By I. Miguel. University of Texas Health Center at Tyler.

Chapter 68 / Garlic (Allium sativum) 543 A frequently used dose is 400 to 1000 mg of dried garlic or 2 to 5 g of fresh garlic buy periactin 4mg lowest price allergy symptoms cold. An analysis of eight reviews indicated that although garlic has a modest short-term lipid-lowering effect periactin 4mg visa allergy testing johns hopkins, its clinical relevance is uncertain cheap periactin 4 mg free shipping allergy forecast shreveport. Consequently order 4mg periactin with visa allergy shots vs medicine, potential bene- fits from garlic ingestion cannot yet be definitely excluded. It remains possible, albeit improbable, that regular daily ingestion of 4 g or 2 average-sized cloves of fresh garlic may help prevent atherosclerosis and hypertension. Consuming 300 to 900 mg of standardized garlic powder over 2 or more years may protect against age-related changes in aortic elas- ticity. Despite inconsistency in dosage, standardization of garlic preparations, and period of treatment, most findings suggest that garlic decreases choles- terol and triglyceride levels in patients with increased levels of these lipids. When analyses of eight placebo-controlled trials were pooled, total cholesterol outcomes at 6 months showed no significant reductions in total cholesterol with garlic as compared with placebo. The reasons for sta- tistically significant positive short-term effects, but negative longer-term effects, are unclear. A ran- domized, double-blind, placebo-controlled, parallel treatment study showed that administration of garlic powder for 12 weeks (900 mg/d, 300 mg taken with meals three times daily) was ineffective in lowering cholesterol levels in patients with hypercholesterolemia. Despite several positive results, a review of trials suggests that the benefit of garlic to the cardiovascular system is limited; garlic has possible small short- term beneficial effects on some lipid and antiplatelet factors, insignificant effects on blood pressure, and no effect on glucose levels. Meta-analyses of the epidemiologic literature suggests that a high intake of garlic (28 g/day) may be associated with a protective effect against stomach and col- orectal cancers. Topical use of sliced cloves or garlic oil three times daily for 1 to 2 weeks may also be useful for managing superficial infections. Chapter 68 / Garlic (Allium sativum) 545 Other, more common adverse reactions reported are gastrointestinal com- plaints such as dyspepsia, flatulence, and heartburn. Garlic should be used with caution or avoided by patients taking drugs or herbs that increase the risk of bleeding. This includes aspirin, nonsteroidal anti-inflammatory drugs, anticoagulants, platelet inhibitors, ginger, ginseng, Ginko biloba, feverfew, and willow bark. Patients taking aspirin or warfarin should avoid taking garlic in doses of 4 g or more and should only take garlic in these quantities if under medical supervision. Ali M, Thomson M, Afzal M: Garlic and onions: their effect on eicosanoid metabolism and its clinical relevance, Prostaglandins Leukot Essent Fatty Acids 62:55-73, 2000. Linde K, ter Riet G, Hondras M, et al: Systematic reviews of complementary therapies—an annotated bibliography. Breithaupt-Grogler K, Ling M, Boudoulas H, et al: Protective effect of chronic garlic intake on elastic properties of aorta in the elderly, Circulation 96:2649-55, 1997. Garlic: effects on cardiovascular risks and disease, protective effects against cancer, and clinical adverse effects. Bianchini F, Vainio H: Allium vegetables and organosulfur compounds: do they help prevent cancer? Ledezma E, Marcano K, Jorquera A, et al: Efficacy of ajoene in the treatment of tinea pedis: a double-blind and comparative study with terbinafine. The effects of ginkgo and garlic on warfarin use, J Neurosci Nurs 32:229-32, 2000. The rhizome of Zingiber officinale (ginger) is used both as a spice and a medic- inal. In fact, there is scientific approval for using this ancient medicine to stimulate digestion in persons with gastroin- testinal problems. Its ability to increase gastrointestinal activity has resulted in its use as an appetite stimulant for anorexia and for relief of dyspepsia, nausea, and flatulence. Gingerols are potent inhibitors of prostaglandin synthesis and are also effective inhibitors of leukotriene biosynthesis. By modifying thromboxane and prostacyclin synthesis, ginger reduces arachidonate-induced platelet aggregation. Fresh, unpeeled ginger, if tightly wrapped in plastic, will last for up to 14 days in the refrigerator or for up to 2 months in the freezer. Recommended therapeutic doses are 500 to 1000 mg of fresh root three times daily or 500 mg of dried root two to four times a day. The efficacy of ginger rhizome for the prevention of nausea, dizziness, and vomiting in motion sickness has been well documented and proved beyond doubt in numerous high-quality clinical studies. However, although ginger may be of benefit, pyridoxine (vitamin B6) appears to be more effective in reducing the severity of nausea in preg- nancy. The ability of ginger to inhibit prostaglandin and leukotriene biosynthe- sis from arachidonic acid favors a less inflammatory state and may explain the symptomatic relief reported by some patients with arthritis and fibromyalgia. An effective dose may be achieved by taking 100 to 1000 mg of ginger in tablet form per day or by consuming 50 g of lightly cooked ginger or 5 g of raw ginger per day.

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Step 5: Perform descriptive analysis of cases Descriptive analysis is extremely valuable in helping to identify hypotheses about the source of the outbreak that will be useful to guide a full analytic investigation buy periactin 4 mg without a prescription allergy headache. This information may also be sufficient in itself to help identify ways to control the outbreak periactin 4 mg allergy medicine doesn't work, but beware discount periactin 4 mg visa allergy shots testimonials, characteristics common among cases may be found just as commonly among people who are not cases order 4mg periactin free shipping allergy shots yourself. Obtaining background levels for such characteristics is of vital importance in avoiding unnecessary investigations. An analytic epidemiological study may still be needed to confirm the initial findings. Analysis of the descriptive data aims to characterise the cases in terms of time, place and person. In these situations a proxy date, for example, the date of specimen collection or notification may have to be used. Time associations are usually best examined by drawing an epidemic curve (see Step 6) that depicts the distribution of cases by onset of symptoms. Person and place associations can be assessed most easily by examining variables within a line listing of cases. As well as examining the data for these associations, describe the clinical characteristics of the cases. If a disease agent has not been identified by laboratory testing, predominant signs and symptoms among cases may be useful in identifying the agent and directing further laboratory testing. The incubation period (interval between exposure and disease onset) will also be useful (see page 33). Step 6: Draw an epidemic curve An epidemic curve depicts the time course of the onset of symptoms among cases in an outbreak. The epidemic curve is a two-dimensional bar graph or histogram with an x- and a y-axis that helps to illustrate the dynamics of the outbreak, including the number of people affected the time course of the outbreak and whether the outbreak is continuing. It may also indicate the mode of transmission and help to relate the timing of key events (such as possible exposures and control measures) to the onset of symptoms. The epidemic curve has the following format: the x-axis depicts the time or date of onset of symptoms. Choose an x-axis scale based on the period covered by the outbreak and the incubation period of the disease (if known). For example, an outbreak of hepatitis A may have a scale of days-to-weeks, whereas an outbreak of staphylococcal food poisoning may have a scale of hours. The scale of the y-axis will depend on the number of cases involved in the outbreak. Interpreting the epidemic curve The shape of the curve may indicate the mode of transmission. The length of the curve will be approximately equal to one incubation period of the infection. The curve will continue over a period equivalent to the duration of several incubation periods of the disease (Figure 5). The outbreak may have mixed characteristics, and random variation may also affect the shape of the curve. Figure 4: Epidemic curve of food poisoning Figure 5: Epidemic curve for a following a dinner party (common event cryptosporidiosis outbreak at a child outbreak) care centre (person-to-person spread) 10 18 16 8 14 3-4 yr-olds 12 1-2 yr-olds 6 10 8 4 Dinner served 6 2 4 2 0 0 19:00 21:00 23:00 1:00 3:00 1 2 3 4 5 6 7 8 9 Time of onset of symptoms Week of Outbreak 5. Step 7: Calculate an incubation period The incubation period is the interval between exposure to the disease agent and appearance of initial symptoms of the illness. While each disease has a characteristic incubation period, the incubation period for the disease will vary among individuals, due to physiological variations, differences in the degree of exposure to the disease agent and biological factors that influence susceptibility. If the exposure time is known, calculation of the incubation period can help to narrow the range of possible disease agents and will therefore direct subsequent laboratory tests and control measures. If the disease agent is known, but the time of exposure is not, the incubation period (as recorded in the published literature) can determine the approximate time of exposure, enabling the outbreak team to narrow the focus of the remainder of the investigation, including any analytic epidemiological, environmental and laboratory components. The incubation period of gastrointestinal illness is particularly useful in categorising the potential disease agent as either an infection or intoxication. Appendix 6 lists the incubation periods of common disease agents causing gastroenteritis. Calculate the incubation period for each individual by subtracting the time of exposure from the time of onset of the first symptoms consistent with the case definition, that is, if cases are defined by the presence of diarrhoea or vomiting, do not use onset of nausea, headache or other symptoms to calculate the incubation period. The median incubation period is calculated by sorting incubation periods from the shortest to the longest. The median incubation period is the incubation period of the individual at the mid-point on the list (or the average of the two middle values if the list has an even number of cases). The mean incubation period is the average or the sum of all incubation periods divided by the number of observations. In practice, the median incubation period is often preferred because, unlike the mean incubation period, it is not influenced by a small number of cases with extremely short or long incubation periods (called outliers). Table 3 presents case data for 10 people who developed nausea and vomiting following a dinner party at a restaurant. The table shows times of exposure and onset of illness, and the calculated incubation period for each person who became ill. This short incubation period and the clinical presentation are highly suggestive of the ingestion of a bacterial enterotoxin, such as that of Staphylococcus aureus, Clostridium perfringens or Bacillus cereus.

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Shawna expressed frustration because her naturopath “cancelled [her] August recheck because [her naturopath] was too busy as a school nurse generic periactin 4mg allergy eye swelling. Some participants expressed difficulty with accessing a doctor due to financial constraints discount 4 mg periactin visa allergy shots skin reactions. In Diane’s search for a doctor buy periactin 4mg with mastercard allergy zentrum wien, the initial cost for seeing the doctor who listened to her and took her seriously was $400 order 4 mg periactin fast delivery allergy symptoms september. While Diane was able to afford this fee, an out-of-pocket payment of $400 is too expensive for many patients. For example, Jenna shared, “I think [my doctor] could be a little more up to date but again, going through a free clinic I am limited. In addition to affecting patients’ access to doctor, financial constraints can also prevent patients from accessing their medication. Six out of the 11 participants whose treatment experiences were influenced by economics had difficulty with accessing thyroid medication. April reported switching from synthetic thyroid medication to natural thyroid medication in order to save money. She explained, “I used Synthroid 150 and Cytomel for almost 3 years but it was costing $60+ a month. When that happened, this doctor knew of nothing else to do but go back to Synthroid and did not understand when I was upset at that suggestion. However, as previously mentioned, numerous thyroid patients don’t feel well on synthetic thyroid medication and report feeling better taking natural thyroid medication (Armour thyroid is the most popular brand). Although some doctors prescribe natural thyroid medication, the general consensus of the conventional medical field is that Armour thyroid is outdated and Synthroid is better (Dommisse, 2009; Gaby, 2004). According to Gaby (2004), the negative reaction of the conventional medical community to natural thyroid medication “represents, at least in part, a biased attitude” (p. Dommisse (2009) contends that the medical community’s preference for synthetic thyroid medication is based upon biased research in which pharmaceutical companies are involved. Research indicates that diagnostic and treatment decisions are influenced by competing perspectives among pharmaceutical, medical, and insurance 226 companies (Hearn, 2009) and that patients fear their doctors’ recommendations for medication are influenced by pharmaceutical companies (Goff et al. Thus, considering that numerous patients report feeling well on natural thyroid medication, it seems that research on natural thyroid medication is warranted. Additional Findings As previously mentioned, I recognized some additional findings that were meaningful to some participants. Although these findings do not represent the treatment experiences of the participants as a whole, these data are nevertheless poignant examples of the phenomenon from individuals who have lived the phenomenon. Additional findings include a belief that the public is misinformed about thyroid disease (Diane), the experience of grief (Carla), the experience of empathy from one’s doctor (Michelle), and the experience of respect from one’s doctor (Michelle). More specifically, individuals with chronic pain and medically unexplained symptoms often report feeling discredited by not only their doctors, but their family and friends as well (Nettleton, 2006; Slade, Molloy, & Keating, 2009; Stenberg et al. Diane shared that she searched for over 30 years for the cause of her rapid weight gain and chronic fatigue. At one point, her symptoms were so severe that she was “bedridden and in danger of losing [her] job. Diane struggled and worked hard for her thyroid-related symptoms to be perceived as legitimate and worthy of attention. In sharing her thyroid disease treatment experience, one of Carla’s comments was indicative of grief. In sharing her experience, Carla reported that she used to be a body builder and had a successful career. However, Carla is now mobility impaired as a result of not receiving treatment in time for her “thyroid storm” 20 years ago. Before receiving radioactive iodine treatment for her thyroid storm, the doctor gave her an informed consent form and told her, “Sign it or die. She stated, “[My doctor] is very caring and listens to my needs…he has made clear that he is a good listener and has my best interest at heart. Research indicates that empathy is a vital component to an effective doctor- patient relationship and positive health outcomes (Houle et al. According to Gelhaus (2012a), empathy involves “…taking seriously the patient as a complete, distinct, unique human being…” (p. Although only four of the 16 total participants interviewed in this study specifically expressed experiencing a lack of empathy from their doctors, Michelle is the only participant to specifically indicate that she experienced empathy from her doctor. Furthermore, considering that nine of the 16 total participants believed their doctors did not take them seriously, it could be argued that at least nine participants had doctors who struggled with demonstrating empathy. Because empathy has the potential to reduce patients’ anxiety (Finset, 2012; Fogarty et al. Michelle indicated that she experienced respect from her doctor—the same doctor who provided her with empathy. When asked whether or not the gender of her doctor is important, Michelle responded, “I think he is so respectful of his patients that it does not matter if [it is a] male or female patient.

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Sugar-sweetened linked with oral recommended daily intake for different that it is pushing beverages should be avoided buy periactin 4mg cheap allergy symptoms child. In turn cheap 4 mg periactin with amex allergy symptoms in adults, these are infu- enced by wider socioeconomic and An essential entry point to improv- “The political circumstances generic periactin 4mg free shipping sun allergy treatment tips. Oral ing oral health globally is health generic periactin 4mg online allergy shots oklahoma city, like general health, improvement therefore to address the so- is also characterized by in dental health, as with cial determinants of oral a social gradient, with the improvement in general health. In this respect better health status at health, must be enjoyed by all in the Ottawa Charter the top and a higher society. This worthy goal is unlikely for Health Promo- disease burden at tion, with its focus to be achieved unless we put social the bottom of the on empowerment, justice at the heart of all decision gradient. Health at University College perspective and acquiring London, 2010 This social gradient in health a better understanding of why means that inequalities in general people with lower socioeconomic health and oral health affect everyone. Access ling of foods and restricting the availability of to oral healthcare shows particularly strong sugar-sweetened beverages in schools. Health inequal- percentage of five-year-olds with % The social gradient in oral diseases has 88 experience of toothache 2012 inequalities needs to ity is not simply about differences between the profound implications for policy. Tower Hamlets employment; health steadily worsens in line with socioeconomic Instead, action is needed to address the scope Brent deprivation and disability; status. Social gradients national professional bodies have an import- 20% 42% can be observed in all countries and popula- ant advocacy role in promoting policies to 85 tions around the world. What causes this reduce health inequalities in the populations Barking Havering Ealing universal social patterning of oral disease? Yet, the full significance of this million days of school were lost due to oral cancer productivity losses. Dental expenditure also plays a signifi- have doubled in the last 10 years and related cant part in household medical spending. A Canadian reduce inequalities unless those worse off are Spain Spain study found that 3. Many of these risk factors Minister, recognized that oral diseases are an are shared between oral disease and other obstacle to human development. However, the fnancial and human resource The integration of oral and general health costs of this approach are unaffordable for should be the cornerstone of policy approaches many countries, and unsustainable on a global to improve prevention and control of oral scale. This is acknowledged in the Oral vented through simple, cost-effective measures Health Action Plan adopted by the 60th World that involve reducing exposure to recognized Health Assembly in 2007. Prevention of oral disease and promotion of oral health can be directed towards individuals, The challenge in addressing oral diseases and communities or entire populations. Adequate promoting oral health will require the right access to fuoride is one of the most successful balance between a greater emphasis on population-based preventive interventions. It therefore 0 relates disease burden to 10 Strategic dental workforce planning should thus available dentistry be embedded in overall planning for human 20 80 personnel, thus showing resources in health, so that pressing social the potential for providing 30 70 determinants of oral and general health can be oral care. A country with a 40 high disease burden and 60 addressed effectively, and crucial service and 50 low provider numbers will 50 access gaps be reduced. The gap between the score high, while a country 60 40 burden of disease and the availability of care with a similar disease 70 30 can be addressed by creating dentist-led oral burden but higher provider numbers will score lower 80 20 healthcare teams, that include a flexible mix of (more detail provided in complementary mid-level providers and others, the annex). Innovative and flexible workforce with training 3 The four basic types of illegal practice motion, screening, and referral when needed. It is healthcare have generally evolved separately Clinical oral healthcare is generally costly and possible even for around the world over the last 150 years. Oral thus unaffordable for the weaker health systems resource-poor health healthcare is often only partially integrated characteristic of resource-poor economies. As a result, access to appropriate and oral care by integrating basic oral healthcare and prevention dentists and evidence-based affordable oral healthcare services is a distant into the entry levels of healthcare systems. Untreated tooth decay in permanent and Advanced oral care health system model for the management of the prevention and primary teeth ranks first and tenth respectively provided by dentist (may be commonest oral diseases. These are components that can be adapted and scaled healthcare system in settings with damning statistics and provide stark evidence of to match available resources and community more resources) the neglect of oral health. It has an initial focus on self-care and An ideal primary (oral) healthcare system prevention, with other priorities set according Basic oral healthcare services – first entry should provide universal coverage; be to disease burden and available resource. Curative and health in all policies, including labour, environ- specialist care can be added, resulting in the Informal community care and traditional medicine ment and education. It is more likely to benefit full range of services in a universal coverage (self-help groups, community health programmes a greater proportion of the population than context. It is relatively painless, minimizing the need for local anaesthesia Africa Faso and making cross-infection control easier. They fluoride policies promoting fluoride 2001 confirmed that universal salt 2013 toothpaste and mouthrinses. Furthermore, the protective effect is though widely available for purchase, the Wales quality to ensure increased. Labelling requirements are not always met, Most toothpaste sold in high-income countries so that transparency for the consumer is now contains fluoride, and its widespread use compromised, and counterfeit toothpaste is seen as the main reason for the significant may not even contain fluoride. This represents a new challenge for oral health professionals and policy makers oral healthcare, as it raises questions about need to collaborate closely in order to identify access and quality of care, legal aspects and and implement adequate solutions. Dental education is an area where new solu- The challenges for research in oral health are tions are needed so that the educational model diverse and fundamental.

Sethi T cheap periactin 4 mg otc allergy shots risks, Rozengurt E (1992) Gastrin stimulates Ca2 + -mobilization and clonal growth in small cell lung cancer cells purchase periactin 4mg allergy asthma and immunology. In contrast generic periactin 4mg allergy treatment for 1 year old, host- derived hormones increase the bacterial proliferative capacity and pathogenicity buy discount periactin 4mg on line allergy shots psoriasis. In the gut lumen, this type of cross-talk between microorganisms and the host is presumed to be performed continually through various kinds of luminal molecules, as numerous types of bacteria and host cells are in close proximity in the gastro- intestinal tract of mammals. Sudo (*) Department of Psychosomatic Medicine, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan e-mail: [email protected] These bacteria not only play a principal role in the postnatal maturation of the mammalian immune system [3], but also aid in the digestion and absorption of macromolecules and act as a barrier to gut pathogens by blocking attachment to gut binding sites [4]. In contrast, host hormones can signal commensal microbial cells via converging pathways directed to bacterial signaling molecules. This type of bidirec- tional communication is called “microbial endocrinology” [15] or “interkingdom signaling” [17, 18], which mediates the symbiotic and pathogenic relationships between the bacteria and mammalian host. Since numerous kinds of bacteria and host cells are in close proximity in the gastrointestinal tract of mammals, interkingdom signaling via various kinds of luminal molecules is presumed to be performed continually in the gut lumen [19] and to participate in the regulation of various pathophysiological functions. Colonization of the adults was ineffective, which suggests a critical window of susceptibility to the effects of bacteria-host interactions. Recently, animal studies performed by several independent groups have shown the commensal microbiota to be a crucial factor modulating the host behavioral profile [6–9, 11]. Monoassociation with Clostridium (Brautia) coccoides reduced the anxiety levels; however, it did not affect the 180 N. The baseline data were obtained via cardiac puncture in mice killed using cervical dislocation before stress exposure. Therefore, the commensal gut microbiota affects the development and regula- tion of the biobehavioral stress response of the host. Such an ability to recover from adverse changes, known as “stress resilience,” includes psychological and biological pro- cesses that allow an individual to avoid or reduce the harmful consequences of extreme stress. In addition to genetic factors, a broad range of environmental factors contribute to resilience. In fact, a recent elegant study conducted by Lehmann and Herkenham [30] showed that enriched environmental housing (environmental enrichment) confers stress resilience through an infralimbic cortex-dependent neuroanatomical pathway in a mouse model of social defeat stress. Taken together, these findings lead us to the following interesting hypothesis: newborn babies are likely to recognize colonizing bacteria as a stressor when encountering them for the first time because the babies have little capability to discern whether a novel stimulation from the external environment is good or bad. Such colonizing microbes, however, are not harmful to the host, but rather offer beneficial stimulation for enhancing host resistance to future severe stressors. Selye called this type of stressor “eustress,” a positive form of stress usually related to desirable events in a person’s life [31]. Restraint stress was applied to the reconstituted mice at 9 (panel A) and 17 (panel B) weeks of age (n¼18–24 per group). Possible Luminal Molecules Mediating Gut Microbe-Host Interactions The exact mechanisms whereby commensal bacteria interact with the host in the gut and what molecules are involved in this interaction remain to be elucidated. Alpha 2-adrenergic receptors are also reported to be present on gut epithelial cells [48]. A microscopic test revealed that the enriched bacteria had no contaminants, such as epithelia or debris. Other Hormones in Microbial Cells Hormones and hormone-binding proteins with homology to those of vertebrates are reported to be present in fungi, yeast and bacteria [60, 61]. In particular, insulin and insulin-like materials contained in microbes have been the most extensively studied [62–64]. Corticotropin [65] and somatostatin [66] have also been identified in a unicellular organism (Tetrahymena pyriformis) and Bacillus subtilis, respectively. This concept is substantiated by the growing body of evidence showing that bacteria produce small molecules that are formally involved in bacteria–bacteria communication and have now become involved in bacteria-host communication. Bacterial signaling helps us maintain homeo- stasis, keeping us healthy and happy. Clearly, further studies are called for; however, the recent findings described herein provide strong evidence in this rapidly developing field of research. We foresee a day when a comprehensive view regarding the interactions and pathways involved in the “microbiota-gut-brain axis” will be unraveled. Kurokawa K, Itoh T, Kuwahara T, Oshima K, Toh H, Toyoda A et al (2007) Comparative metagenomics revealed commonly enriched gene sets in human gut microbiomes. Sudo N, Sawamura S, Tanaka K, Aiba Y, Kubo C, Koga Y (1997) The requirement of intestinal bacterial flora for the development of an IgE production system fully susceptible to oral tolerance induction. Nishino R, Mikami K, Takahashi H, Tomonaga S, Furuse M, Hiramoto T et al (2013) Commensal microbiota modulate murine behaviors in a strictly contamination-free environ- ment confirmed by culture-based methods.

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The Medical Services will monitor and manage any emerging public health risk but particularly from communicable diseases and periactin 4mg mastercard allergy medicine prescription nasal sprays, when required generic periactin 4mg fast delivery allergy kxan, will coordinate contact tracing when employees are affected by inflight cases discount 4mg periactin overnight delivery allergy symptoms latex. This is why it is very important that any airline and its Medical Services establish and maintain good contact with the local and/or national public health authorities purchase 4 mg periactin with visa allergy medicine immunity. The Medical Services can insure that the training content is compliant with what is required by the different authorities. Cabin crew must be well trained in First Aid to enable them to assist a passenger, or fellow crew member who becomes unwell in-flight. These training programmes may be subcontracted out to specialist trainers or carried out “in house”. Either way the Medical Services is responsible for ensuring the content and quality are acceptable and appropriate to the airline’s operation and conform to Aviation Regulatory Authority requirements. Some airlines now have in-flight access to ground-based medical services that the crew can contact using available communication systems. Such systems are invaluable as they not only provide experienced medical advice relevant to air travel, but also assist the captain of the aircraft in making decisions about a potential medical diversion. Using such telemedicine systems to minimise the risk of diversion will not only save the airline cost, the passengers inconvenience, but also helps the sick passenger, who, even if unwell, does not want to be hospitalised in a foreign place with all the problems and difficulties that entails. Crew need to be trained and updated on the use of the aircraft emergency medical equipment. Most international aircraft now carry both First Aid Kits and Emergency Medical Kits as described elsewhere in this manual. Crew must be familiar with the contents and their use, even if they do not use them themselves. Any on-board passenger physician who comes forward to assist during an in-flight medical event will rely on the crew’s familiarity of the equipment to assist with the management of the sick passenger. Many airlines now carry automatic external defibrillators to be used by crew in the event of sudden cardiac arrest. The crew must be trained in their use and limitations and be sufficiently confident and competent to use them promptly when the need arises. All cabin crew must undergo regular re-training as part of their annual Safety Equipment checks to maintain their competence. The Medical Services can use this as an informal discussion forum with crew to gain feedback on their experiences and concerns. It also gives crew the opportunity to talk through situations they have been in and gain a medical explanation of the emergency. Because aircrew have safety sensitive position and are often travelling it is important for the airline to provide a 24/7 advisory service for aircrew health events including cabin air contamination events. However, other departments involved in shift work will also benefit from fatigue management. Many airlines will establish a fatigue risk management group where the airline physician may be one of the subject matter experts. The Medical Services can: • Provide regulator compliant policy and procedures and accredit providers for testing and intervention. Some activities that the Medical Services may be involved in include: • Development of Health and wellbeing strategies • Oversight of the airline health and wellbeing activities e. Employees generally appreciate this activity and respond in a positive, co-operative way. Pamphlets, posters, colour films, video-cassettes, demonstrations on manikins, audio-visual presentations, and newsletters may all be helpful. The Medical Services can be very useful when it comes to advise on strategic health matters and the many liabilities that an airline may face. Insurance and Disability Some airlines have comprehensive insurance schemes for their employees which provide cover for health, illness, accident, death, or loss of licence. The airline Medical Services may be required to work in close conjunction with the insurers and insurance department of the airline, to provide accurate information and to ensure the claimant is both properly investigated and treated and also that the claim is justified. Informed consent to release of confidential medical information from the employee is essential. Some airlines will “self-insure” for some of these contingencies and the onus then falls especially on the Medical Services to ensure that a fair and reasonable balance is struck between employee claim and investigation and the corporate response. Claims should be properly investigated and reported on by the Medical Services in an impartial way to ensure that the employee is fairly treated. Occasionally, the employee or the employee’s union will attempt to steer the investigation or management of such a claim by suggesting or demanding use of experts specifically designated by them. That is not in the airline’s best interest, and the airline Medical Services should ensure that they seek, on behalf of the company the best, most independent and expert opinion available. Medico-Legal The airline Medical Services must be prepared to work closely with the legal department on claims of a medical nature against the company as well as any other legal matters requiring medical input. These claims may come from either passengers or employee, and the legal department will look to the Medical Services for expert medical advice and evidence. Customer Relations Customer enquiries and complaints may have a medical content or demand some medical explanation. This may range from complaints of “food poisoning on the flight” to allegations of injuries or illnesses caused during the flight.

Sample response Device Maker Devise User Sampling frame 5 buy periactin 4 mg line allergy otc,996 7 generic 4mg periactin with visa allergy help,991 Total returns 277 287 Rejected surveys 35 25 Final sample 242 262 Response rate 4 generic periactin 4mg allergy shots water retention. By design generic periactin 4mg amex allergy treatment results, almost half of the respondents (49 percent) are at or above the supervisory levels. By design, half of the respondents (53 percent) are at or above the supervisory levels. Caveats to this study There are inherent limitations to survey research that need to be carefully considered before drawing inferences from findings. The following items are specific limitations that are germane to most Web-based surveys. We sent surveys to a representative sample of individuals, resulting in a large number of usable returned responses. Despite non-response tests, it is always possible that individuals who did not participate are substantially different in terms of underlying beliefs from those who completed the instrument. Sampling-frame bias: The accuracy is based on contact information and the degree to which the list is representative of individuals who have a role or are involvement in contributing to or assessing the security of medical devices. We also acknowledge that the results may be biased by external events such as media coverage. Finally, because we used a Web-based collection method, it is possible that non-Web responses by mailed survey or telephone call would result in a different pattern of findings. Self-reported results: The quality of survey research is based on the integrity of confidential responses received from subjects. While certain checks and balances can be incorporated into the survey process, there is always the possibility that a subject did not provide accurate or truthful responses. Ponemon Institute: Private & Confidential Report 22 Appendix: Detailed Survey Results The following tables provide the frequency or percentage frequency of responses to all survey questions contained in this study. Do you have any role or involvement in contributing to or Device assessing the security of medical devices? If you are involved, how many years have you spent contributing Device to or assessing the security of medical devices? How familiar are you with your organization’s security practices in Device the development and/or use of medical devices? What best describes your organization’s role in development of Device medical devices for use by clinicians and/or patients? What type of medical devices does your organization design, Device develop and/or use? Please provide your response Device according to the proportion of medical devices by risk level. If your organization manufacturers medical devices, who is Device primarily responsible for their security? If your organization is a healthcare provider, who is primarily Device responsible for medical device security? Does your organization provide training/and or policies that defines the acceptable and secure use of medical devices in healthcare Device organizations? Do you feel empowered to raise concerns about the security of Device medical devices in your organization? How concerned are you about the security of medical devices designed or built by or for your organization for users of medical Device devices? How concerned are you that the medical device industry is not doing Device enough to protect patients/users of medical devices? How concerned are you that your security protocols cannot keep Device pace with changing medical device technologies? How concerned are you that your security protocols cannot keep Device pace with changing regulatory requirements? How concerned are you that hackers may target the devices Device designed and built by or for your organization? How confident are you that the security protocols or architecture built inside your organization’s devices adequately protects clinicians Device (users) and patients. How confident are you that you can detect security vulnerabilities Device in medical devices? Approximately, how many different types of medical devices or Device “products” are manufactured by your organization today? How likely is an attack on one or more medical devices built or in Device use by your organization over the next 12 months? How does the use of mobile devices affect the security risk posture Device of the healthcare organizations that use these devices? Has your organization been audited for compliance with medical Device device security standards? Does your organization disclose the privacy and security risks of Device its medical devices to clinicians and patients? Medical device security practices The following items are rated using a 10-point scale ranging from 1 = lowest to 10 = highest. On average, what percentage of medical devices is tested for Device security vulnerabilities?