By C. Dan. Saint Norbert College. 2018.

Figure 12 Average Pharmaceutical Cumulative Costs per Annum for One Diabetes Patient in Vanuatu 400 350 300 250 200 150 100 50 0 Blood glucose Oral medication Oral medication Insulin stage* Insulin stage with testing strips (metformin) stage 2 additional (Glibenclamide) drugs** Progressive requirements of different stages of diabetes Source: (Anderson et al cheap synthroid 100 mcg fast delivery medications used for depression. The average annual cost at each stage of treatment was based on the actual unit cost of the main drugs and the dosage used at the various stages in treating diabetes in Vanuatu generic synthroid 25 mcg on line medicine of the future. Figure 13 Average Pharmaceutical Cumulative Cost per Annum for One Hypertensive Patient in Vanuatu 22 80 70 60 50 40 30 20 10 0 Hydrochlorothiazide Add Enalapril Add Atenolol Add Simvastatin and Aspirin Progressive drug therapies beginning with Hydrochlorothiazide Source: Anderson et. The average annual cost at each stage of treatment was based on the actual unit cost of the main drugs and the dosage used at the various stages in treating hypertension in Vanuatu. But there is more to be done to improve the allocation and technical efficiency of public expenditure, and increase equitable outcomes. Recent analysis of the pharmaceutical diabetic costs in Vanuatu found that less than two percent of the population could be treated with insulin before the total government drug budget was exhausted. That analysis confirmed the overwhelming importance of allocating scarce resources to primary and secondary prevention efforts for high risk groups if treatment is to be financially sustainable for governments (Anderson et al. It is unclear whether Pacific Island governments are, in fact, focusing scarce resources on targeted prevention. Despite a lack of transparency and accountability in the use of public funds, it appears that the health outcomes for this older and privileged group were limited and modest at best, raising fundamental questions about the efficiency and equity gains in reallocating health resources. Strengthening the evidence base for improved investment Strengthening the evidence base is key to improving investment planning, program effectiveness, and ensuring value for money spent. French Polynesia, Cook Islands, Fiji, and Samoa are now in advanced planning or already undertaking surveys. Few, if any countries – or their development partners – are undertaking baseline studies prior to commencing interventions or seeking to measure the financial and broader resource cost (including human resources) of scaling up interventions, especially to more remote areas. Expanding the evidence base of “what works”, for whom, and at what cost, starting with a few key countries in the Pacific, would be a useful knowledge product and regional public good that policy makers throughout the Pacific could use to improve their resource allocation decision making. The Ministry of Agriculture could more actively promote the farming and marketing of fresh fruit, vegetables, and fish (perhaps by supporting investments in refrigeration at local markets) and restrict the use of land for small-scale tobacco leaf production. The Ministry of Communication could counter the aggressive marketing of unhealthy food and sugar-sweetened drinks, especially those deliberately targeted at children. The economic impacts, such as increased health expenditure, which is a greater proportion of income for the poor, job loss, and reduced productivity, tends to continue the poverty status (Murthy et al. Because high-fat, lower-fiber foods are usually cheaper than healthier alternatives, poorer people are generally more constrained to purchase low-cost food. Dietary choices, more sedentary lifestyles, and genetic factors have led to the obesity problem in the Pacific. As of 2015, just three of the 11 Pacific Possible nations do not meet this threshold. In addition, if diagnosed, poverty reduces the probability of complications being diagnosed early due to the inability to access, or lack of available quality healthcare. The greater diabetes prevalence in females is often due to the more sedentary lifestyle that women lead, causing obesity which is more prevalent among Pacific women than men (Ng et al. Unfortunately, diabetes is further known to precede the onset of heart disease and stroke (Hu, 2013). In the case of Papua New Guinea, the male smoking prevalence is more than double that of females (Eriksen, Mackay, Schluger, Gomeshtapeh, & Drope, 2015). The smoking prevalence of boys and girls in more than half of the world indicates no significant difference across the genders (Warren et al. Future health policies should begin to address the closing gender gap in smoking and identify ways to educate the female population particularly because they are more adversely affected by tobacco use. Designated caregivers often must interrupt their education or withdraw from the workforce which in turn impacts their security and health (Brands & Yach, 2002). Because females are more likely to assume the caregiving position, the aforementioned relationship is more burdensome for females than males. The correlation between the poor – often women and children – and ill health requires more gender-specific health policies (Brands & Yach, 2002).

The author of Conditions of Women made use of one of the Hippocratic texts synthroid 50mcg with visa medications zolpidem, the Book on Womanly Matters71 and may have made a passing allusion to a section of Mus- cio’s Gynecology order 100mcg synthroid amex symptoms before period,72 but he was either ignorant of all the other texts or actively chose to ignore them. Treatments for Women exhibits no direct textual parallels at all with the pre-Salernitan works, while cosmetics, the topic of both large parts of Treatments for Women and Women’s Cosmetics, was almost never com- bined with gynecological matters in early medieval medical writings. For all the wealth of the early medieval gynecological corpus, then, the new Salerni- tan writings on women are largely independent of the Latin works preceding them. Still, it seems likely that the author of Conditions of Women took the existence of some of these texts—and, perhaps, the rhetoric of at least one of them—as a spur to writing his own specialized text about an area of medicine that some were reluctant to speak about openly. The former and, to a far lesser degree, the latter, have their origin in theories and practices developed in Greco-Roman antiquity. From the disease categories they envisioned to the therapeutic practices they deployed, the uniqueness of each Trotula text can best be seen by analyzing the content of the texts in relationship to the theories and practices from which they derived. Entitled, in its sole complete copy, Treatise on the Diseases of Women (Trac- tatus de egritudinibus mulierum), this first attempt to synthesize the new Ara-  Introduction bic medicine employs a simplified, colloquial vocabulary to render technical concepts accessible. Conditions of Women proper reflects a greater confidence with the Arabic material and is a thoroughly revised version; for all intents and purposes, it can be considered a new text. A slightly later version (Conditions of Women ) was to add aids for normal birth. Although we cannot be entirely certain that it was composed at Salerno, its strong philosophical and stylistic similarities to other Salernitan writings make a southern Italian origin likely. Arabic medicine, in turn, was distinct from its early medieval Latin counterpart in its adherence to the philosophical principles of the great- est—or at least the most prolific—physician of antiquity, Galen of Pergamon (ca. Galen, like his predecessor Soranus, was a Greek physician who left his native Asia Minor to seek out a career of medical practice in Rome. When he died in the early third century, Galen left behind a huge body of writings (well over three hundred individual titles). Galen had addressed female physiology and disease inter- mittently in his general writings on physiology and pathology, using, for ex- ample, the female model paradigmatically in his discussion of bloodletting or the nature of the faculties. Galen’s medical writings, though philosophically sophisticated, were not only numerous but too often tedious, long-winded, and obtuse. Greek medical writers and teachers in late antiquity focused on only a handful of Galen’s more concise and cogent works, using them as a basis for teaching in such centers as the school of Alexandria in Egypt. Other writers, such as Oribasius (–), compiled large, synthetic works of medical theory and practice. They drew for Introduction  theseworks on a wide arrayof ancient Greek writers,of whom Galen was given pride of place. With the rise of Islam in the seventh century and the fall of the former Greek territories of Asia Minor and North Africa to the Arabs, Greek medical learning passed to the Arabic-speaking world. Here, Galen’s writings (at least  of which were translated into Arabic) again took precedence and led to newer, even grander synthetic works. These Arabic medical encyclopedias included sections on women’s dis- eases, based in their substance on thework of the Methodist physician Soranus. But their content was stripped of its overlay of Methodist theory, in whose place were substituted Hippocratic and Galenic principles of the workings of the elements (hot, cold, wet, and dry), the humors (blood, phlegm, yellow or red bile, and black bile), the temperaments (the actual elemental or hu- moral predominance that would characterize any given individual), the facul- ties (physiological processes we would today describe in terms of chemical or muscular action), and so forth. Whereas Soranus had argued that the Meth- odist physician need only know the three states—lax, constricted, or mixed— in a Galenic system disease must be distinguished according to which of the four humors predominates in the body (any imbalance in their proper propor- tion being itself a sign of disease). This fusion of Soranus’s nosographies and therapies with Galenic theory resulted in the creation of a Galenic gynecology, which bore the distinctive stamp of its Arab and Muslim creators, not only for the increased philosophical rigidity of the humoral system (which Galen had never been so formal about), but also for the new, unique Arabic contribu- tions to therapy and especially to materia medica (pharmaceutical ingredients). Thus, for example, when the North African writer Ibn al-Jazzār described the various possible causes of menstrual retention, he distinguished between the faculty, the organs, and the substance (of the menses themselves) as the caus- ative agents, dialectically breaking down each of these three categories into their various subcategories. Whereas in modernWestern medical thought menstruation is seen as a mere by-product of the female reproductive cycle, a monthly shedding of the lining of the uterus when no fertilized ovum is implanted in the uterine wall, in Hippocratic and Galenic gynecology menstruation was a necessary purgation, needed to keep the whole female organism healthy. The Hippocratic writers had been incon- sistent on whether women were hotter or colder than men by nature. In Galenic gynecology, in contrast (which in this respect built on the natural philosophical principles of Aristotle), women were without question constitu-  Introduction tionallycolder than men.

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Antibodies: Serum protein produced by lymphocytes in response to the presence of specific antigens buy 50mcg synthroid otc medicine ball chair. Anticoagulated: The prevention of coagulation (clotting) purchase synthroid 50mcg amex medications j-tube, usually referring to blood taken into tubes containing an additive e. An invertebrate animal with an external skeleton, a segmented body and jointed appendages (e. Ascitic: An abnormal accumulation of serous fluid (or serum) in the abdominal cavity. Ataxia: Neurological disorders which cause the loss of ability to coordinate muscular movement. Bioassay: Bioassay (biological assay) is a procedure that determines the concentration of a particular biological constituent of a mixture. Biochemical: Chemical composition of a particular living system or biological substance. Biosecurity: The precautions taken to minimise the risk of introducing infection (or invasive alien species) to a previously uninfected site and therefore preventing further spread. Biotic diseases: Those caused by a living agent, such as a bacterium, virus, fungus or protist. This zone may consist of physical barriers, an absence of hosts, an absence of disease vectors or only immune hosts e. Carrier (disease): A person or organism infected with an infectious disease agent but displaying no symptoms (asymptomatic). Challenge: The physiological, and especially immunological, stress a host is subjected to by a pathogen. Chemotaxis: The characteristic movement or orientation of an organism or cell along a chemical concentration gradient either toward or away from a chemical stimulus. Cloacal: The common cavity into which the intestinal, genital and urinary tract open in vertebrates such as birds, fish, reptiles and some primitive mammals. Colostrum: The first secretion from the mammary glands after giving birth, rich in antibodies. Communicable: Capable of being transmitted from one person/species to another, infectious or contagious in nature. Convulsions: Uncontrolled shaking of the body as a result of the body muscles rapidly and repeatedly contracting and relaxing. Counter immune- A laboratory technique that uses an electrical current to migrate antibodies and electrophoresis: antigens across a buffered agar gel. Culture: The growth and multiplication of biological cells in a controlled nutrient-rich medium. Decontamination: The process of cleansing to remove contamination from substances. Diagnosis: Determining the nature and cause of a disease through examination of physical and chemical symptoms. Disease: A departure from a state of health or any impairment to health resulting in physiological dysfunction. Disease ecology: The interaction of the behaviour and ecology of hosts with the biology of pathogens in relation to the impacts of diseases on populations. Ecohealth: The concept of health at the level of ecosystem, appreciating the interconnectivity of humans and all living organisms and functions within this and how these linkages are reflected in a population’s state of health. Ecthyma: A contagious viral disease of sheep and goats marked by lesions on the lips. A diagnostic test that uses disease specific proteins (antigens or antibodies) to detect antibodies (or antigens), and therefore disease. Emerging disease: A disease that has appeared in a population for the first time, or that may have existed previously but is rapidly increasing in incidence or geographic range, or has recently evolved from another disease. Endemic: Native to a population, or a disease characteristic of a particular area. Epidemic: A disease affecting many organisms at the same time, spreading rapidly within a population where the disease is not usually prevalent. Epidemiology: The study of the distribution and determinants of health-related states and its application to the control of diseases. Eradicate: To exterminate an infectious agent so no further cases of a specific disease arise. Gastroenteritis: Inflammation, infection or irritation of the digestive tract, particularly the stomach and intestine.

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Classically the patient has a brief loss of consciousness Management at the time of injury cheap 75 mcg synthroid fast delivery medicine 02, then a lucid interval followed r Resuscitate as necessary with management of the air- by development of headache effective synthroid 25mcg medications recalled by the fda, progressive hemipare- way, breathing and circulation. Headache, drowsiness, and confusion in cerebellar bleeds which may cause obstructive hy- (dementia if chronic) are common. Anyrisk factors present, particularly hypertension, should be managed to help prevent recurrence. Subarachnoid haemorrhage Aetiology Definition Tearingofbloodvesselswhichmaybetraumaticorspon- Spontaneous intracranial arterial bleeds into the sub- taneous. Risk Incidence factors include a tendency to fall and clotting abnormal- 15 per 100,000 per year. Saccular or berry aneurysms arise due to defects in the 2 Oral nimodipine (a calcium-channel blocker) has internal elastic lamina of arteries and occur in 2% of the been shown to reduce mortality. Severe hypertension may junctionsofarteriesonthecircleofWillisorwithitsadja- needtobecontrolledbuthypotensionmustbeavoided cent branches. Common sites include the anterior com- to prevent further loss of perfusion pressure, so pa- municating artery, the posterior communicating artery tients are kept well hydrated with intravenous saline. Most are idiopathic, but 3 In suitable patients surgical or radiological interven- theyareassociatedwithdiseasessuchasarteritis,coarcta- tion for aneurysms takes place a few days later in a tionoftheaorta,Marfan’ssyndromeandadultpolycystic neurosurgical centre: kidney disease. Neurolog- ical signs, papilloedema and retinal haemorrhages may Prognosis be present. Without Alayer of blood is present over the brain in the subara- interventiontheriskofrebleedingis30%inthefollowing chnoid space and in the cerebrospinal fluid. Complications Intracranial venous thrombosis The blood acts as an irritant, causing vascular spasm leading to further ischaemia, infarction and cerebral Definition oedema. Pathophysiology r Cortical vein thrombosis results in a stroke and The organisms may spread directly from the nasophar- seizures. This condition arises from raisedintracranialpressure,cranialnervepalsiesorother mastoiditis and is now rare. Neisseria meningitidis may cause meningitis, sep- loedema, focal signs, confusion and epilepsy. Associated symptoms in- Anti-coagulation (despite evidence of haemorrhage), cludephotophobia,confusionandnon-specificsymp- anti-convulsant drugs and treat the underlying cause toms such as malaise, nausea and vomiting, and neck wherever possible. Patients are examined for a petechial rash which sug- Bacterial meningitis gests N. Complications Aetiology Neurological and cerebrovascular complications in- The likely organism changes with age. In adults, the clude intracranial venous thrombosis, cerebral oedema most common are Neisseria meningitidis, Streptococcus and hydrocephalus. Less common intravascular coagulation occur in 8–10% of patients organisms include gram-negative bacilli (particularly as with meningococcal meningitis. There may be r Nasopharyngeal clearance may be recommended for oedema, focal infarction and congested vessels in the the patient and household ‘kissing contacts’, e. Cephalosporins provide good clearance of nasal carriage in the patient, but penicillins do not. Poor givenstill demonstrates the causative organism in many prognostic markers include hypotension, confusion and cases. Abroad-spectrum antibiotic such as a cephalosporin at high doses is initially recommended due to the increasing emergence of penicillin-resistant strepto- Viral meningitis cocci. Once cultures and sensitivities are available, the course and choice of agent can be determined Definition (ceftriaxone/cefotaxime for Haemophilus influenzae Acute viral infection of the meninges is the most com- andStreptococcuspneumoniae,penicillinforN. Chapter 7: Infections of the nervous system 303 Aetiology Geography Avariety of viruses may infect the meninges including Rare in the developed world but a major problem in enteroviruses, mumps, herpes simplex (see page 400), developing countries. Aetiology Pathophysiology Mayarise as a complication of miliary tuberculosis or In viralmeningitis there is a predominantly lymphoid in primary or post primary infections. Clinical features Patients present with headache usually over 1–2 days, Pathophysiology fever, nausea, photophobia, malaise and neck stiffness. Ifatuberculous focus develops in the brain, meninges or Rash, upper respiratory symptoms and occasionally di- skull and ruptures into the subarachnoid space, a hyper- arrhoeamaybepresent.

His expertise in protein and amino acid metabolism was a special asset to the panel’s work order 100mcg synthroid mastercard denivit intensive treatment, as well as a contribution to the understanding of protein and amino acid requirements synthroid 75 mcg visa medicine 801. Close attention was given throughout the report to the evidence relating macronutrient intakes to risk reduction of chronic disease and to amounts needed to maintain health. Thus, the report includes guidelines for partitioning energy sources (Acceptable Macronutrient Distribution Ranges) compatible with decreasing risks of various chronic diseases. Thus, although governed by scientific rationales, informed judgments were often required in setting reference values. The quality and quantity of information on overt deficiency diseases for protein, amino acids, and essential fatty acids available to the com- mittee were substantial. Unfortunately, information regarding other nutri- ents for which their primary dietary importance relates to their roles as energy sources was limited most often to alterations in chronic disease biomarkers that follow dietary manipulations of energy sources. Also, for most of the nutrients in this report (with a notable exception of protein and some amino acids), there is no direct information that permits estimating the amounts required by children, adolescents, the elderly, or pregnant and lactating women. Dose–response studies were either not available or were suggestive of very low intake levels that could result in inadequate intakes of other nutrients. These information gaps and inconsistencies often precluded setting reli- able estimates of upper intake levels that can be ingested safely. The report’s attention to energy would be incomplete without its substantial review of the role of daily physical activity in achieving and sustaining fitness and optimal health (Chapter 12). The report provides recommended levels of energy expenditure that are considered most com- patible with minimizing risks of several chronic diseases and provides guid- ance for achieving recommended levels of energy expenditure. Inclusion of these recommendations avoids the tacit false assumption that light sedentary activity is the expected norm in the United States and Canada. With more experience, the proposed models for establishing reference intakes of nutrients and other food components that play significant roles in pro- moting and sustaining health and optimal functioning will be refined. Also, as new information or new methods of analysis are adopted, these reference values undoubtedly will be reassessed. Many of the questions that were raised about requirements and recommended intakes could not be answered satisfactorily for the reasons given above. Thus, among the panel’s major tasks was to outline a research agenda addressing information gaps uncovered in its review (Chapter 14). The research agenda is anticipated to help future policy decisions related to these and future recommendations. This agenda and the critical, com- prehensive analyses of available information are intended to assist the private sector, foundations, universities, governmental and international agencies and laboratories, and other institutions in the development of their respective research priorities for the next decade. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Arne Astrup, The Royal Veterinary and Agricultural University; George Blackburn, Beth Israel Deaconess Medical Center; Elsworth Buskirk, Pennsylvania State University; William Connor, Oregon Health and Science University; John Hathcock, Council for Responsible Nutrition; Satish Kalhan, Case Western Reserve University School of Medicine; Martijn Katan, Wageningen Agricultural University; David Kritchevsky, The Wistar Institute; Shiriki Kumanyika, University of Pennsylvania School of Medicine; William Lands, National Institutes of Health; Geoffrey Livesey, Independent Nutrition Logic; Ross Prentice, Fred Hutchinson Cancer Research Center; Barbara Schneeman, University of California, Davis; Christopher Sempos, State University of New York, Buffalo; Virginia Stallings, Children’s Hospital of Philadelphia; Steve Taylor, University of Nebraska; Daniel Tomé, Institut National Agronomique Paris-Grinon; and Walter Willett, Harvard School of Public Health. The review of this report was overseen by Catherine Ross, Pennsylvania State University and Irwin Rosenberg, Tufts University, appointed by the Institute of Medicine, who were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution. The Food and Nutrition Board gratefully acknowledges the Canadian government’s support and Canadian scientists’ participation in this initia- tive. This close collaboration represents a pioneering first step in the har- monization of nutrient reference intakes in North America. The respective chairs and members of the Panel on Macronutrients and subcommittees performed their work under great time pressures. All gave their time and hard work willingly and without financial reward; the public and the science and practice of nutrition are among the major beneficiaries of their dedication. The Food and Nutrition Board thanks these indi- viduals, and especially the staff responsible for its development—in par- ticular, Paula Trumbo for coordinating this complex report, and Sandra Schlicker, who served as a program officer for the study. The intellectual and managerial contributions made by these individuals to the report’s comprehensiveness and scientific base were critical to fulfilling the project’s mandate. This report includes a review of the roles that macronutrients are known to play in traditional deficiency diseases as well as chronic diseases. The overall project is a comprehensive effort undertaken by the Stand- ing Committee on the Scientific Evaluation of Dietary Reference Intakes of the Food and Nutrition Board, Institute of Medicine, the National Academies, in collaboration with Health Canada (see Appendix B for a description of the overall process and its origins).

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