By F. Pranck. Capella University.
There are major concerns about the vulnerability of organ donors motivated by financial incentives (The Declaration of Istanbul of Organ Trafficking and Transplant Tourism has condemned transplant tourism and the associated practices) discount actos 30mg with amex diabetes symptoms of high and low blood sugar. Particular worries concern the possibility of poor aftercare and absence of separate clinical advocacy for donors purchase 45 mg actos overnight delivery diabetic recipes. Officially it has become illegal for the organs of executed Chinese prisoners to be made available for transplant to foreign transplant tourists (Rhodes and Schiano, 2010). Questions remain, however, over how transplant programmes in high-income countries should deal with returning patients who have managed to circumvent overseas restrictions. Given that ability to pay rather than need alone is the allocative mechanism in the medical tourism market, there are concerns that commercial rather than professional priorities are privileged in decision-making. There are also treatments where there are more likely to be associated psychological factors than with the broader population – such as those seeking cosmetic surgery who may have associated conditions such as body dysmorphic disorder (Grossbart and Sarwer, 2003). Human stem-cell therapies are a controversial procedure and scientifically are of unproven value, especially as beauty therapies. Within the medical tourism field there are examples of countries offering stem-cell therapies targeted at specific conditions including Parkinson‘s, stroke and brain infections. What should be made of such treatments given there are no clinical trials to assess efficacy and effectiveness? The pursuit of unproven – and even dangerous – therapies across national boundaries may be particularly marketed as treatments for desperate patients who cannot obtain these in their own country of origin. There are particular ethical issues when these are pursued for children (Zarzeczny and Caulfield, 2010), and complex ethical dilemmas of ‗hopeful‘ treatments being marketed to those who are gravely ill (Murdoch and Scott, 2010). There are therefore many potential roles for professional associations, regulatory authorities and domestic physicians in counselling, advising, providing information and in the extreme possibly deterring would-be medical tourists. Such activity itself needs to be balanced with consideration of the principle of patient autonomy. Despite high-profile media interest and coverage, there is a lack of hard research evidence on the role and impact of medical tourism. Whilst there is an increasing amount written on the subject of medical tourism, such material is hardly ever evidence-based. In order to make sense of the diversity of material and the gaps in extant knowledge, it is worth framing the conclusions and recommendations in terms of Frenk‘s (1994) framework for health policy analysis. This hierarchical framework presents four levels within any health system: systemic (regulation and finance), programmatic (system priorities), organisational (service management) and instrumental (clinical interface with patients). Despite concerns generated by the current financial crisis, there is no sign that economic liberalization is slowing down. As the trading opportunities in other sectors become exhausted, as experience within services trade generally expands, and as the financial climate stabilises, countries will increasingly look to the opportunities that international trade in services has to offer. For exporting services, this will centre on technology transfer, skill enhancements and foreign income. At present, medical tourism is driven by commercial interests lying outside of organised and state-run health policy-making and delivery. Are there possibilities to bring it more within the remit of domestic policy competency, involving for example third-party payers sending patients overseas? Given the heavily ‗politicized‘ nature of health care in all countries (even those with substantial private health care sectors), there will also be concerns about the threats this poses, including aspects related to brain drain, quality of care and equity. If an agreement is achieved to send patients abroad on a more bi-lateral basis, then this may open channels for other agreements such as these, which can then combine international recruitment with training and work experience programmes to address brain drain issues in the importing country. If such a route were taken, this would effectively be a form of outsourcing, with such agreement typically following the well-worn tracks of medical tourist mobility. Countries continue to evaluate their positions on trade liberalization in health, as part of wider bi- lateral, regional and multilateral trade agreements. The latter especially has been the focus of debate, centred on the World Trade Organization‘s General Agreement on Trade in Services (Blouin et al. However, there is widespread recognition that the trade agenda (in services generally, and health specifically) is increasingly pursued at the regional or bi-lateral levels (Smith et al.
If the medication is continued on an outpatient basis actos 45mg discount diabetes symptoms joints, this medication would be considered unnecessary because there is no longer an indication for the medication discount actos 30 mg on-line diabetes signs and symptoms nhs. In the United States, about half of elderly patients admitted to hospitals take seven or more medications. Polypharmacy was deﬁned as at least nine medications, a higher threshold compared with other studies in ambulatory or hospitalized settings. However, one study of 2014 residents, the majority of whom were 85 years or older, in 193 assisted living facilities reported a mean of 5. They reported that 57% of patients were taking at least one unnecessary medication. Hanlon and colleagues25 reported similar ﬁndings; lack of indication was the most common reason for unnecessary medications in a study of 397 hospitalized elderly veterans. Common unnecessary medications include gastrointesti- nal, central nervous system, and therapeutic nutrient/mineral agents. A study of ambulatory Medi- care patients revealed that the most common drug classes prescribed in a 1-year period were cardiovascular agents, antibiotics, diuretics, analgesics, antihyperlipi- demics, and gastrointestinal agents. The most common nonprescription medications consumed by older adults were analge- sics (aspirin, acetaminophen, and ibuprofen), cough and cold medications (diphen- hydramine and pseudoephedrine), vitamins and minerals (multivitamins, vitamins E and C, calcium), and herbal products (ginseng, Ginkgo biloba extract). Aside from increased direct drug costs, patients are at higher risk for adverse drug reactions, drug interactions, nonadherence, diminished functional status, and various geriatric syndromes. In a prospective, randomized controlled longitudinal multicenter European study of 1601 community-dwelling elderly adults, 46% of patients had a potential drug-drug interaction. The risk of drug-disease interactions has been shown to increase as the number of drugs as well as the number of comorbidities increase. The prevalence rates should be interpreted cautiously, because they may be overestimated due to how interactions and their clinical importance are deﬁned. These interactions are signiﬁcant because they may decrease the efﬁcacy or increase the risk of toxicity of a drug. As a result, the prescriber may change the dose or add more medications, further increasing the risk for other interactions and side effects. Nonadherence Complex medication regimens related to polypharmacy can lead to nonadherence in the elderly. The number of medications has been shown to be a stronger predictor of nonadherence than advancing age, with higher rates of nonadherence as the number of medications increases. Increased Health Service Utilization and Resources The use of multiple medications leads to increased costs for both the patient and the health system as a whole. Whereas the proper use of medications may lead to decreased hospital and emergency room admissions, the use of inappropriate medications may not only increase patients’ drug costs but cause them to use more health care services. A retrospective population study in Ireland concluded that approximately 9% of the total drug-related expenditures were on potentially inappro- priate medications. A retrospective cohort study of elderly Japanese patients reported that patients with polypharmacy were at risk of having a potentially inappropriate medication, which then increased the risk for hospitalization and outpatient visits and resulted in a 33% increase in medical costs. In a review of 42 cohorts of medical inpatients composed of mostly older adults, the rate of delirium ranged from 11% to 42%. Another study of 156 hospitalized older adults found that the number of medications was an independent risk factor for delirium. Similarly, drug classes that can exacerbate dementia are benzodiazepines, anticonvulsants, and anticholinergic drugs such as tricyclic antidepressants. A cohort study of 294 Finnish elders reported that those with polypharmacy were found to have a decrease of 1. Twenty-two percent of patients with no polypharmacy were found to have impaired cognition as opposed to 33% and 54% with polypharmacy and excessive polypharmacy, respectively. A cross-sectional study in older outpatients found that the number of prescribed medications was signiﬁcantly associated with the risk of falls. Z a r w iz et a l Ou a t ien t m a n a ged ca r e ( ﬁr in t er ven t i n ) lin ica lp ha r m a ci eview ed T he r a t e o fp ly ha r m a cyr educed b y 2 eco n d dr ug r egim en s educa t ed a ft er ﬁr in t er ven t i n , fr m in t er ven t i n ) hyicia n s a n d p a t ien t n even t a t ien t p ly ha r m a cy a n d w o ked ft er he s eco n d in t er ven t i n , he w ih p hyicia n s educe ly ha r m a cyr a t e w a s educed b y p ly ha r m a cy fr m even t 1 a t ien t Scha m der et a l I n p a t ien t a n d o u a t ien t I n p a t ien t a n d o u a t ien t er ia t ic eva lua t i n a n d m a n a gem en t 2 fr a ilelder lyvet er a n s ger ia t ic eva lua t i n a n d educed t he n um b er fun n eces a r y m a n a gem en t co n s i in g o f a n d in a p ia t e dr ugs in ger ia t icia n , n u e, cia l in p a t ien t b u n o in w o ker a n d p ha r m a ci u a t ien t H a n l n et a l Ou a t ien t vet er a n s lin ica lp ha r m a ci eview ed Us in g t he M edica t i n ia t en es 1 egim en s a n d co m m un ica t ed I n dex, in a p ia t e p es cr ib in g r eco m m en da t i n s in w r iin g ign iﬁca n t lydecr ea s ed in he a n d ver b a llyt im a r y in t er ven t i n gr u co m p a r ed w ih p hyicia n. G a l Ou a t ien t vet er a n s Pha r m a ci ha r m a co her a p y educed a ver a ge n um b er f co n s ul es cr i i n s er a t ien t F illi et a l Ou a t ien t edica r e u veyed, lder lyM edica r e b en eﬁcia r ies Oft he 1 a t ien t w ho cheduled a 1 b en eﬁcia r ies a t ik fo ly ha r m a cy m edica t i n eview , ep ed r es n ded, w er e s en t let er b ym a n a ged ha vin g a m edica t i n dico n t in ued.
There is only one published study of family therapy for patients with borderline personality disorder (12) generic 45mg actos fast delivery diabetes diet who, which found that a psychoeducational approach could greatly enhance commu- nication and diminish conflict about independence discount actos 45mg line blood glucose of 102. Published clinical reports differ in their recommendations about the appropriateness of family therapy and family involvement in the treatment. Whereas some clinicians recommend removing the patient’s treatment from the family setting and not attempting family therapy (12), others recommend working with the patient and family together (42). Treatment of Patients With Borderline Personality Disorder 23 Copyright 2010, American Psychiatric Association. Clinical experience suggests that family work is most apt to be helpful and can be of critical importance when patients with borderline personality disorder have significant involvement with, or are financially dependent on, the family. The decision about whether to work with the family should de- pend on the degree of pathology within the family and strengths and weaknesses of the family members. Clinical experience suggests that a psychoeducational approach may lay the ground- work for the small subset of families for whom subsequent dynamic family therapy may be ef- fective. Family therapy is not recommended as the only form of treatment for patients with borderline personality disorder. Pharmacotherapy and other somatic treatments A pharmacological approach to the treatment of borderline personality disorder is based upon evidence that some personality dimensions of patients appear to be mediated by dysregulation of neurotransmitter physiology and are responsive to medication (43). Pharmacotherapy is used to treat state symptoms during periods of acute decompensation as well as trait vulnera- bilities. Although medications are widely used to treat patients who have borderline personality disorder, the Food and Drug Administration has not approved any medications specifically for the treatment of this disorder. Pharmacotherapy may be guided by a set of basic assumptions that provide the theoretical rationale and empirical basis for choosing specific treatments. Pharmacotherapy has demonstrated significant efficacy in many studies in diminishing symptom severity and optimizing functioning. Second, borderline personality disorder is characterized by a number of dimensions; treatment is symptom-specific, directed at particular behavioral dimensions, rather than the disorder as a whole. Third, affective dysregulation and impulsive aggression are dimensions that require particular attention because they are risk fac- tors for suicidal behavior, self-injury, and assaultiveness and are thus given high priority in se- lecting pharmacological agents. Fourth, pharmacotherapy targets the neurotransmitter basis of behavioral dimensions, affecting both acute symptomatic expression (e. Symptoms exhibited within three behavioral dimensions seen in patients with borderline personality disorder are targeted for pharmacotherapy: affective dysregulation, impulsive- behavioral dyscontrol, and cognitive-perceptual difficulties. For example, fluoxetine has been found to improve depressed mood, mood lability, rejection sensitivity, impulsive behavior, self-mutilation, hos- tility, and even psychotic features. Studies have been reported with fluoxetine (in doses of 20–80 mg/day), sertraline (in doses of 100–200 mg/day), and the mixed norepinephrine/sero- tonin reuptake blocker venlafaxine (in doses of up to 400 mg/day) (45). Empirical trials of tricyclic antidepressants have produced inconsistent results (50, 51). Pa- tients with comorbid major depression and borderline personality disorder have shown im- provement following treatment with tricyclic antidepressants. However, in one placebo- controlled study, amitriptyline had a paradoxical effect in patients with borderline personality disorder, increasing suicidal ideation, paranoid thinking, and assaultiveness (50). Since affective dysregulation is a dimension of temperament in patients with borderline per- sonality disorder and not an acute illness, the duration of continuation and maintenance phases of pharmacotherapy cannot presently be defined. Significant improvement in the quality of the patient’s coping skills and interpersonal relationships may be required before medication can be discontinued. Clinical experience suggests caution in discontinuing a successful antidepressant trial, especially if prior medication trials have failed. In one study of patients with borderline personality disorder (45), one-half of the patients who failed to respond to fluoxetine subsequently responded to sertraline. At this point, the use of a benzodiazepine should be considered, although there is little systematic research on the use of these medications in patients with borderline personality disorder. Use of benzo- diazepines may be problematic, given the risk of abuse, tolerance, and even behavioral toxicity. Despite clinical use of benzodiazepines (52), the short-acting benzodiazepine alprazolam was associated in one study with serious behavioral dyscontrol (53). Case reports demonstrate some utility for the long half-life benzodiazepine clonazepam (54).
Barrier: A treatment or disinfection process that constitutes an impediment to the transmission of waterborne pathogenic microorganisms or other contaminants to humans in drinking water actos 15 mg with visa diabetic readings. The term barrier encompasses treatment and disinfection processes that either remove or inactivate such microorganisms and contaminants cheap actos 45mg on-line metabolic disease nhs. The three forms of free chlorine exist together in equilibrium, the relative portions of which are determined by the pH value and temperature. This is the parameter used which is monitored downstream of contact tank as C for calculation of the Ct value necessary for the verification of primary disinfection systems. Combined chlorine can be accurately estimated as the difference between the measured total chlorine and measure or known free chlorine residual. Total; Total chlorine residual equal the sum of free chlorine residual and combined chlorine residual Clarifier: A large circular or rectangular treatment process tank through which water is passed upwards for a period of time, during which the heavier suspended solids or coagulated floc particles (including colloidal particles bound up therein) are removed from the water. Colloidal: A type of very small, finely divided particulate matter ranging in size from approximately 2 - 1,000 nm in diameter, which can be present in water. Colloids do not settle out rapidly and remain dispersed in a liquid for a long time due to their small size and electrical charge. Repulsion of similarly charged particles can prevent the particles from becoming heavier and settling out. Colour: Colour in water may result from a number of sources including metallic ions (iron and manganese), and particulate and dissolved organic material. Conventional A method of treating water which consists of the addition of coagulant chemicals, Treatment: flash mixing, coagulation, flocculation (not necessarily in separate tanks or basins), clarification, by sedimentation or flotation and filtration, resulting in substantial particulate removal. Ct: The product of “residual disinfectant concentration” (C) in mg/l determined before or at the first customer, and the corresponding “disinfectant contact time” (t) in minutes, expressed in mg. This Ct value is widely utilised in international standards and guidance on disinfection practice for the establishment of target log inactivation for various pathogens and is used in practice to determine the disinfectant concentration” (C) necessary to achieve the target inactivation given the available contact arrangements. Cryptosporidium: A disease-causing protozoon widely found in surface water sources. Cryptosporidium is spread by the fecal-oral route as a dormant oocyst from human and animal faeces. In its dormant stage, Cryptosporidium is housed in a very small, hard-shelled oocyst form that is environmentally robust and very resistant to chlorine and chloramine disinfectants. When water containing these oocysts is ingested, the protozoa replicates within the intestinal tract of the host causing a severe gastrointestinal illness called cryptosporidiosis. Cryptosporidiosis: The gastrointestinal illness caused by infection with cryptosporidium. Disinfectant Any chemical oxidant, including but not limited to chlorine, chlorine dioxide, chloramines, and ozone which is added to water in any part of the treatment or distribution process and which is intended to kill or inactivate pathogenic microorganisms. The intensity of the reddish tint to the water formed in the sample relates directly to the amount of disinfectant such as free chlorine, chlorine dioxide and/or permanganate, present in the sample. These bacteria, which are of definite faecal origin (human and animal), are excreted in vast numbers and their presence in a water supply is proof that faecal contamination has occurred and is a definite indication that pathogens may be present. Epidemiology: The study of the occurrence and causes of health effects in human populations. Filtration: A treatment process for removing particulate matter from water by passage through porous media Water Treatment Manual: Disinfection Floc: In drinking water treatment, floc refers to the fine cloud of spongy particles that form in water to which a coagulant has been added. Flocculation: A process to enhance agglomeration or collection of smaller floc particles into larger, more easily settleable particles through gentle stirring by hydraulic or mechanical means following chemical addition of aluminium or iron salts and polyelectrolytes. Hardness: Hardness in water, usually expressed in mg/l CaCo3 is the measure of the concentration of dissolved calcium and magnesium salts, particularly carbonates and bicarbonates. There is no health risk associated with hard water, however, it can be difficult to lather and can cause scaling problems in hot water systems Headloss: The head, pressure or energy lost by water flowing in a pipe, in a channel or through a tank as a result of turbulence caused by the velocity of the flowing water and the roughness of the pipe, channel walls or restrictions caused fittings. Water flowing in a pipe or channel loses head, pressure or energy as a result of friction losses. The head loss through a filter is due to friction losses caused by material building up on the surface or in the interstices of the filter media. When water containing these cysts is ingested by a new host, the protozoa cause a severe gastrointestinal illness called giardiasis. Granular The term refers to Activated Carbon: a) the highly porous adsorbent filter media which is produced by heating coal or wood in the absence of air prior to crushing the material into granulated form approximately 1mm in size b) the constituent element of a water treatment process by which treatment process water is passed through such media. Activated carbon is positively charged and therefore able to remove negative ions from the water such as chlorine and ozone and is recognised as an effective method of reducing dissolved organics and associated taste and odour problems in water by adsorption.
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