitalization will reduce exposure to the public and relatives, but will increase exposure to hospital staff. Hospitalization often involves a significant psychological burden as well as monetary and other costs that should be analysed and justified. Patients travelling after radioiodine therapy rarely present a hazard to other passengers if travel times are limited to a few hours. Environmental or other radiation detection devices are able to detect patients who have had radioiodine therapy for several weeks after treatment. Personnel operating such detectors may need specific training to identify and deal with nuclear medicine patients. Records of the specifics of therapy with unsealed radionuclides should be maintained at the hospital and given to the patient along with written precautionary instructions. In the case of death of a patient who has had radiotherapy with unsealed radionuclides in the last few months, special precautions may be required. Primum non nocere, the old Latin motto meaning ‘first, do no harm’ should be prevalent in the medical uses of radiation. Deriving from the maxim, one of the principal precepts of radio-diagnostic and radio-therapeutic practitioners should be non-maleficence or mischief, namely that given a medical problem, it may be better not to do something, or even to do nothing, than to risk causing more harm than good. It reminds the practitioner that other diagnostic or therapeutic procedures may be available and that they must be taken into consideration when debating the use of any procedure that carries an obvious risk of harm but a less certain chance of benefit. Prevention of accidents to patients undergoing radiation therapy Many accidents and mis-administrations have occurred involving patients undergoing treatment from external beam or solid brachytherapy sources. Therapy involving unsealed sources is also a cause of mishaps, but affects a different kind of professional and should be treated separately. An effective approach for preventing such situations is to study illustrative severe accidents, discuss the causes of these events and contributory factors, summarize the sometimes devastating consequences of these events, and provide recommendations on their prevention. Challenges include institutional arrangements, staff training, quality assurance programmes, adequate supervision, a clear definition of responsibilities and prompt reporting. It addresses a diverse audience of professionals directly involved in radiotherapy procedures, hospital administrators, and health and regulatory authorities. In many of the accidental exposures that have occurred, a single cause cannot be identified. Usually, there was a combination of factors contributing to the accident, for example, deficient staff training, lack of independent checks, lack of quality control procedures and absence of overall supervision. Such combinations often point to an overall deficiency in management, allowing patient treatment in the absence of a comprehensive quality assurance programme. The use of radiation therapy in the treatment of cancer patients has grown considerably and is likely to continue to increase. Major accidents are rare, but are likely to continue to happen unless awareness is increased. Explicit requirements on measures to prevent radiotherapy accidents are needed with respect to regulations, education and quality assurance. Preventing accidental exposures from new external beam radiation therapy technologies New external beam radiation therapy technologies are becoming increasingly used. These new technologies are meant to bring substantial improvement to radiation therapy. However, this is often achieved with a considerable increase in complexity, which, in turn, brings with it opportunities for new types of human error and problems with equipment.
Thus vardenafil 20 mg discount, traditional gender • describe some of the challenges commonly faced by phy- roles in Canadian culture are clearly undergoing a healthy evo- sician parents purchase 10mg vardenafil otc, lution. However, these shifts have created new challenges for • summarize supports that programs can use to facilitate training programs as they strive to balance principles of sound sustainability of residents who are parents, and education and training, human rights and responsibilities, and • identify strategies for resident physicians to promote their health care human resource issues. Medical students are watching this transition and may choose not to Case engage in specialty medicine if it is perceived to be adverse to A second-year resident has recently adopted an infant their family-related values and expectations. However, several residents in the year are In the meantime, academic medicine has not been particularly off on parental leave, and the frequency of call is higher kind to physician parents who have typically enjoyed less insti- than usual. Several colleagues mention that they hope the tutional support (research funding, mentorship, administrative resident is not planning on taking parental leave, as that support) than non-parents, tend to have fewer publications, would increase call frequency to 1:4. In fact, the resident is perceive a slower progression of career goals, and have lower planning on taking leave, but is now dreading approaching levels of career satisfaction. Children add a dimen- sion to life that is unique and delightful, and the parental role Unique challenges of parenting provides opportunities to know ourselves better. That being Physician parents are in an unique position as they promote said, parenting can add to the complexity of managing busy and monitor their children’s health and development. Where some may argue that knowledge about health is valuable and helpful, but—as is the physician parents lack full professional commitment, others case with any parent—their objectivity is limited. Issues that they ensure their children have a primary care provider confronting physician parents are many, and their complexities who is skilled and comfortable working with the dynamics concern both professional and personal roles. It is also essential that physicians avoid boundary crossings or violations with their children; only in Parental leave emergencies should they assume a direct clinical role; other- Every provincial housestaff organization has negotiated paren- wise, they should join in a collaborative relationship with their tal leave policies for their members, and many directly address child’s physician and their child. These policies mesh nicely with the principles and goals of the federal paren- Physician parents report that long work hours reduce the qual- tal leave program and allow many trainees up to a year of leave. Where possible, Residents should be supported and, indeed, encouraged to parents should protect structured time to engage with their take advantage of parental leave during their training. Healthy children, be consistently involved with their children’s com- attachment and bonding with a child requires time. Adequate munity, and ensure that a culture of open and welcome com- leave also allows for the entire family to grow together as they munication is fostered. Children will not accept medicine as an move through the phases of expectation, arrival, integration excuse for parental distance or under-involvement, nor should and, fnally, resumption of professional roles. Besides, spending time with children is a healthy way to in physician families is a smart one and directly contributes to remove oneself from the stresses of medical training, return the long-term sustainability of the physician workforce. Career choices Specialty medicine in Canada is experiencing signifcant demo- graphic shifts, including with respect to the gender and age of practitioners. This creates a remarkably busy family environment that re- Case resolution quires careful planning, open communication, fexibility and The resident books a meeting with the program director creativity to manage well. Busy physician parents need to pay and formally requested the maximum parental leave open particularly good attention to their partner’s emotional and to them. The program director expressed his happiness physical needs in order to bring richness and closeness to for the resident and family while indicating that he will the relationship. However, there was one month in counselling should signifcant relationship diffculties arise: particular that posed a challenge in terms of call and early intervention is associated with high rates of success. This was readily managed with the resident’s Inadvertently, this can lead to physician parents having unreal- partner, and everyone was satisfed. Physician parents are well resident considers this year of leave one of their best life served by engaging in community activities with a diversity of experiences. Health Awareness Workshop Reference University programs are encouraged to openly and warmly Manual. Staying human in the medical family: the family members to program orientation sessions and retreats unique role of doctor-parents. Family-friendly programs often have an edge in recruiting and retaining ex- cellent residents who, in turn, contribute to the goals of the department in a spirit of collegiality, community and respect. Thus physical As a rule, they are energetic, hard-working, enthusiastic, intel- activity become a low priority, and a lack of healthy exercise ligent and self-disciplined. They have learned to delay gratifca- erodes one’s energy level and sense of well-being even more. They are idealistic, and most come to medicine because they are inspired to contribute Emotional and physical fatigue lead to behavioural changes. Decreased interest in activities that were once enjoyed during free time leads to social withdrawal and personal isolation. However, the profession of medicine is demanding, and it is Relationships with family and friends are compromised, and diffcult to put limits around its practice. Poor constant exposure to suffering, heavy workloads, long hours, coping strategies that are adopted might include the increased time pressures, physical and mental demands, and a lack of intake of caffeine and alcohol, or the use of illicit drugs. Physicians are acutely Faced with some or all of these effects, one might experience aware of the distress of others but are often less attentive to at the same time a reduced sense of accomplishment and the stress and fatigue that they experience themselves. It is easy to lose sight of one’s accomplishments caring for others often leads to neglect of oneself. This is the sign of We know that physicians, as a group, are well informed with signifcant stress. We also know that when physicians are overwhelmed by the demands Given that the demands of the profession are ever present, of their profession, they are vulnerable to neglecting those what is the solution? It requires, frst and foremost, awareness of the risks mises not only the physician’s health, but his or her ability to that will be present and deliberate attention to measures of continue to provide care for others.
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