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Those who did avail themselves of the hepatitis C education opportunities generally assessed them favorably buy cheap phenergan 25 mg anxiety symptoms treated with xanax. Of all the patients cheap phenergan 25 mg otc anxiety in teens, many were unaware that hepatitis C education was offered in their programs through individual sessions with staff discount phenergan 25 mg on line anxiety quick fix, group meetings 25mg phenergan mastercard anxiety symptoms in kindergarten, and books and pam- phlets (42%, 49%, and 46% of the patients, respectively), and 22% were unaware that any hepatitis C education opportunities existed (Strauss et al. Thus, efforts need to focus especially on ensuring that all drug-treat- ment program patients are made aware of and encouraged to use hepatitis C education services in their programs. Such awareness and encouragement, however, will be useful only if staff of drug-treatment programs have up- to-date knowledge about the virus and treatment options so that they can share hepatitis C information with their patients accurately. Recommendation On the basis of the above fndings, the committee offers the follow- ing recommendation to increase educational and awareness opportunities about hepatitis B and hepatitis C. The Centers for Disease Control and Prevention should work with key stakeholders to develop, coordinate, and evalu- ate innovative and effective outreach and education programs to target at-risk populations and to increase awareness in the general population about hepatitis B and hepatitis C. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. The programs should include shared resources that are linguistically and culturally appropriate and support integration of education about viral hepatitis and liver health into other health programs that serve at-risk populations. Successful programs like those discussed above should serve as models for interventions and existing materials, such as the American Congress of Obstetricians and Gynecologists patient edu- cation materials on viral hepatitis (American College of Obstetricians and Gynecologists, 2007, 2008, 2009), should be used as a basis for producing linguistically and culturally relevant materials. Programs should be evaluated to ensure that they are effectively tar- geting the general public and at-risk people and populations. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Broader community education should include print and multimedia educational materials about viral hepatitis for the public, large employers, and health insurers. It should work to mobilize and facilitate a grassroots movement among community stakeholders, including health-care provid- ers, employers, mainstream and ethnic media, community-based organiza- tions, and students. The lack of knowledge and awareness about hepatitis B and hepatitis C in the general population suggests that integration of viral-hepatitis and liver-health education into existing health-education curricula in schools will help to eliminate the stigma of those chronically infected and improve prevention of viral hepatitis. There is evidence that adolescents are unaware of hepatitis B and hepatitis C risks and how to prevent becoming infected (Moore-Caldwell et al. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Some 30% of the programs were supported by local government funding, 27% by state fund- ing, and 10% by federal funding. Other sources include pharmaceutical and insurance companies, research and service grants, community hospitals, and other private funding sources (Rein et al. Education and prevention programs should be expanded to provide services in underserved regions of the United States given that the highest rates of acute hepatitis B incidence are in the south (Daniels et al. The major risk factors for viral hepatitis in people in correctional facilities are injection-drug use, tattooing, and sexual activity (see Chapters 4 and 5 for additional information about incarcerated populations). Increased knowledge and awareness about the dis- eases will lead to a greater understanding among inmates about how to prevent them, the advantages of hepatitis B vaccination, why they should be tested for chronic hepatitis B and hepatitis C, and what to do about a positive test result for either infection. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. The addition of hepatitis education to existing peer-based inmate educational programs is feasible and will prob- ably incur minimal additional cost. Women and young people who inject drugs are less likely than others to attend needle-exchange and drug-treatment programs (Bluthenthal et al. Novel programs are needed that will access the hidden injectors, and outreach and peer-education programs are potentially effective ways to achieve this goal. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. The women should be given culturally and linguistically ap- propriate educational information about the importance of administration of the birth dose of the hepatitis B vaccine and hepatitis B immunoglobulin within 12 hours of birth if needed, completion of the hepatitis B vaccine series by the age of 6 months, and postvaccination testing. There is a need to develop a novel program to educate pregnant women in perinatal-care facilities about hepatitis B to prevent perinatal transmission, to refer women who are chronically infected for medical care, and to refer family and household contacts for testing, vaccination, and care if needed. Hepatocellular carcinoma inci-Hepatocellular carcinoma inci- dence, mortality, and survival trends in the United States from 1975 to 2005. Screening and counseling practices reported by obstetrician-gynecologists for patients with hepatitis C virus infec- tion. The ef- fect of syringe exchange use on high-risk injection drug users: A cohort study. Hepatitis B virus: A comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination: recommendations of the Immunization Practices Advisory Committee. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Hepatitis C virus transmission from an antibody-negative organ and tissue donor—United States, 2000-2002. Transmission of hepatitis B and C viruses in outpatient settings—New York, Oklahoma, and Nebraska, 2000-2002. Transmission of hepatitis B virus among persons undergoing blood glucose moni- toring in long-term-care facilities—Mississippi, North Carolina, and Los Angeles county, California, 2003-2004. Screening for chronic hepatitis B among Asian/Pacifc Islander populations— New York City, 2005.

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Familiarisation with country responses with reference to potential disease outbreaks at the site buy 25 mg phenergan with mastercard anxiety online test. Establish standardised report forms for disease surveillance including definitions such as “confirmed” and “suspected” discount phenergan 25 mg mastercard anxiety symptoms rapid heart rate. Identify and collaborate with ongoing animal disease surveillance efforts at other wetland sites and government Ministries or Departments e discount 25mg phenergan amex anxiety symptoms in adults. Identify efficient and effective communication channels with the relevant health authorities and laboratories and other wetland stakeholders and include opportunities for feedback effective phenergan 25 mg anxiety symptoms one side. Prioritising diseases for surveillance The following factors should be considered when determining which diseases to prioritise for surveillance: Whether the disease is of public health or agricultural importance. Whether the disease is a specific target of a local, regional, national or international control programme. Whether the information to be collected will lead to significant successful human/animal health action. Communicable Disease Management Protocol Manual: Communicable disease surveillance. Climate change and the expansion of animal and zoonotic diseases: What is the Agency’s contribution? Wild birds and avian influenza: an introduction to applied field research and disease sampling techniques. Planning an integrated disease surveillance and response system: a matrix of skills and activities. Concepts for risk based surveillance in the field of veterinary medicine and veterinary public health: review of current approaches. Animal disease surveillance: a framework for supporting disease detection in public health. Identifying a departure from ‘usual’, ‘natural’ or ‘expected’ levels of mortality or morbidity can be complex and measures need to be put in place to help this process. Many of the other sections of this Manual will help in identifying a disease problem [e. Apparently healthy wildlife: identifying when a problem is emerging relies on a good understanding of what constitutes ‘normal’ mortality and morbidity and good early warning systems (Sally MacKenzie). Capacity requirements for identifying disease problems and informing early warning systems A good understanding of the use of the site by wild and domestic animals throughout the year and an understanding of their biology, abundance, behaviour and movements. A reasonable understanding of the epidemiology of particular diseases and of the stressors and other factors associated with disease outbreaks. Robust disease surveillance (both active and passive) in wildlife and livestock at a site. Ideally this should include regular visual checks of animal groups to screen for unusual behaviour, reduced body condition or productivity of domestic stock, signs of disease and/or mortality. Clear systems for reporting concern to a site manager and from the site manager to the local disease control authority. Use of these systems for immediate reporting of an unusual animal health problem to the local disease control authority. An understanding and capability to provide information and samples from a site to aid disease diagnosis [►Sections 3. A communication network established between surveillance diagnosticians, site managers and disease control authorities both for two-way information flow about surveillance at the site but also from authorities about disease in surrounding areas including neighbouring countries. A communication network between site users in particular farmers and those working and living within wetlands. Awareness amongst wetland stakeholders of disease issues and an understanding of how to respond if there is an apparent problem. Early identification of a disease problem and the ability to respond are dependent on clear and well established channels of communication and formal or informal networks. A problem disease may manifest itself in various subtle ways and a site manager should have available a communication network that allows rapid synthesis of seemingly disparate information. For example, a flow of information should allow a site manager to become aware that there has been a recent incursion of wildlife due to disturbance in surrounding areas, that there has been some loss of productivity in the livestock using the site, or that a higher than expected number of dead or sick wild animals has been observed. Although these may all be entirely unrelated it should prompt the site manager to investigate further. This sort of approach to disease intelligence is key as it supplements disease surveillance data by making full use of additional qualitative information, enhancing awareness of disease related issues that may otherwise remain undetected. Once a disease problem has been identified the response plan can then be put into action. Samples may include carcases, tissues, parasites, whole blood, serum, swabs, environmental material, faeces or ingested food etc. Choosing a specimen The most useful sample to collect is an entire carcase, which is fresh and undamaged by decomposition or scavengers. Such a sample allows a pathologist to carry out gross examination, take a variety of samples and perform a range of tests.

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Yet the big picture—the extent of the revolution—has eluded healthcare providers buy discount phenergan 25mg online anxiety symptoms on dogs, because they cannot see how all these tech- nologies will come together to change how the care team behaves and how consumers interact with the health system cheap phenergan 25mg online anxiety symptoms 3 days. This chapter explores this convergence by looking at the different knowledge domains—molecular and cellular 25mg phenergan otc anxiety symptoms feeling unreal, tissues and organ systems buy 25 mg phenergan mastercard anxiety poems, care processes—relevant to treatment. It also discusses the technical as- pects of care as they evolve and how they will affect healthcare delivery, including remote medicine, the Internet, and electronic medical records. The chapter continues with an examination of a navigation system for clinical care and the prospects for its use by physicians in a teacher/protector role, and it concludes by addressing technical requirements for the digital revolution to continue. It is digital software—the most complex software known in the universe—comprising three billion bits of chemical “code” embedded in the nucleus of each cell in the body. This amazing molecule contains not only the template for every one of the hundreds of thousands of proteins in the body, but also the assembly instructions for turning those proteins into a functioning human being. Most major illnesses troubling patients today, including heart disease, cancer, Alzheimer’s disease, and many forms of mental ill- ness, have genetic roots. As Matt Ridley remarks in his poetic and insightful book, Genome, genes are not there to cause disease, but to support normal functioning. Genomics is information technology; shut down the computers, and modern cell biology rapidly grinds to a halt. With the completion of the Human Genome Project in late 2000, western society was inundated with a great deal of hype heralding the seemingly immediate impact that mapping the lo- cation of all of a person’s genes would have on his or her health. It seemed for a brief, giddy moment that a new wave of genetically based cures for disease would shortly be unleashed. When asked what stood between the gene map and a comprehensive understanding of human disease, one scientist, Dr. William Neaves of the Stowers Institute of Medical Research, responded, “About one hundred years of hard work. These genes fluidly and continuously interact with a person’s environment, his or her behavior, and each other in a bewilderingly complex manner to create disease risk. Translating information about genetic risk of disease into focused prevention, such as gene therapy, that extinguishes disease risk at the molecular level, remains a daunting scientific and technical challenge. However, one hundred years will not have to pass before genetic information reshapes healthcare. This signature is then 16 Digital Medicine compared to computer libraries of known strains of the virus that are susceptible or resistant to various drugs in the therapeutic cocktail. By tailoring the elements and dosages in the cocktail to the genetic signature of the virus, far more rapid and efficient clearing of the virus has been achieved. Giving the drug to patients whose cells do not display this receptor means wasting $20,000 on a drug with no clinical effect. Many new drugs will be approved in the next few years conditional upon a genetic test to determine if the therapy is likely to be effective. These uses represent only the beginning of a new era of personal- ized, genetically customized medicine (Figure 2. Within a decade, the genetic signature of a pathogen such as a virus or a cancer cell may form the basis for fabrication of customized therapies, such as vaccines, specifically targeted at that pathogen. Clinical laboratories will use genetic information to identify targets on the cell surface or in the nucleus of the pathogen that can be blocked by antibodies or by agents that retard or prevent dangerous genes from expressing in the first place. Progress in gene therapy has been ham- pered, however, by the vigor of the immune response to new genetic material introduced into the body, as well as by an inability to target new genetic information to the right places in the genome. Control over expression of disease-causing pathogens or genes may be a more achievable goal than inserting the “correct” genetic information. This curative role will be the result of molecular infor- mation technologies—microarrays and computerized cell sorting, principally—focused on acquiring genetic information about the patient and the pathogen. Pathologists will also find themselves competing in genetic diagnosis with the radiologists as they develop molecular imaging technology. Impact on Health Systems The ability to use genetic information to guide and craft therapy will become a key differentiator of hospitals and health centers within the next decade, much as open-heart surgery was during the 1970s. Personalized medicine based on genetic testing represents the leading edge of a huge new service opportunity for our nation’s health system, as well as a powerful tool set for making drug therapy safer and more effective. Previously, the output of these analyses was paper notes with line drawings, x-ray film, and pathology slides. Today, the analyses are in digital form, and the results can be stored, retrieved, and sent electronically. Diagnostic results will flow seamlessly through the so-called “electronic medical record” into structured and timely recommendations to the care team. Clarke once said that at some level of sophistica- tion, technology is indistinguishable from magic. Flow Cytometry Flow cytometry enables a laboratory technician to count and sort individual cells flowing through a highly pressurized thread of water up to a rate of up to 70,000 cells per second, plucking single cells of interest (each less than one-twentieth of the width of a human hair) out of the stream with magnetic pulses and dropping them into wells in a laboratory tray. This remarkable specificity is made possible by computerized interpretation of the diffraction patterns of a laser beam passing through the thread and bouncing off individual cells. The scat- tered light reaches electronic plates positioned around the stream, which record the pattern of light as digital information. Using a computer-controlled magnetic pulse, the operator can pluck specific cells from the stream for further analysis.

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More recent case-control and prospective studies fur- ther support the minimal effect of n-6 polyunsaturated fatty acids on breast cancer risk (Männistö et al discount 25 mg phenergan visa anxiety symptoms panic attacks. A similar relation- ship has been reported for linoleic acid intake and prostate cancer (Giovannucci et al safe 25 mg phenergan anxiety symptoms definition. The range of intake of polyunsaturated fat was sufficiently large in these combined studies to comfortably conclude that the epidemiological evi- dence largely contradicts the animal studies buy phenergan 25mg amex anxiety loss of appetite; at least to date cheap phenergan 25 mg line performance anxiety, no association between polyunsaturated fat, mainly n-6 fatty acids, and risk of breast cancer has been detected. Furthermore, in a review of the literature and meta-analyses of case-controlled and prospective epidemiological studies, Zock and Katan (1998) concluded that it was unlikely that high intakes of linoleic acid substantially raise the risk of breast, colorectal, or prostate cancer. Risk of Nutrient Excess High intakes of linoleic acid can inhibit the formation of long-chain n-3 polyunsaturated fatty acids from α-linolenic acid, which are precursors to the important eicosanoids (see Chapter 8). Many of the epidemiological studies used fish or fish oil intake as a surrogate for n-3 polyunsaturated fatty acid intake. The amounts of n-3 fatty acids vary greatly in fish, however, and unless the amounts of n-3 fatty acids are known, any conclusions are open to question. Furthermore, other components in fish may have effects that are similar to n-3 fatty acids and therefore may confound the results. A similar result was found in Rotterdam that compared older people who ate fish with those who did not (Kromhout et al. In the Physicians’ Health Study, eating fish once per week decreased the relative risk of sudden cardiac death by 52 percent compared with eating fish less than once per month (Albert et al. In this study, although dietary total n-3 fatty acid intake correlated inversely with total mortality, no effect on total myocardial infarction, nonsudden cardiac death, or total cardiovascular mortality was observed. After adjustment for classical risk factors, the reduction was only 32 percent and no longer significant. There are fewer data with regard to the effects of fish and n-3 poly- unsaturated fatty acids on stroke. In the Zutphen Study, consumption of more than 20 g/d of fish was associated with a decrease in the risk of stroke (Keli et al. In contrast, in the Chicago Western Electric Study and the Physicians’ Health Study, fish intake was not signifi- cantly associated with decreased stroke risk (Morris et al. Some studies, however, did not show an effect on platelet aggregation after the consumption of 4. There was a significant reduction in risk for cardiac death for the experimental group after 27 months, and a reduction after a 4-year follow-up. The extent to which these reductions in risk were due to n-3 fatty acids is uncertain. This group also expe- rienced a 20 percent reduction in all-cause mortality and a 45 percent reduction in sudden deaths compared with the control group. Vitamin E, in contrast to n-3 polyunsaturated fatty acids, had no beneficial effects on cardiovascular endpoints. A meta-analysis of 31 placebo- controlled trials estimated a mean reduction in systolic and diastolic blood pressure of 3. Further- more, a statistically significant dose–response effect occurred with the smallest reduction observed with intakes of less than 3 g/d and the largest reduction observed with intakes at 15 g/d. Because impaired heart rate variability is associated with increased arrhythmic events (Farrell et al. However, the beneficial effect was found only in men with low initial heart rate variability. Several studies have examined whether n-3 polyunsaturated fatty acids affect growth of adipose tissue. Parrish and colleagues (1990, 1991) found that rats given a high fat diet supplemented with fish oil had less fat in perirenal and epididymal fat pads and decreased adipocyte volumes compared with rats fed lard. Adipose tissue growth restriction appeared to be the result of limiting the amount of triacylglycerol in each adipose tissue cell rather than by limiting the number of cells. The researchers concluded that the rats supplemented with n-3 fatty acids demonstrated reduced oxidation of fat and increased carbo- hydrate utilization. Little data exist with respect to the specific effects of dietary n-3 polyunsaturated fatty acids on adiposity in humans; therefore, prevention of obesity cannot be considered an indicator at this time. While several studies have reported a nega- tive relationship between polyunsaturated fatty acid intake and risk of diabetes (Colditz et al. A review of the epidemiological data on this association concluded that polyunsaturated fatty acids, and possibly long- chain n-3 fatty acids, could be beneficial in reducing the risk of diabetes (Hu et al. Studies conducted in rodents have shown that administration of fish oil results in increased insulin sensitivity (Chicco et al. Substituting a proportion of the fat in a high fat diet with fish oil prevented the devel- opment of insulin resistance in rats (Storlien et al. Thus, animal evidence suggests that the fatty acid composition of the diet may be an important factor in the effect of dietary fat on insulin action. Whether a change of dietary fat composition will alter insulin sensitivity in humans remains an open question. Studies in humans have demon- strated a relationship between increased insulin sensitivity and the proportion of long-chain n-3 polyunsaturated fatty acids in skeletal muscle phospho- lipids (Borkman et al.