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To reduce microbes and contaminants from foods erectile dysfunction labs buy 100mg viagra super active fast delivery, all produce erectile dysfunction 16 years old buy viagra super active 50mg on-line, regardless of where it was grown or purchased erectile dysfunction doctor in phoenix purchase generic viagra super active from india, should be thoroughly rinsed. However, any precut packaged items, like lettuce or baby carrots, are labeled as prewashed and ready-to-eat. Page 119 - 2015-2020 Dietary Guidelines for Americans Rinse fresh vegetables and fruits under running water just before eating, cutting, or cooking. Use one of the three safe ways to thaw foods: (1) in the refrigerator, (2) in cold water. Separate Foods When Preparing & Serving Food Always use a clean cutting board for fresh produce and a separate one for raw seafood, meat, and poultry. Cook & Chill Seafood, meat, poultry, and egg dishes should be cooked to the recommended safe minimum internal temperature to destroy harmful microbes (see Table A14-1). Food thermometers should be cleaned with hot, soapy water before and after each use. When cooking using a microwave, foods Separate Separating foods that are ready-to-eat from those that are raw or that might otherwise contain harmful microbes is key to preventing foodborne illness. Attention should be given to separating foods at every step of food handling, from purchase to preparation to serving. Separate Foods When Shopping Place raw seafood, meat, and poultry in plastic bags. Recommended Safe Minimum Internal Temperatures Consumers should cook foods to the minimum internal temperatures shown below. The temperature should be measured with a clean food thermometer before removing meat from the heat source. For safety and quality, allow meat to rest for at least 3 minutes before carving or consuming. For reasons of personal preference, consumers may choose to cook meat to higher temperatures. Food Degrees Fahrenheit Ground Meat & Meat Mixtures Beef, Pork, Veal, Lamb Turkey, Chicken 160 165 Fresh Beef, Pork, Veal, Lamb Steaks, Roasts, Chops 145 Poultry Chicken & Turkey, Whole Poultry Breasts, Roasts Poultry Thighs, Wings Duck & Goose Stuffing (Cooked Alone or in Bird) 165 165 165 165 165 160 Fresh Pork Ham Fresh Ham (Raw) Pre-cooked Ham (to Reheat) 145 140 Eggs & Egg Dishes Eggs Egg Dishes Cook until yolk and white are firm. Shucked clams and shucked oysters are fully cooked when they are opaque (milky white) and firm. Consumption of raw or undercooked animal food products increases the risk of contracting a foodborne illness. Cooking foods to recommended safe minimum internal temperatures and consuming only pasteurized dairy products are the best ways to reduce the risk of foodborne illness from animal products. Always use pasteurized eggs or egg products when preparing foods that are made with raw eggs. Consumers who choose to eat raw seafood despite the risks should choose seafood that has been previously frozen, which will kill parasites but not harmful microbes. Women who are pregnant, infants and young children, older adults, and people with weakened immune systems should only eat foods containing seafood, meat, poultry, or eggs that have been cooked to recommended safe minimum internal temperatures. They should reheat deli and luncheon meats and hot dogs to steaming hot to kill Listeria, the bacteria that causes listeriosis, and not eat raw sprouts, which also can carry harmful bacteria. Resources for Additional Food Safety Information Federal Food Safety Gateway: The outcome of contracting a foodborne illness for these individuals can be severe or even fatal. More than nine out of 10 people with digital eye strain use devices for two or more hours each day. Symptoms Reported: Neck/shoulder/back pain 36% 35% 25% 25% 24 % 76% of Americans look at their digital devices in the hour before going to sleep. Adults under 30 experience the highest rates of digital eye strain symptoms (73%) compared with other age groups. Women (56%) are more likely than men (51%) to use their smartphones to get directions. More than half of adults use their smartphone most frequently to check the weather. We work for hours on our computer screens, perhaps stopping to look at something on another screen-a television, a tablet, a smartphone. The pattern is repeated again and again as our days are filled with electronic images of news reports, online shopping, video games, movies, emails and texts. For centuries, we have evolved our sight by viewing a wide variety of objects outside from varying distances. Digital eye strain is characterized by dry, irritated eyes, blurred vision and neck and back pain. It is not uncommon to start experiencing this discomfort after spending two or more hours staring at a device, or more realistically, multiple devices. In fact, on average, 75 percent of people who use two or more devices simultaneously report experiencing symptoms of digital eye strain compared to only 53 percent of people who use just one device at a time. However, the modern day workspace is far from "eye-gonomical, " likely contributing to the strain in our necks and backs. This is especially true today in our modern society, where any place can become a workspace. Whether it is a kitchen island, a coffee shop lounge chair, a crowded airplane or even a bed, Americans are always connected, no matter the setting. Americans report using devices on the go, turning to their ever-present smartphones to keep in touch with family and friends (54 percent), get directions (54 percent) and check the weather (51 percent). Because individuals typically hold these smaller devices 8-12 inches away from their faces, blinking rates can decrease with prolonged use, resulting in dry, irritated eyes. The angle at which devices are held can also contribute to neck and shoulder pain. Researchers have found that tilting your head forward to check your phone increases the pressure and stress on the spine contributing to "text neck" that leads to early wear, tear and degeneration. In addition to using devices for play, children are using technology during school and for homework. Eye care providers have reported seeing an increase in accelerated cases of myopia, 3 or nearsightedness in children, 4 which may be due to the increase of near-range activities, such as using a digital device. Parents are also apprehensive, nearly 80 percent report being very or somewhat concerned about the impact of digital devices on developing eyes. Innovative eyewear and lens technology can shield eyes from the side effects of excessive use of technology. Designed to alleviate strain, eliminate glare, and filter out harmful blue light, computer eyewear is one option to protect vision while using technology responsibly. During a visit to an eye-care provider, an individual should plan to discuss technology use habits and the issue of digital eye strain, the impact of blue light penetration on vision, and the various optical options and/or lifestyle changes to protect against future discomfort. The Vision Council, seeking to raise awareness about digital eye strain and solutions, commissioned its fourth annual VisionWatch6 survey to examine the increasing usage of digital devices and their impact on vision.
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As Richard Arnold high cholesterol causes erectile dysfunction 50mg viagra super active free shipping, a doc tor in Savannah erectile dysfunction icd 9 code wiki purchase viagra super active with a mastercard, wrote in 1838 to erectile dysfunction cholesterol lowering drugs buy generic viagra super active a friend in Philadelphia, I will in return beg a favor of you. Leeches sell here at the very high price of 50 cents each and there is not a regu lar leecher here to apply them. The Medical Society made a contract with a druggist to supply the public at not exceeding 25 cents each. Some critics of the technique believed that George W ashington was bled to death in his last illness on Friday 13 D ecem ber 1 799. P r i m a r y Ca r e 123 In m edical practice well into the tw entieth century, fever was omnipresent. And few physicians would not face the sadness of death in the young from the epidemic diseases o f child hood. This gave relief for several hours; then it was evident that the tube was becoming clogged. I explained the desperate nature of the trouble, the extreme weakness of the circulation due to the tox aemia, and the danger of even mild manipulative treatment. The mother left the room, the father took the child in his arms, and with little difficulty the tube was removed. Before the tw entieth century, therefore, infectious diseases dominated over all others. Tuberculosis, syphilis, diphtheria, plague, m eningitis, malaria, and post partum sepsis were the diseases against w hich medical graduates and physicians everywhere had to struggle. For this task, the doctrines of traditional physicians had singularly ill-equipped them. In the middle of the nineteenth century, medical theories about the causes of disease would be turned inside out. By the eighteenth century, these Galenic humoral doctrines had undergone considerable modification. Tuberculosis was an example of weakness of the solid parts, throm bosis and blood clots examples of overly rigid fibres. Give milk and iron for weak fibres; do bloodletting for rigid ones, Boerhaave coun selled in the early eighteenth century. Yet virtually all theorizing about the m ech anisms of disease before 1800 was like a castle built in the air: it had little em pirical foundation and was com pletely false in modern scientific terms. Therapies derived from these hum oral theories were alm ost w ithout exception injurious to the patient. Little was cured and m uch damage caused by depleting 124 The C am bridge Illustrated H istory of M edicine the body o f its natural physiological constitutents and dosing it with toxic metals. Boerhaave was the quintessential scientific physi cian and medical teacher of the early Enlightenment. His introduction of the study of the natural sciences into the medical curriculum was espe cially innovative. Traditional medical therapeutics therefore amounted to making patients anaemic through bloodletting, depleting them o f fluids and valuable electrolytes via the stool, and poisoning them with compounds o f such heavy metals as mer cury and lead. Even some contemporary physicians had the wit to notice what damage traditional therapeutics inflicted. Getting deep-seated poisons out o f the body could be done by irritating the skin. Physicians used blistering agents such as cantharides (spanish fly) or acetic acid to raise a serum blister on the skin. In these cases, we find tha t issues do little good unless they be somewhat painful, or be in the 13 this com posite illustration from the seventeenth century depicts surgical practice. On the left, a barber-surgeon is cauterizing, to cleanse and seal a w ound; on the right, another is applying a seton. It was the excesses o f traditional therapeutics, not its basic principles, that caused unease among sufferers, making primary care seem more a last resort than a route to wellbeing. The sight of them is enough to make a man serious, for we may lay it down as a maxim, that when a nation abounds in physicians it grows thin of people. At the outset of the story o f primary care, therefore, we find the the brusque physician on the right is a caricature by Charles de Villiers of the dis tinguished early nineteenthcentury French doctor, Francois Broussais. It was his belief that alm ost all dis ease was caused by inflamma tion, especially in the diges tive tract. Before the Napoleonic years most medical care in Britain was furnished by men who were not qualified physicians but had trained as apprentices and passed the exam inations of the Society of Apothecaries or the Company of Surgeons. This Act Primary Care 127 Traditional quack medicine, involving spectacular theatri cal perform ance, remained com m on till the close of the nineteenth century. As this illustration suggests, the simi larities between the charlatan and the itinerant preacher were close. Many itinerants pretended to com e from Eastern p arts, with its impli cations of mystique and magic. In reality, he was a cer tain William Hartley, born in Yorkshire in 1 8 5 7, who picked up the tricks of the medicine shows in America and Australia and made a for tune touring England in the 18 8 0 s. In the first half o f the apprentice ship the aspirant would read basic medical textbooks and help compound drugs; in the second, he would go riding with the doctor on house calls. There were scientific reasons, too, for the emergence of the modern family doc tor. Awareness was dawning that medicine was som ething more than an art, that it possessed a scientific basis with a corpus o f knowledge from such disciplines as physiology that must be mastered before one could diagnose or treat patients effectively. And this p rise d e con scien ce, in addition to the social needs of the mid dle classes, also drove forward medical reform on both sides of the Atlantic. Once medicine had som ething to teach other than anatomy and get-thosepoisons-out-of-there-style therapeutics, medical com petence would be acquired 128 The C ambridge Illustrated H istory o f M edicine in a stepped programme of study and verified with qualifying examinations. The typical consultation concluded with the drawing up o f elaborate prescriptions for laxatives. In this scientific prac tice, the clinical investigation as well as the differential diagnosis were historically quite new. It was a style that swept the traditional approach to primary care out the window. The modern style of practice assumed that sim ilar signs and symptoms of ill ness could be caused by a wide range of different disease mechanisms. W e are, for example, dealing with a blue-ish, cough ing patient who reports a history of blood-flecked sputum. The scientifically ori ented modern doctor approached the problem quite differently. In pathology class, he would have studied slides of tuberculo sis, pneumonia, and lung cancer, each with a different m echanism and producing its own unique changes in lung tissue, w hich were visible under the microscope. At the end of the consultation the physician would be able to give the patient his or her prognosis, and determine a rational plan of treatment.
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The amount of butter that is added to erectile dysfunction injection drugs generic viagra super active 50 mg otc foods can be minimized or replaced with vegetable oils or nonhydrogenated vegetable oil spreads erectile dysfunction after 80 cheap viagra super active online. Vegetable oils erectile dysfunction onset order viagra super active amex, such as canola and safflower oil, can be used to replace more saturated oils such as coconut and palm oil. Such changes can reduce saturated fat intake without altering the intake of essential nutrients. A reduction in the frequency of intake or serving size of certain foods such as liver (375 mg/3 oz slice) and eggs (250 mg/egg) can help reduce the intake of cholesterol, as well as foods that contain eggs, such as cheesecake (170 mg/slice) and custard pie (170 mg/slice). There are a number of meats and dairy products that contain low amounts of cholesterol. Therefore, there are a variety of foods that are low in saturated fat and cholesterol and also abundant in essential nutrients such as iron, zinc, and calcium. Trans fatty acids are high in stick margarine and those foods containing vegetable shortenings that have been subjected to hydrogenation. Examples of foods that contain relatively high levels of trans fatty acids include cakes, pastries, doughnuts, and french fries (Litin and Sacks, 1993). Therefore, the intake of trans fatty acids can be reduced without limiting the intake of most essential nutrients by decreasing the serving size and frequency of intake of these foods, or by using unhardened oil. Several studies suggest that these changes are primarily due to a reduction in lipid uptake by adipocytes (Pariza et al. Blankson and coworkers (2000) conducted a study in overweight and obese men and women given either placebo or 1. After 12 weeks, none of the groups exhibited significant reductions in body weight or body mass index. Ip and Scimeca (1997) conducted a study in female rats chemically induced for mammary tumors and fed a diet containing either 2 percent or 12 percent linoleic acid. A number of adverse clinical effects, including impaired laxation and increased risk of cancer, obesity, heart disease, and type 2 diabetes, have been associated with the chronic consumption of low amounts of Dietary Fiber or Functional Fiber. The studies to support a beneficial role of these fibers are reviewed in Chapter 7. Certain animal studies have shown that some fibers can actually enhance mineral absorption (Demignй et al. There are several potential mechanisms by which ingestion of Dietary Fiber may actually enhance mineral status. For example, a more acidic pH in the colon is produced with fiber fermentation, and this results in more ionized calcium, which is better absorbed (Rйmйsy et al. Dietary Fiber in the colon can also stimulate bacterial fermentation, which has been associated with increases in calcium, magnesium, and potassium absorption (Demignй et al. Many fiber sources, such as karaya gum, sugar beet fiber, and coarse bran, are also excellent sources of minerals (Behall et al. Several investigators have shown that inulin and fructooligosaccharides actually enhance calcium and magnesium absorption (Coudray et al. There is also indirect evidence of this same enhancement with calcium in humans (Trinidad et al. A direct effect of fiber on mineral absorption has also been reported in humans where inulin increased the apparent absorption and balance of calcium (Coudray et al. Gastrointestinal distress can occur with the consumption of high fiber diets, but this often subsides with time. Epidemiological analysis from 53 developing countries indicated that 56 percent of deaths in young children were due to the potentiating effects of malnutrition in infectious diseases (Pelletier et al. The increased duration or susceptibility to infectious diseases such as respiratory infections and diarrhea are due, in part, to the involvement of protein in immune function. Impaired Growth Low protein intake during pregnancy is correlated with a higher incidence of low birth weight (King, 2000). These deficits can be corrected by the provision of a high protein diet (Badaloo et al. Low Birth Weight Rush and coworkers (1980) found decreases in both gestational length and birth weight and increases in very early premature births and mortality with high density protein supplementation (additional 40 g/d) in poor, black pregnant women at risk of having low birth weight infants. In contrast, Adams and coworkers (1978) reported no differences from the controls in mean birth weights of infants of mothers at risk of having a low birth weight infant when these women were supplemented with 40 g/d of protein. No reports were found of protein toxicity in healthy pregnant or lactating women that were not at risk of having a low birth weight infant. Risk of Nutritional Inadequacy High quality protein is typically consumed via animal products, and therefore vegetarians may consume less high quality protein than omnivores. Because animal foods are the primary sources of certain nutrients, such as calcium, vitamin B12, and bioavailable iron and zinc, low protein intakes may result in inadequate intakes of these micronutrients. As an example, Janelle and Barr (1995) reported significantly lower intakes of riboflavin, vitamin B12, and calcium by vegans who also consumed lower amounts of protein (10 versus 15 percent of energy) compared with nonvegetarians. Vegetable protein has been shown to decrease plasma cholesterol concentrations in experimental animals and humans (Nagata et al. When the ratio of casein:soybean protein in the diet was decreased, there was a reduction in total and non-high density lipoprotein cholesterol concentrations (Fernandez et al. In laboratory animals, it was shown that the onset of atherosclerosis was significantly reduced when animals were fed a textured vegetable protein diet compared to a beef protein diet (Kritchevsky et al. The magnitude of this effect for a doubling of the protein intake, in the absence of change in any other nutrient, is a 50 percent increase in urinary calcium (Heaney, 1993). This has two potential detrimental consequences: loss of bone calcium and increased risk of renal calcium stone formation. Loss of calcium from bone is thought to occur because of bone mineral resorption that provides the buffer for the acid produced by the oxidation of the sulfur amino acids of protein (Barzel and Massey, 1998). However, although increased resorption of bone with increased protein intake has been shown (Kerstetter et al. It has recently been concluded that there may be no need to restrain dietary protein intake. Poor protein status itself leads to bone loss, whereas increased protein intake may lead to increased calcium intake, and bone loss does not occur if calcium intake is adequate (Heaney, 1998). In a recent prospective study of men and women aged 55 to 92 years, consumption of animal protein was positively associated with bone mineral density in women, but not in men (Promislow et al. In contrast, Dawson-Hughes and Harris (2002) reported no association between protein intake and bone mineral density in 342 healthy men and women aged 65 years and older. However, when the individuals were given calcium citrate malate and vitamin D in addition to the high protein intake, there was a favorable change in bone mineral density. Kidney Stones It has been estimated that 12 percent of the population in the United States will suffer from a kidney stone at some time (Sierakowski et al. The most common form of kidney stone is composed of calcium oxalate, and its formation is promoted by high concentrations of calcium and oxalate in the urine.
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Overall and among children ages 2-9 erectile dysfunction incidence age viagra super active 100 mg with mastercard, Hispanics had higher rates than non-Hispanic Whites impotence icd 10 buy viagra super active us. Regular dental visits help to erectile dysfunction treatment psychological causes discount 100mg viagra super active fast delivery improve overall oral health and prevent dental caries. Children ages 2-17 with a dental visit in the calendar year, by race/ethnicity and income, 2002-2008 75 Total White Black Hispanic 65 75 Poor Low Income Middle Income High Income 65 55 Percent 55 Percent Chapter 2 Maternal and Child Health 45 45 35 35 25 Z 0 2 4 25 Z 0 200 200 3 200 200 5 200 6 7 200 200 8 200 2 200 3 200 4 200 5 200 6 200 7 200 8 Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2008. Adolescents ages 13-17 with untreated dental caries, by race/ethnicity and income level, 2005-2008 combined 25 20 Chapter 2 15 Percent 10 Maternal and Child Health 5 0 t To al W hit e Bl ac k Am er ica n Po or w Inc om e l nc eI om Hi e Inc om e Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health and Nutrition Examination Survey, 2005-2008. M ic ex an Lo M idd gh n Overall, 11% of adolescents ages 13-17 had untreated dental caries (Figure 2. Survey data indicate that roughly 21% of children ages 12-17 have special health care needs (Bethell, et al. Adolescents frequently engage in high-risk behaviors resulting in morbidity and mortality, including injuries, unintended pregnancies, sexually transmitted diseases, and alcohol, tobacco, and substance abuse. Many adult chronic diseases and adverse health behaviors begin in adolescence (Forrest & Riley, 2004). Prevention: Receipt of Meningococcal Vaccine Meningitis is an infection of the membranes that cover the brain and spinal cord. Meningococcal diseases are infections caused by the bacteria Neisseria meningitidis. Although Neisseria meningitidis can cause various types of infections, it is most important as a potential cause of meningitis. The meningococcal vaccine can prevent most cases of meningitis caused by Neisseria meningitidis and is recommended for all children ages 11-12 years. Source: Centers for Disease Control and Prevention, National Center for Health Statistics and National Center for Immunization and Respiratory Diseases, National Immunization Survey, 2009. There were no statistically significant differences related to race/ethnicity or income (Figure 2. National Healthcare Disparities Report, 2011 91 Effectiveness of Care Mental Health and Substance Abuse Importance Mortality Number of deaths due to suicide (2009). Mental health treatment includes counseling, inpatient care, outpatient care, and prescription medications. This section highlights four measures of mental health and substance abuse treatment: n Receipt n Suicide n Receipt of treatment for depression. Mood disorders were the most common principal diagnosis for all nonelderly people. Treatment for depression can be very effective in reducing symptoms and associated illnesses and returning individuals to a productive lifestyle. The Sequenced Treatment Alternatives to Relieve Depression study, funded by the National Institute of Mental Health, was the largest clinical trial ever conducted to help determine the most effective treatment strategies for major depressive disorder. Participants included people with complex health conditions, such as multiple concurrent medical and psychiatric conditions. This study found that between 28% and 33% of participants achieved a symptom-free state after the first round of medication, and nearly 70% achieved remission after 12 months (Insel & Wang, 2009). Strategies for treating depression in primary care settings, such as the collaborative care model, have also been shown to generate positive net social benefits in cost-benefit analyses compared with usual care (Glied, et al. Barriers to high-quality mental health care include cost of care, lack of sufficient insurance for mental health services, social stigma, fragmented organization of services, and mistrust of providers. In rural and remote areas, limited availability of skilled care providers is also a major problem. For racial and ethnic populations, these problems are compounded by the lack of culturally and linguistically competent providers. Chapter 2 Mental Health and Substance Abuse National Healthcare Disparities Report, 2011 93 Effectiveness of Care Figure 2. Adults with a major depressive episode in the last 12 months who received treatment for depression in the last 12 months, by race/ethnicity and education, 2008-2009 Total White Black Hispanic <High School High School Grad Any College 75 75 65 65 Percent 45 Percent Chapter 2 Mental Health and Substance Abuse 55 55 45 35 35 25 Z 0 25 Z 0 200 8 200 9 200 8 200 9 Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2008-2009. Note: Major depressive episode is defined as a period of at least 2 weeks when a person experienced a depressed mood or loss of interest or pleasure in daily activities and had a majority of the symptoms of depression described in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders. Treatment for depression is defined as seeing or talking to a medical doctor or other professional or using prescription medication in the past year for depression. Outcome: Suicide Deaths Most individuals who die by suicide have mental illnesses, such as depression or schizophrenia, or have substance abuse problems (Moscicki, 2001). A previous suicide attempt is among the strongest predictors of subsequent suicide. Cognitive- 94 National Healthcare Disparities Report, 2011 Effectiveness of Care behavioral therapy can significantly help those who have attempted suicide consider alternative actions when thoughts of self-harm arise and may reduce suicide attempts (Tarrier, et al. Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System-Mortality, 2000-2007. Since 2002, people ages 45-64 have had higher suicide death rates than people ages 18-44. Treatment: Receipt of Treatment for Illicit Drug Use or Alcohol Problem Illicit drugxx use is a medical problem that can have a direct toxic effect on a number of bodily organs and exacerbate numerous health and mental health conditions. Heavy drinking can increase the risk of certain cancers and cause damage to the liver, brain, and other organs. Alcoholism and illicit drug use increase the risk of death from car crashes and other injuries (Ringold, et al. Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2002-2009. Denominator: Civilian noninstitutionalized population age 12 and over who needed treatment for illicit drug use or an alcohol problem in the last 12 months. Note: Treatment refers to treatment at a specialty facility, such as a drug and alcohol inpatient and/or outpatient rehabilitation facility, inpatient hospital setting, or a mental health center. People age 12 and over treated for substance abuse who completed treatment course, by race/ethnicity and education, 2005-2008 75 Total White Black Hispanic 75 <High School High School Grad Any College 65 65 Chapter 2 55 Percent Percent 55 Mental Health and Substance Abuse 45 45 35 35 25 Z 0 25 Z 0 200 5 200 6 200 7 200 8 200 5 200 6 200 7 8 200 Source: Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set, Discharge Data Set, 2005-2008. Denominator: Discharges age 12 and over from publicly funded substance abuse treatment facilities. It tracks several quality measures for prevention and management of this broad category of illnesses that includes osteoporosis and arthritis. One measure was moved from the section on functional status and highlighted here: n Osteoporosis screening among older women. A multidisciplinary panel of experts on arthritis and pain reviewed scientific evidence to help develop the Quality Indicator Set (Pencharz & MacLean, 2004). The measures were tracked as part of Healthy People 2010 and continue to be tracked in Healthy People 2020: n Arthritis education among adults with arthritis. For example, of patients with hip fractures, one-fifth will die during the first year, one-third will require nursing home care, and only one-third will return to the functional status they had before the fracture. Preventive Services Task Force recommends routine osteoporosis screening of women age 65 and over. Female Medicare beneficiaries age 65 and over who reported ever being screened for osteoporosis with a bone mass or bone density measurement, by race/ethnicity and income, 2000-2008 100 Total White Black Hispanic 100 Poor Low Income Chapter 2 Musculoskeletal Diseases Middle Income High Income 80 80 60 Percent Percent 0 3 6 8 200 60 40 40 20 20 0 200 200 200 0 200 0 200 3 200 6 200 8 Source: Medicare Current Beneficiary Survey, 2000-2008. Denominator: Female Medicare beneficiaries age 65 and over living in the community.
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Taussig worked on congenital heart disease in association with the cardiac surgeon Alfred Blalock impotence depression buy viagra super active 50 mg low cost. She w as actively involved in the diagnosis and aftercare of the patients on whom Blalock operated erectile dysfunction statistics uk order viagra super active discount. Here she is (on the right of the photograph) with one of her patients in about 1 9 4 5 erectile dysfunction cure video discount 25mg viagra super active with visa. So long a Cinderella, clinical science - the application of scientific methods to the actual experience of sickness - has come into its own, thanks partly to the randomized clinical trial, developed from the m id-1940s. They have arisen from the vast endowment o f medicine as a social utility (discussed in Chapter 9). Its programmes of disease prevention and eradication, especially in devel oping countries, have had some striking successes, notably the global eradication o f smallpox in 1977. To put developments in a nutshell, two facts give pow erful (if conflicting) evidence of the growing significance of medicine. Second, the introduction of the contraceptive pill, which, in theory at least, paved the way for a safe and simple m eans to control that population. These developments are well known, but familiarity does not detract from the achievement. Many revolutions have occurred in hum an history - the introduction o f agriculture, the growth of cities, printing, the great scientific advances in the seventeenth century, and the industrial revolutions. But not until the last half of the tw entieth century has there been a m edical revolution with dra matic therapeutic im plications, if we take as our yardstick the dependable ability to vanquish life-threatening disease on a vast scale. The healthiness and longevity of the rich world, and the populousness of the poor world, alike attest this. A m ajor aim of this volume is to set those changes in m edicine in their histor ical context. W e trace the long tradition that arose out o f A ncient Greece, w hich first set medicine on a rational and scientific foundation. W e exam ine the trans formations stimulated by the Renaissance and the Scientific Revolution, w hich presented medicine with the triumphs of physics and chemistry. Medicine advanced from traditional practice to scientific research once Renaissance anatom ists, such as Harvey, began the sys tem atic dissection of the human body and laid bare for the first time its various sys tem s. Observation and experim ents in the seven teenth century put medicine on a new footing. M ajor advances were made early in the twentieth century: X-rays, immunology, the understanding of horm ones and vitamins, chem other apy, even psychoanalysis. As the following chapters show, a historical understanding of medicine is far more than a cavalcade of triumphs. It involves the attempt to explain the more distant and indirect antecedents of modern changes, to show why one path was taken and not another, to exam ine the interconnections of the theoretical and practical aspects of m edicine, science, and healing, and doctor and patient; to analyse the relations between the broad trends and leading individuals; and, not least, to lay bare the thinking - often to our minds bizarre and unscientific - that lay behind the physiological and therapeutic systems of the past. But the C am bridge Illustrated History o f M edicine also attempts to go beyond simply telling the story of the rise of m edicine and its interplay with science, soci ety, and the public. It aims, through historical analysis, to put m edicine under the m icroscope, and to raise questions about the great forces that have fuelled med ical change over the centuries and continue to do so. The Colombian scientist Manuel Patarroyo with a model of his new chem ical vaccine against m alaria, a disease that affects more than 3 0 0 million people and kills around 2 million people each year, m ost of them children in tropical Africa. But an effective vaccine is urgently needed because drug-resistant strains of the malaria parasite are spreading. Introduction 11 involvement of German doctors and scientists with the Nazi final solution, from unethical and deadly human experim entation to the supervision of the gas cham bers at Auschwitz and elsewhere, needs to remembered alongside the selfless ded ication of innumerable other physicians and health professionals. Partly by way of recoil from the atrocities of the Second World War, doctors have been conspicu ous in hum anitarian movements during the past 50 years, including campaigns for nuclear disarmanent and against torture. Questioning the roles of m edicine is im portant, not for any cynical reasons but because if we are to understand the directions medicine is taking now - its prior ities, funding, and regulation - it is crucial that we have a historical perspective on how it has come to be. In spite of all the tremendous advances, an atmosphere of disquiet and doubt now prevades medicine. Euphoria bubbled up over penicillin, over the com ing of heart transplants, and over the first test-tube baby, Louise Brown, in 1978. Now, fears are growing over the strange powers that medicine might assume as genetic engineering and biotechnology expand. At the same time, as health costs get out of hand, prospects loom of real medical cutbacks in m ajor W estern societies. W ill the development of scientific m edicine make it unaffordable to many people? Growing awareness in the 1 9 8 0 s of the vast scale of infection with the human immunodeficiency virus in Africa led to different responses in the W est. Media hysteria about epidemics of new and deadly viral infec tions, such as Ebola and Marburg disease, continue to enflame the latter reaction. M edicine is arguably going through a serious crisis, one that is in large part the price of progress and unrealistically high expectations that have been whipped up by the media and indeed by the medical profession itself. M edicine may appear to be losing its way, or rather having to redefine what its goals are. In 1949, in an arti- Introduction 13 cle in the British M edical Jou rn al, the distinguished physician Lord Horder posed the question: `W hither M edicine? For centuries, the m edical enterprise was too paltry to attract radical critiques of itself. As Edward Shorter suggests in Chapter 4, in what m ight paradoxically be called the good-old-bad-old-days, things were simple: people did not have high expectations of medicine, and when the Old D oc typically achieved rather little, his patients did not blame him too much. M edicine was a profession, but it car ried no great prestige and had rather little power. In the tw entieth century, by co n trast, m edicine has claimed greater authority, and has becom e im mensely costly. And once it proved effective, the scourge of pestilence was forgotten, and the physician becam e exposed to being viewed primarily as a figure of authority, the tool of patriarchy, or the servant of the state. Having finally conquered many grave diseases and provided relief for suffering, its goals have ceased to be so clear and its mandate has becom e muddled. Is its prime duty to keep people alive as long as pos sible, whatever the circum stances? Or is it but a service industry, to fulfil whatever fantasies its clients may frame for their bodies -for instance, a facelift or cosm etic remodelling? In the particular case, many o f these quandaries can be resolved reasonably sat isfactorily with the aid of com m on decency, good will, and a sensible ethics com mittee. But in the wider world, who can decree for the directions m edicine may now be taking? Now that (in the rich world at least) m edicine has accom plished most of its basic targets as understood by Hippocrates, W illiam Harvey, or Lord Horder, who decides its new missions? Ironically, the healthier W estern society becom es, the more medicine it craves; indeed, it com es to regard maximum access to med icine as a political right and a private duty. Scares about new diseases and con The C am bridge Illustrated H istory o f M edicine ditions arise. People are bamboozled into more and more lab tests, often of dubi ous reliability.
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Phrenology - the belief that char in other words impotence from blood pressure medication buy cheapest viagra super active and viagra super active, fromacrimo the American M ary Baker Eddy (1 8 2 1 - 1 9 1 0) erectile dysfunction treatment shots buy cheap viagra super active 50mg on line, founder of the Christian Science move ment erectile dysfunction recovery stories purchase cheap viagra super active on line. She suffered a multi tude of ailm ents as a child and young wom an before, at the age of forty, being cured of hysterical paralysis through faith mind and the body, the health healing. Each argued in its own language that the whole system of allo pathic medicine was radically wrong. Characteristically, they accused the orthodox of striving to blitz disease with poison ous drugs. Each professed to invest the indi vidual with new control over his health as part of a culture of self-improvem ent and realization. Medical heretics typically doubled as heretics in politics and faith as well, while cultivat ing unorthodox lifestyles. Many nineteenth-century alternative m edicines com bined a popular, anti-ortho dox message with the colour ful appeal of the skilful adver tiser. In Britain, the early m aster of this was Jam es M orison; he was later out stripped by Thomas Holloway. Alternative medicine could thereby claim for itself that exaltation of the natural made popular by the Romantic poets. They are threatening your well-being with chem icals and pesticides, processed food, and pollution. You can safeguard it by following Nature - eating natural fare and, in so doing, discovering your natural energies and vital forces. Moreover, alternative cults often carry unsavoury, victim -blam ing hidden agendas. But this turns out to be another variant on sturdy Protestant self-help, masquerading as a radical alternative: w orking-out is the old Protestant work ethic in a new guise. It might be thought that we live in an age in w hich the questions of illness and dis ease should be sewn up as never before. M edicine has enjoyed exceptional suc cess: of special sym bolic significance was the final global eradication of smallpox in 1979. Public dissatisfac tion grows; dreams fade, promises are broken, people vote with their feet and try alternative m edicines and psychotherapies. For one thing, diseases, like empires, rise and fall: plague has declined - although occasional localized outbursts remain severe - but cancer has worsened. One does not need to em brace a modish sociological scepticism to rec ognize that diseases, like beauty, are somewhat in the eye of the beholder: people see what they want or are programmed to see. Particular anxieties, academic training, new technologies, and so forth cause conditions to com e into focus and create pressures to create labels. Different circum stances lead to different facets of life - pains, fevers, bad habits, im pair ments - being called disease. The fit between what som eone experiences as sick ness and what doctors deem disease may be close or it may be loose. W ider issues are often at stake: quests for research funds, insurance company regulations, med ical exoneration before the law or at the workplace, social excuses. But it must be remembered that m edicine has always been embedded both in hum an cultural m ilieux and in the diverse needs of intelligent warm-blooded bodies. The doctor m ight be in a hospital emergency room or in a local clinic, but, historically, gen eral practitioners have been the first point of call. This is a story of how patients and general practitioners have collided and colluded over the past two centuries. The story could, of course, be extended m uch further back in time than the late eighteenth century. Yet that is when the practice of medicine, w hich had been fairly constant in its hum oral theories and drastic treatments over the centuries, began to change. Although medical theories had been in flux over the seventeen centuries from Galen of Pergamon to Herman Boerhaave of Leiden, the actual practice of m edicine, or primary care, had changed little. With the infusion of sci ence into medicine late in the eighteenth century, however, the story begins to change. Most of his diagnos tic methods were old tried and tested ones, such as tak ing the pulse. Modesty inhib ited extensive physical exam i nation, especially with female patients. To attract patients, they often felt obliged to offer whatever it was the patients wanted. Tradi tional patients often had (to us) bizarre notions of what was wrong with them and how it might be fixed. One popular idea in the eighteenth century stressed ridding the body of the poisons that cause disease by drawing them out through the skin. This entailed sweating cures, and patients cherished the idea - as did physicians to a lesser extent - o f sweating a patient with a fever. Edinburgh physician W illiam Buchan wrote in his best-selling medical guide D om estic M edicine in 1769, `It is a com m on notion that sweating is always necessary in the beginning of a fever. The com m on practice is to heap clothes upon the patient, and to give him things of a h ot nature, as spirits, spiceries, & c. Bleeding was much beloved by the com m on people, extending past the time when it lost popularity with physicians. One was vomiting, relinquished relatively early by academ ic medi cine but cherished until the tw entieth century by patients. Taking em etics was intended to produce therapeutic puking, ridding the stom ach of toxicity that was supposedly making the whole body sick. The German physician Adolf Kussmaul him self took em etics therapeutically until around the age of forty in 1864. The father, busy Debate ranged in pre-modern medicine as to the curative properties of sweating as a cure. Free perspiration was claim ed by some to be neces sary for removing poisons from the body (especially syphilitic contagions). Hom eopathic principles in any case regarded fever sw eats as therapeutic rather than harmful. Followers of Thomas Sydenham, by con trast, were advocates of `co o l m ethods with fevers - plenty of ventilation and cold drinks. Apparently, the m essenger had fallen asleep en route, and as he snoozed under a tree the cork had popped out o f the bottle, giving a local ant colony a chance to check out the syrupy prescription by clim bing into the bottle. The peasant, so im plicitly convinced o f the restorative powers o f em etic therapy, had vomited heartily after downing the ants - and was well again. The point is that sweating, bleeding, and vomiting, in addition to salivating, urinating, purging, and many other ways o f getting the bad humours out, had a hold on the popular mind that reached back for centuries, existing alongside med ical doctrines of belief in such procedures. Thus the patients arrived in primary care with their own definite views o f what was needed. Fever was the axis about w hich the traditional con sultation turned - the hot bedridden patient, his pulse quickened and respiring rapidly, the doctor making a house call.
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Tubercles erectile dysfunction nicotine buy viagra super active with visa, tuberosities impotence 20s order viagra super active with a visa, fossae erectile dysfunction latest treatments order viagra super active once a day, canals, and fissures represent important features relative to connective tissue attachment, vascular supply, bone growth, and bone marrow function. Joint alignment, articular cartilage, and soft tissue support; as well as muscular insertions, origins, and innervations; and principle including agonist/antagonist pairing should be studied. Such understanding underpins the importance for the identification and preservation of normal anatomy during surgery. Muscle Physiology: Muscle tissues throughout the body, including striated, smooth, and cardiac muscle types operate via myofibril motor units activated by nerve impulse and neurotransmitter action. Acetylcholine release and reuptake represents one key biochemical step in muscle metabolism and may be acted on by anesthetic agents used in the operating room. Another point of pharmaceutical intervention comes from the calcium ion and potassium ion exchange following contraction. Lactic acid buildup in muscles becomes a potential issue for patients who have not been moved during very long procedures. The mechanism for this problem is described in which of the following statements: Potassium in the intracellular space blocks repolarization of the muscle cell membrane Calcium and potassium inside the cell reach toxic levels Potassium displaces calcium across the nuclear membrane Calcium displaces sodium across the nuclear membrane 10 B. A working knowledge of the blood supply to all organs, extremities, and tissues remains paramount to surgical success. Arteries, arterioles, capillaries, venules, and veins all have distinct properties and require specific handling. A working knowledge of this anatomy, as well as vascular tissue handling techniques, optimizes surgical success. Deliberate and permanent hemostasis for resection procedures also require precise planning and excellent technique. One measure of this phenomenon is "shear rate", defined as the local velocity gradient between adjacent blood flow. Shear rate, incidentally, has also been shown to be one of the main regulators of platelet activation and thrombosis. This basic understanding underpins the necessity for resecting aneurismal tissue with meticulous care. The Cardio-Pulmonary System: Cellular function throughout the tissues and organs of the body rely on the delivery of oxygen and nutrients, and facilitation of cellular waste removal. Osmotic forces maintained at the cellular level, and physiologic safeguards such as vasodilation and vasoconstriction, preserve the integrity of the closed circulatory loop. Patient blood volume, blood pressure, oxygen saturation, and cardiac function must be protected. Which of the following cardio-pulmonary conditions may responsible and require urgent surgery? For the surgical assistant, however, an in-depth knowledge of neuroanatomy from a procedurespecific regional approach is also paramount. Careful study of the cranial nerves and their function provides a surgical assistant the ability for high-level communication with the surgeon on the potential complications of misidentification of structures especially in head and neck procedures. The spinal nerves, their dorsal and ventral roots, and their exit points along the spinal canal must be protected. On the front end of many surgical procedures, identification of these nerve structures must be accomplished with certainty. From the esophagus, through the diaphragm, and at numerous points along the alimentary canal, commonly performed surgical procedures address acute and chronic G. Access to each area of the abdomen, therefore, must be carefully planned and executed. Constant proactive prevention of intra-operative injury and post-operative surgical adhesions represent a skillset retained by the competent surgical professional. An in-depth study of microscopic anatomy and physiology of the digestive system should also be undertaken. This fundamental understanding underpins the necessity for adherence to proper technique. Furthermore, crucial production of digestive enzymes, hormones and chemical messengers are carried out in the pancreas, liver, and cells within the epithelial layers of the G. I tract itself and must be maintained to facilitate normal digestion of nutrients. Hormones are distributed by glands through the bloodstream and carry widespread, long-lasting, and powerful effects on cells of organs and tissues throughout the body. Careful study of the anatomy, function, control, and hormones produced by these glands must be undertaken. Surgery on these areas, furthermore, carry significant risk to vital structures adjacent to the glands themselves, thus intraoperative identification of structures is key. Minimally 21 invasive approaches often improve outcomes, but also add complexity to these procedures. By default, gross anatomy of the pelvis becomes critical, including skeletal structures and landmarks, innervation and vascular supply, and the extremely relevant pelvic floor. Pelvic systems and structures must be studied by the competent surgical assistant, especially with regard to female reproductive procedures. There are organ systems of the body that are involved in this process such as sweat glands, lungs, and the kidneys. The liver plays an important role as well, in detoxifying metabolites for excretion elsewhere. Sweat glands actively excrete lactic acid, urea, as well as various salts, pulling water from the tissues. Alveolar structure within 24 the lungs facilitate carbon dioxide and other toxic gases release from hemoglobin, as well as the uptake of oxygen. One of the most important functions of the kidney is the filtration and excretion of nitrogenous waste products from the blood. Through a complex physiologic process, the kidney nephron also maintains blood pH, regulates water content in blood, and therefore further affects systemic blood volume and blood pressure. Thorough knowledge of kidney anatomy, the urinary system, and normal blood chemistry and osmotic forces involved in excretion are necessary for complete understanding of this complex process. An adult body contains around 10 liters of lymph, consisting of salts, sugars, amino acids, hormones, coenzymes, neurotransmitters, fatty acids and the metabolic waste products. Movement of lymph occur through peristalsis, and muscular action of surrounding tissues. Blood components do not come in direct contact with the tissue cells, but must exit the blood vessels and pass into the interstitial lymphatic fluid. The lymph then carries out cellular exchanges, and subsequently carry materials which do not re-enter the blood stream through the lymphatic vessels, through plexi and lymph nodes before entering the large lymphatics trunks for ultimate collection and drainage to the subclavian vein. Removal of the entire downstream chain of lymph nodes may be performed to eliminate further lymphatic spread.
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Poor communication is defined as responded "sometimes" or "never" to erectile dysfunction drugs in ayurveda purchase viagra super active with amex the set of survey questions: "During this hospital stay erectile dysfunction treatment bay area order generic viagra super active from india, how often did doctors/nurses treat you with courtesy and respect? Blacks erectile dysfunction causes n treatment generic 100mg viagra super active amex, American Indians and Alaska Natives, and patients of more than one race were more likely to report poor communication with doctors. Patient and Family Engagement: Enabling Effective Patient Navigation and Management of Care To effectively navigate the complicated health care system, health care providers need to give patients access to culturally and linguistically appropriate tools to support patient engagement. For people with limited English proficiency, having language assistance is of particular importance, so they may choose a usual source of care in part based on language concordance. Not having a language-concordant provider may limit or discourage some patients from establishing a usual source of care. National Healthcare Quality Report, 2011 171 Patient Centeredness Patient Language Diversity at Hospitals the overall percentage of Americans that belong to minority groups is increasing, and the total number of minorities in the United States surpassed 100 million in 2007 (U. A large number of these groups are made up of recent immigrants and groups that may not speak English as their primary language (Shin & Kominski, 2010). When members of these groups seek health care, language barriers may present significant challenges to communication with their providers and caregivers. The ability to capture the variety and numbers of patients who speak languages other than English is a recent new development, and two States (California and New Jersey) seem to have data that are robust enough to be reported at present. The following figures present some of these new State-level data that allow more insight into this topic. California and New Jersey hospitals with a high number of patients for whom English was not their primary language, by ownership, teaching status, occupancy load, and geographic location, 2009 High Numbers of Non-English Speakers Low Numbers of Non-English Speakers 100 90 80 70 60 Percent Chapter 5 50 40 30 20 10 Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, State Inpatient Databases. High-percentage Spanish hospitals represent the top 10% of facilities with the highest percentages of patients for whom English is not their primary language. About 16% of public hospitals had a high percentage of non-English-speaking patients. Only 8% of medium-occupancy hospitals had a high percentage of non-Englishspeaking patients, and just 3% of low-occupancy hospitals had a high percentage of non-Englishspeaking patients. Thirteen percent of large metropolitan hospitals had a high percentage of non-English-speaking patients, and only 4% of small metropolitan hospitals had a high percentage of non-English-speaking patients. No micropolitan or noncore hospitals had a high percentage of non-English-speaking patients. About 43% of these patients were from very low-income communities, while 24% were from low-income communities. These standards, which are directed at health care organizations, are also encouraged for individual providers to improve accessibility of their practices. The 14 standards are organized by themes: Culturally Competent Care (Standards 1-3), Language Access Services (Standards 4-7), and Organizational Supports for Cultural Competence (Standards 8-14). Need for a Translator the ability of providers and patients to communicate clearly with each other can be compromised if they do not speak the same language. Communication problems between the patient and provider can lead to lower patient adherence to medication regimens and decreased participation in medical decisionmaking. It also can exacerbate cultural differences that impair the delivery of quality health care. Adults age 18 and over who needed a translator during last doctor visit, California, by race/ethnicity, income, and education, 2008 25 Chapter 5 20 15 Percent 10 5 s se e e n or e e e ol ad ge ics an ca hit ian ine es ho Gr lle Po com com com an exic eri W As Ch am In In In Sc ool Co ll sp M Am nic n i h A w le h et a l ig ch ny lH Vi Lo idd Hig tra isp Al <H h S A M en n-H g C o Hi N 0 Source: University of California, Los Angeles, Center for Health Policy Research, California Health Interview Survey, 2008. Non-Hispanic Whites also were less likely than Mexicans and Central Americans to need a translator. Asians were significantly more likely than non-Hispanic Whites to need a translator during their last doctor visit (3% compared with 0. There were, however, no statistically significant differences between the overall Asian population and Chinese or Vietnamese patients. There also were no statistically significant differences between Chinese and Vietnamese patients. Patients need to be provided with information that allows them to make educated decisions and feel engaged in their treatment. Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2008. Think cultural health: bridging the health care gap through cultural competency continuing education programs. Chapter 5 National Healthcare Quality Report, 2011 177 178 National Healthcare Quality Report, 2011 Chapter 6. Clinical services are frequently organized around small groups of providers who function autonomously and specialize in specific symptoms or organ systems. Therefore, many patients receive attention only for individual health conditions rather than receiving coordinated care for their overall health. For example, the typical Medicare beneficiary sees two primary care providers and five specialists each year (Bodenheimer, 2008). Communication of important information among providers and between providers and patients may entail delays or inaccuracies or fail to occur at all. Care coordination is a conscious effort to ensure that all key information needed to make clinical decisions is available to patients and providers. Care coordination is multidimensional and essential to preventing adverse events, ensuring efficiency, and making care patient centered (Powell-Davies, et al. Patients in greatest need of care coordination include those with multiple chronic medical conditions, concurrent care from several health professionals, many medications, and extensive diagnostic workups, or transitions from one care setting to another. Effective care coordination requires well-defined multidisciplinary teamwork based on the principle that all who interact with a patient must work together to ensure the delivery of safe, high-quality care. In early 2011, the Partnership for Patients was created to improve the quality, safety, and affordability of health care for all Americans. One of the two major goals of this public-private partnership is to heal patients without complications arising. This goal specifically ties to care coordination by seeking to decrease preventable complications during transition from one care setting to another. The objective is to decrease all hospital readmissions by 20% overall by the end of 2013 (compared with 2010). National Healthcare Disparities Report, 2011 179 Care Coordination Importance Morbidity and Mortality n Care o o o o Chapter 6 coordination interventions have been shown to: Reduce mortality among patients with heart failure. Cost n Care coordination interventions have been shown to: o Reduce hospitalizations among patients with heart failure. Measures the National Strategy for Quality Improvement in Health Careii identified care coordination as one of six national priorities for health care. The vision is health care providers working together to "ensure that the patient gets the care and support he needs and wants, when and how he needs and wants it. Measures reported in this chapter are organized around these goals: n Transitions of care: o Adequate hospital discharge information. Important information may be lost or miscommunicated as responsibility is delivered to new parties.
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Vargas and Campos64 offer examples of diversification initiatives from which several lessons may be drawn erectile dysfunction treatment medications order 25 mg viagra super active with mastercard. For example erectile dysfunction from a young age buy discount viagra super active 50mg on line, beginning in the late 1980s the search for an alternative model led to diabetes erectile dysfunction wiki buy cheap viagra super active 25mg the establishment of various "agro-ecological" endeavors based on the principles of organic farming in Santa Cruz do Sul, a municipality in the Rio Pardo Valley. Farm products-including a wide variety of horticultural crops, erva-mate (Brazilian tea), peaches, oranges, beans, and corn-are sold in fairs and to regional and local supermarkets and restaurants. The financial returns that are reported for agro-ecological enterprises, however, are very uncertain, and the estimates do not show how these enterprises compare with respect to variable costs, labor requirements, investment needs, returns to capital, and other matters of importance to farmers. Moreover, Vargas and Campos64 report that more than 330 families are involved in agro-ecological products in the Rio Pardo Valley, which is a very small number compared with the number of tobacco growers. For widespread farmer participation, market linkages clearly need to be extended beyond local fairs and restaurants and will therefore involve completely different cost and price structures than the ones encountered so far. Horticulture production and marketing is one of the most demanding areas of agriculture and requires specialized infrastructure. Other initiatives have yielded similar lessons, including the need for diverse distribution networks, coordination, and government support. About 90% of the tobacco grown in Canada was produced in a highly concentrated area in southwestern Ontario near the north shore of Lake Erie. Historically, tobacco companies in Canada have encouraged and helped farmers to begin growing tobacco, and tobacco has made a major contribution to the local economies of four Ontario counties. The Diversification Plan 372 Monograph 21: the Economics of Tobacco and Tobacco Control had a substantial impact. By 1990, about one-third of tobacco growers across Canada had left tobacco production. Of the Ontario farmers who ceased growing tobacco, half said they would have done so regardless, and one-third said the program prompted them to discontinue. However, many eligible farmers did not take advantage of the program because they felt they were better off financially continuing to grow tobacco. Of the farmers who did leave, about 40% were still involved in tobacco growing afterward, typically as employees of other farmers. This effort was not immediately successful, as some farmers were reluctant to leave tobacco, a high-income crop, for a riskier, low-income activity, and some funded ventures failed. Despite these difficulties, "since the early 1980s many Canadian farmers who once grew tobacco have produced alternative crops, including ginseng, baby carrots, rhubarb, Spanish onions, zucchini, coriander, garlic, melons, early and sweet potatoes, buckwheat, and hay. As the demand for Canadian tobacco fell in the 1980s, farmers realized they could make more money by growing something else, either instead of or in addition to tobacco. By the late 1980s, tobacco farming had stabilized and the number of farmers exiting tobacco dwindled. The Future of Crop Substitution and Diversification For countries planning substitution and diversification programs, these and other case studies offer valuable examples and highlight the types of issues and challenges that may be encountered. These case histories show that alternative crops can substitute for some of the income earned from tobacco, but that programs designed to promote diversification simply for the sake of promoting diversification are likely to face significant challenges. Alternatives must be competitive and well managed; if they have not developed of their own accord, factors other than the dominance of tobacco may be at work. Approaches to crop diversification and substitution vary considerably across countries. In general, a consensus is growing that alternatives to tobacco farming do exist, but they tend to be highly country- or region-specific. Livelihoods diversification should be the concept guiding implementation of economically sustainable alternatives to tobacco growing. Tobacco growers and workers should be engaged in policy development concerning Articles 17 and 18 in line with Article 5. Policies and programs to promote economically sustainable alternative livelihoods should be based on best practices and linked to sustainable development programmes. The promotion of economically sustainable alternative livelihoods should be carried out within a holistic framework that encompasses all aspects of the livelihoods of tobacco growers and workers (including the health, economic, social, environmental, and food security aspects). Policies promoting economically sustainable alternative livelihoods should be protected from commercial and other vested interests of the tobacco industry, including leaf companies, in accordance with Article 5. Partnership and collaboration should be pursued in the implementation of these policy options and recommendations, including in the provision of technical and/or financial assistance. As described in the case histories above, at least in some countries other crops have the potential to rival or surpass tobacco in terms of gross and net profits, returns to cash, and returns to family labor. In Kenya, initial trials have shown that bamboo can be a successful commodity, offering a diversity of uses and higher profits. In Indonesia, potato, chilli, nilam, and oranges were all found to return higher profits than tobacco, depending on farm management. Similarly, in Zimbabwe, analysis shows that paprika, coffee, and specialty horticulture crops offer greater profits than tobacco, and in Malawi, tomato, paprika, rice, confectionery groundnuts, and coffee all provide higher incomes for smallholder farmers, depending on market arrangements. Policy incentives that encourage tobacco growers to use their incomes to invest in other farm activities are well worth considering. Hu and colleagues66 conclude that tobacco growing provides lower returns than alternative crops such as grains, oilseeds, beans, and fruit. However, they also observe that local governments use various incentives to promote tobacco growing because of its importance to their tax revenues, and the quotas mandated by local governments do not allow farmers to determine which crops they will grow. The markets for most high-value products that could to some extent make up for a loss of tobacco revenue are much smaller and more difficult to penetrate. The challenge of developing new supply chains for alternative products may appear daunting, but this does not mean that new products cannot, or will not, emerge over time to replace tobacco. As the markets for tobacco begin to shrink, other commodities could become relatively more attractive and gradually emerge alongside tobacco. As described in chapter 2, these products can be grouped into two broad categories: smoked products such as cigarettes, cigars, bidis, kreteks, roll-your-own tobacco, and waterpipe tobacco; and smokeless products such as chewing tobacco, moist snuff, and dry snuff products. All tobacco products carry health risks for the user, but the risks vary due to differences in product characteristics and consumer usage patterns. From 1970 to 2004, world production of cigarettes increased by 57%, but most of this increase occurred in the 1970s. The largest share is produced by China, which is the largest cigarette-producing and -consuming country in the world. The African Region produces large quantities of raw tobacco, 8 but manufactures few cigarettes. The Eastern Mediterranean Region also has a very small share of global cigarette production. The South-East Asia Region, which includes Indonesia and India, produces fewer cigarettes as a region than the Western Pacific, European, and Americas Regions. Changes in the product itself and how it is produced and marketed have, at various times, had a dramatic impact on patterns of tobacco consumption. This section briefly reviews some key product design changes that have occurred over the past century, focusing primarily on the U. Before the mid-19th century, most tobacco was consumed in the form of chewing tobacco, plug tobacco, pipe tobacco, snuff, and cigars. Early cigarette manufacturing was a highly labor-intensive activity, given that cigarettes were rolled by hand. Much of the tobacco used in early American and British cigarettes was relatively expensive, imported Turkish tobacco or comparable domestically grown 376 Monograph 21: the Economics of Tobacco and Tobacco Control heavy, dark varieties which produced strong-tasting cigarettes.
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Whether the air be admitted into the pleural sac erectile dysfunction doctor san jose generic viagra super active 100mg with visa, by an opening made in the side from without erectile dysfunction 21 years old buy viagra super active in united states online, or by an opening in the lung itself erectile dysfunction operations viagra super active 100 mg fast delivery, the mechanical principle of the respiratory apparatus will be equally deranged. Pneumo-thorax will be the result of either lesion; and by the accumulation of air in the pleura the lung will suffer pressure. This pressure will be permanent so long as the air has no egress from the cavity of the pleura. The permanent distention of the thoracic cavity, caused by the accumulation of air in the pleural sac, or by the diffusion of air through the interlobular cellular tissue consequent on a wound of the lung itself, will equally obstruct the breathing; and though the situation of the accumulated air is in fact anatomically different in both cases, yet the effect produced is similar. Though the emphysematous lung is distended to a size equal to the healthy lung in deep inspiration, yet we know that emphysematous distention, being produced by extrabronchial air accumulation, is, in fact, obstructive to the respiratory act. The emphysematous lung will, in the same manner as the distended pleural sac, depress the diaphragm and render the thoracic muscles inoperative. The foregoing observations have been made in reference to the effect of wounds of the thorax, the proper treatment of which will be obviously suggested by our knowledge of the state of the contained organs which have suffered lesion. The gall bladder with its duct joining the hepatic duct to form the common bile duct. The hepatic artery is seen superficial to the common duct; the vena portae is seen beneath it. The patent orifices of the hepatic veins are seen on the cut surface of the liver. The transverse colon, between which and the lower border of the stomach is seen the gastro-epiploic artery, formed by the splenic and hepatic arteries. The median line of the body is occupied by the centres of the four great systems of organs which serve in the processes of circulation, respiration, innervation, and nutrition. These organs being fashioned in accordance with the law of symmetry, we find them arranged in close connexion with the vertebrate centre of the osseous fabric, which is itself symmetrical. In this symmetrical arrangement of the main organs of the trunk of the body, a mechanical principle is prominently apparent; for as the centre is the least moveable and most protected region of the form, so have these vitally important structures the full benefit of this situation. The aortal trunk, G, of the arterial system is disposed along the median line, as well for its own safety as for the fitting distribution of those branches which spring symmetrically from either side of it to supply the lateral regions of the body. As the thoracic viscera differ in form and functional character from those of the abdomen, so we find that the arterial branches which are supplied by the aorta to each set, differ likewise in some degree. In the accompanying figure, which represents the thoracic and abdominal visceral branches of the aorta taken in their entirety, this difference in their arrangement may be readily recognised. In the thorax, compared with the abdomen, we find that not only do the aortic branches differ in form according to the variety of those organs contained in either region, but that they differ numerically according to the number of organs situated in each. It is the one thoracico-abdominal vessel, and this circumstance calls for the comparison, not only of the several parts of the great vessel itself, but of all the branches which spring from it, and of the various organs which lie in its vicinity in the thorax and abdomen, and hence we are invited to the study of these regions themselves connectedly. In the thorax, the aorta, G G*, is wholly concealed by the lungs in their states both of inspiration and expiration. The first part of the aortic arch, as it springs from the left ventricle of the heart, is the most superficial, being almost immediately sub-sternal, and on a level with the sternal junctions of the fourth ribs. By applying the ear at this locality, the play of the aortic valves may be distinctly heard. From this point the aorta, G, rises and arches from before, backwards, to the left side of the spine, G*. The arch of the vessel lies more deeply between the two lungs than does its ventricular origin. The descending thoracic aorta lies still more deeply situated at the left side of the dorsal spine. At this latter situation it is in immediate contact with the posterior thick part of the left lung; whilst on its right are placed, L, the thoracic duct; I, the oesophagus; K, the vena azygos, and the vertebral column. In Plate 26 may be seen the relation which the superior vena cava, H, bears to the aortic arch, A. In the span of the aortic arch will be found, H*, the left bronchus, together with the right branch of the pulmonary artery, and the right pulmonary veins. The left pneumo-gastric nerve winds round beneath the arch at the point where the obliterated ductus arteriosus joins it. The pulmonary artery, B, Plates 1 & 2, lies close upon the fore part, and conceals the origin, of the systemic aorta. Whenever, therefore, the semilunar valves of either the pulmonary artery or the systemic aorta become diseased, it must be extremely difficult to distinguish by the sounds alone, during life, in which of the two the derangement exists. The origins of both vessels being at the fore part of the chest, it is in this situation, of course, that the state of their valves is to be examined. The descending part of the thoracic aorta, G*, being at the posterior part of the chest, and lying on the vertebral ends of the left thoracic ribs, will therefore require that we should examine its condition in the living body at the dorsal aspect of the thorax. As the arch of the aorta is directed from before backwards-that is, from the sternum to the spine, it follows that when an aneurism implicates this region of the vessel, the exact situation of the tumour must be determined by antero-posterior examination; and we should recollect, that though on the fore part of the chest the cartilages of the second ribs, where these join the sternum, mark the level of the aortic arch, on the back of the chest its level is to be taken from the vertebral ends of the third or fourth ribs. This difference is caused by the oblique descent of the ribs from the spine to the sternum. The first and second dorsal vertebrae, with which the first and second ribs articulate, are considerably above the level of the first and second pieces of the sternum. In a practical point of view, the pulmonary artery possesses but small interest for us; and in truth the trunk of the systemic aorta itself may be regarded in the same disheartening consideration, forasmuch as when serious disease attacks either vessel, the "tree of life" may be said to be lopped at its root. When an aneurism arises from the aortic arch it implicates those important organs which are gathered together in contact with itself. The aneurismal tumour may press upon and obstruct the bronchi, H H*; the thoracic duct, L; the oesophagus, I; the superior vena cava, H, Plate 26, or wholly obliterate either of the vagi nerves. This anatomical fact also fully accounts for the constant cough which attends some forms of aortic aneurism. This will occur the more certainly if the aneurism spring from the right or the inferior side of the arch, and if the tumour should not break at an early period, slow absorption, caused by pressure of the tumour, may destroy even the vertebral column, and endanger the spinal nervous centre. If the tumour spring from the left side or the fore part of the arch, it may in time force a passage through the anterior wall of the thorax. The principal branches of the thoracic aorta spring from the upper part of its arch. The innominate artery, 2, is the first to arise from it; the left common carotid, 6, and the left subclavian artery, 5, spring in succession. These vessels being destined for the head and upper limbs, we find that the remaining branches of the thoracic aorta are comparatively diminutive, and of little surgical interest. The intercostal arteries occasionally, when wounded, call for the aid of the surgeon; these arteries, like all other branches of the aorta, are largest at their origin. Where these vessels spring from G, the descending thoracic aorta, they present considerable caliber; but at this inaccessible situation, they seldom or never call for surgical interference. As the intercostal arteries pass outwards, traversing the intercostal spaces with their accompanying nerves, they diminish in size. Each vessel divides at a distance of about two inches, more or less, from the spine; and the upper larger branch lies under cover of the inferior border of the adjacent rib. When it is required to perform the operation of paracentesis thoracis, this distribution of the vessel should be borne in mind; and also, that the farther from the spine this operation is performed, the less in size will the vessels be found. The thoracic aorta descends along the left side of the spine, as far as the last dorsal vertebra, at which situation the pillars of the diaphragm overarch the vessel.