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Sources of economic growth: an extensive accounting or changes in life expectancy from disease discount atorlip-5 5mg on line cholesterol statins, estimated exercise order 5 mg atorlip-5 amex cholesterol in ostrich eggs. This would correspond to a rate of decrease in economic welfare due to mortality increase of 2% per annum. This approach, which may seem more complete than the previous approaches, does not account for the total value of the changes in health. It is, however, useful in that it demonstrates fuller returns to investment in health compared to the above approaches. Estimation should be of interest to country development strategists and policy-makers in the health and ﬁnance sectors, and also useful for international comparison. The model was programmed to compute output if there were no deaths due to chronic disease (the counterfactual) against out- put given the projected deaths from chronic disease on an annual basis. This procedure was then repeated for estimating the global goal of an additional 2% annual reduction in chronic disease death rates over and above baseline projections, over 10 years from 2006 to 2015. All the variables in the Cobb-Douglas model were sub- jected to univariate and multivariate analysis (Monte Carlo) using Crystal Ball software. These contributions have been vital to the project, both in creating and enriching the report. The production of this publication was made possible through the generous ﬁnancial support of the Government of Canada, the Government of Norway and the Government of the United Kingdom. Expert and Tropical Medicine, United Stéfanie Durivage reviewers do not necessarily endorse Kingdom Amanda Marlin the full contents of the ﬁnal version. Klumbiene, Kaunas University of Auckland, New Zealand Ofﬁce for Europe Medicine, Lithuania I. Sklodowska-Curie Josie d’Avernas, Health Promotion Health Institute, Finland Memorial Cancer Center and Institute Consulting, Canada Otaliba Libânio de Morais, Ministry of of Oncology, Poland Jarbas Barbosa da Silva Júnior, Health, Brazil Ministry of Health, Brazil V. Mohan, Madras Diabetes Research Ashley Bloomﬁeld, Ministry of Health, Foundation, India New Zealand A. Nissinen, National Public Health Antonio Carlos Cezário, Ministry of Institute, Finland Health, Brazil C. Shanthirani, Madras Diabetes Deborah Carvalho Malta, Ministry of Research Foundation, India Health, Brazil Sania Nishtar, Heartﬁle, Pakistan Rhona Hanning, University of Waterloo, Rafael Oganov, State Research Centre Canada for Preventive Medicine, Russian Lenildo de Moura, Ministry of Health, Federation Brazil J. Dzerve, National Institute of for Preventive Medicine, Russian Cardiology, Latvia Federation Brodie Ferguson, Stanford University, R. Overall, this set of photographs Steve Ewart and stories from ﬁve diverse countries demonstrates that chronic diseases are Maryvonne Grisetti widespread in low and middle income countries and are an underappreciated Peter McCarey source of poverty, requiring comprehensive and coordinated responses. Namperumalsamy, Aravind Eye Reda Sadki Silvio Mariotti Hospital, Madurai Gopal Prasad Pokharel A. Saguti, Ministry of Health, Diego Neri Oliveira e Silva Mzurisana Mosses United Republic of Tanzania, Marystella M. Sarswathy Stephanie Cruickshank Kaushik Ramaiya, International Mana Sekaran Martin Hession Diabetes Federation, Dar es Salaam Menaka Seni Melanie Keane Ramadhan Mongi, International A. Department of Health and Human Services 2 Global Health and Aging Photo credits front cover, left to right (Dreamstime. Rose Maria Li Contents Preface 1 Overview Humanity’s Aging 4 Living Longer 6 New Disease Patterns 9 Longer Lives and Disability 12 New Data on Aging and Health 16 Assessing the Cost of Aging and Health Care 18 Health and Work 20 Changing Role of the Family 22 Suggested Resources 25 3 4 Global Health and Aging Preface The world is facing a situation without precedent: We soon will have more older people than children and more people at extreme old age than ever before. As both the proportion of older people and the length of life increase throughout the world, key questions arise. Will population aging be accompanied by a longer period of good health, a sustained sense of well-being, and extended periods of social engagement and productivity, or will it be associated with more illness, disability, and dependency? Are these futures inevitable, or can we act to establish a physical and social infrastructure that might foster better health and wellbeing in older age? How will population aging play out differently for low-income countries that will age faster than their counterparts have, but before they become industrialized and wealthy? A better understanding of the changing relationship between health with age is crucial if we are to create a future that takes full advantage of the powerful resource inherent in older populations. And research needs to be better coordinated if we are to discover the most cost-effective ways to maintain healthful life styles and everyday functioning in countries at different stages of economic development and with varying resources. Managing population aging also requires building needed infrastructure and institutions as soon as possible. The longer we delay, the more costly and less effective the solutions are likely to be.
The loss of the negative in the opening sentence of ¶ in Treatments for Women atorlip-5 5mg without a prescription cholesterol levels uk vs usa, for example purchase atorlip-5 5 mg amex fasting cholesterol test vitamins, had the result of encouraging treatment of old women suﬀer- ing from a sanious ﬂux, whereas the original text had said it was pointless to treat them because they were already incapable of bearing children. Many errors or corruptions, of course, would not have been obvious to readers without multiple copies of the texts at hand. Yet the failure of later scribes or readers to correct some of the more glaring errors must give us pause when imagining how actively the standardized ensemble in particular might Introduction have been used in any kind of clinical setting. Not a single reader of the extant standardized ensemble manuscripts seems to have noticed, for example, the obvious logical inconsistency within a recipe in Women’s Cosmetics for redden- ing the skin and lips, where an accidental misreading changed a prescription to use a violet dye into one for a green dye (¶). And one wonders how even the most dedicated occultist could have made sense of the garbled magical passages in ¶¶ and . It is likely, however, that the standardized ensemble became the preferred version of the Trotula texts, not because it was scrutinized in de- tail for every possible remedy for women’s conditions (there are, after all, over three hundred diﬀerent prescribed therapies), but because it could serve a more general function as a basic referencework on fertility—a subject on which there was increasing concern from the thirteenth century on. L D The standardized ensemble is today found in twenty-nine manuscripts from all parts of Latinate Europe. In the ﬁfteenth century, even though other forms of the texts were still being tran- scribed in many parts of Europe, the standardized ensemble seems to have been rarely copied in Italy, England, or even in France, where the text had earlier achieved its greatest popularity. Most of the extant ﬁfteenth-century manu- scripts come from central and eastern Europe. The standardized ensemble seems always to have been closely associated with university circles and in this context manuscripts preserved their utilityas reference texts for years after their initial composition. At his death (sometime between and ), the theo- logian Gérard of Utrecht left his copy to the College of the Sorbonne in Paris, where it was to remain until the modern period. Caillau then gave the manuscript to his patron the duke in exchange for another book. A ﬁnal indication of the standardized ensemble’s utility was its translation in the ﬁfteenth century into the vernacular, once into Dutch, once, perhaps twice into French, and twice into German. Copy after copy reproduced the text with hardly any variation, in stark contrast to earlier versions, which copyists often felt free to abridge or emend as they liked. One scribe re- interpreted the title as ‘‘The Good TreatiseWhich Is Entitled ‘The Old Woman on the Suﬀerings [of Women]. Kraut’s major editorial innova- tion was to reorganize all the material from the ensemble into one smoothly ordered summa, rearranging the ensemble’s disparate parts into sixty-one chap- ters. Gone, too, of course, were any remaining hints that the Trotula was a concretion of a variety of sources from a variety of diﬀer- ent authors. While in general Kraut seems to have been concerned to preserve most of the material he found in the standardized ensemble, humanist that he was he could not refrain entirely from tidying up the text. He suppressed the two references to magical practices to aid birth in Conditions of Women (¶¶ and ), he clariﬁed that the contraceptives were to be used only if out of fear of death the woman did not dare conceive,221 and he apologized for the in- clusion of mechanisms to ‘‘restore’’ virginity, saying that he would not have included them were they not necessary to aid in conception. Kraut was apparently motivated by the desire to make both the femininity and the originalityof ‘‘Trotula’’ more apparent. Whereas neither the original Condi- tions of Women nor the standardized ensemble had oﬀered any direct hint of the author’s gender, Kraut, presuming the whole of his newly uniﬁed text to be the work of a single feminine author, altered the preface to stress her gender. He also omitted the names of Hippocrates and Galen and even the author’s clear admission that the work was a compilation of excerpts from other writings. Kraut’s artiﬁcial text with his artiﬁcially uniﬁed and gendered author proved to be authoritative; all subsequent Renaissance editors reprinted this humanist fabrication rather than returning to the medieval manuscripts. Kraut’s edition thus occluded the medieval history of the texts from view, with the result that most of the modern controversy about the authoress ‘‘Trotula’’ has produced little more than idle speculation. The Trotula texts, whoever their authors may have been, were very real and very inﬂuential throughout Europe for nearly half a millennium. What- ever their relationship to Trota or the other women of Salerno, the Trotula were one of the pillars on which later medieval culture was built, being present in the libraries of physicians and surgeons, monks and philosophers, theolo- gians and princes from Italy to Ireland, from Spain to Poland. When Latin- ate physicians or surgeons (such as the anonymous surgeon who owned the Laon manuscript used in the edition here) wanted a handbook on women’s medicine, they used the Trotula. When medieval translators looked for gyne- cological material to render into the vernacular, it was to the Trotula texts that they most frequently turned. Of ten gynecological texts composed in Middle English between the fourteenth and ﬁfteenth centuries, for example, ﬁve are renditions of the Trotula. The Latin texts probably only rarely made their way into women’s hands in the early years after their composition, perhaps not at all after the thirteenth century. The Laon manuscript just mentioned, for example, passed from that anonymous male surgeon into the holdings of the cathedral of Laon, where it was annotated and used by the canons of the cathedral for the rest of the Middle Ages.
Deﬁnition Sclerosis (hardening due to excessive production of con- nective tissue) of collagen affecting the skin (sclero- Aetiology/pathophysiology derma) and the internal organs (systemic sclerosis) generic atorlip-5 5 mg with mastercard calories and cholesterol in shrimp. The condition causes a thrombotic ten- Incidence dency due to loss of phospholipid dependent coagula- Rare generic 5 mg atorlip-5 with visa is there cholesterol in shrimp, 3 per million. Pro-thrombotic stimuli such as preg- nancy, surgery, cigarette smoking, hypertension and Age the use of oral contraceptives further exacerbate this Anyage, mean onset at 40 years. Antibodies include the lupus anti-coagulant (anti-coagulant in vitro but procoagulant in vivo), anti β2glycoprotein-I antibodies and anticardiolipin Sex antibodies. A scleroderma like disor- eration and thickening of the intima and ﬁbrosis of the der is seen following exposure to silica, vinyl chlo- adventitia is seen. Morphoea are patches of sclerotic skin on the trunk r Raynaud’s phenomenon is treated by avoiding cold, andlimbs,whichmaybelocalisedormoregeneralised. Malabsorp- r Limited cutaneous systemic sclerosis begins with tion may require changes in diet. Notreatmenthasbeenshowntoalter r Overlap syndromes have combinations of the features the long-term progression of scleroderma. Diffuse dis- of systemic sclerosis, systemic lupus erythematosus, ease with severe visceral involvement carries the worst dermatomyositis or rheumatoid arthritis. Chapter 8: Connective tissue disorders 369 Nervous system: Cardiovascular system: Ischaemic changes in central and Pericarditis, myocardial fibrosis peripheral nervous system. Peripheral causing a restrictive cardiomyopathy, neuropathy may occur due to conduction tissue fibrosis causes perineural vascular sclerosis. Respiratory system: Pulmonary fibrosis especially in lower Gastrointestinal system: lobes and pulmonary hypertension. Motility disorders including gastro- oesophageal reflux with oesophagitis, ulceration and aspiration pneumonia, malabsorption secondary to bacterial Genitourinary system: overgrowth. Sjogren’s¨ syndrome Pathophysiology There is lymphocytic inﬁltration of salivary glands and Deﬁnition other exocrine glands in the respiratory and gastroin- Achronic inﬂammatory disorder of the lacrimal and testinal tract, the skin and the vagina. Sex 9F : 1M Clinical features Aetiology r Ocular manifestations: Sensation of persistent grit- Sjogren’s¨ syndrome may be primary, or secondary to tiness, photosensitivity, tiredness and an inability to rheumatoid arthritis, systemic lupus erythematosus, produce tears (keratoconjunctivitis sicca). There is r Gastrointestinal system: Lack of saliva (xerostomia) an association with non-Hogkin B cell lymphoma. There 370 Chapter 8: Musculoskeletal system may be oral ulcers, dental caries and ﬁrm non-tender age of 40 years. The skin shows collagenous thicken- phenomenon and an association with other organ ing of the dermis with chronic inﬂammatory cell inﬁl- speciﬁc autoimmune disorders in primary Sjogren’s¨ trates. Occasionally there are systemic features including vasculitis and renal tubu- Clinical features lar defects. Gradual onset of non-speciﬁc systemic features followed by symmetrical, progressive, proximal muscle weakness. Occasionally there is cardiac r Schirmer’s test for keratoconjunctivitis sicca measures involvement leading to heart failure, respiratory involve- tear production. An edge of a strip of ﬁlter paper is ment, including nonspeciﬁc interstitial pneumonia, and placed in the lower eyelid and the length that becomes oesophageal involvement, which may be sufﬁciently se- wetismeasured. Management Sex Acute phases are treated with corticosteroids, which 2F: 1M should be reduced gradually to a low-maintenance dose. Methotrexate, azathioprine or cyclophosphamide are Aetiology/pathophysiology used in resistant cases. Dermatomyositis is associated with malignancy of variable severity, and spontaneous remissions can (e. Chapter 8: Crystal arthropathies 371 Marfan’s syndrome Management r β-blockers have been shown to slow aortic dilata- Deﬁnition tion, and lifelong therapy is recommended by the Inherited condition resulting in abnormalities of con- European Society of Cardiology. The under- r Musculokeletal: Patients have elongated and asym- lyingpathologyisanabnormalityinskin,jointandblood metrical faces with a high arched palate. Some of the reduced upper to lower body segment ratio and an subtypes have been mapped to mutations in the collagen arm span that exceeds the patient’s height. Clinical features r Cardiovascular system: There is degeneration of the There is hyperextensible skin with normal elastic recoil, media of blood vessel walls: hypermobile joints, and fragility of blood vessels causing 1 Dilation of the aortic valve ring producing regurgi- bruising and occasionally aortic dissection and rupture. Hypermobility can lead to early osteoarthritic changes 2 Mitral valve prolapse and associated mitral valve and damage to the joints. The diagnosis is clinical and can be based on clinical cri- r Calcium pyrophosphate causes pseudogout. Once diagnosed patients require periodic r Crystallised injected corticosteroids may result in ia- aortic imaging to detect early dilation.
But some mary disorder that generic atorlip-5 5mg online cholesterol medication names canada, without treatment proven atorlip-5 5mg cholesterol from shrimp is it good, can be progressive and clues can be readily apparent to a caring colleague, especially even fatal. It is if they are familiar with the doctor’s baseline behaviour and characterized by a pattern of maladaptive use of substance(s) personality (see textbox). The desire to return to training or physicians work can in itself motivate a physician to seek the necessary • mood swings and/or irritability, treatment. Finally, the consequences of not complying with • loss of effciency and reliability, the intervention conditions—such as the termination of • a decline in standards of dress and grooming, training or a report to regulatory authorities—must be clearly • increased somatic complaints, illness and fatigue, understood. Successfully treated • alcohol on the breath at work, physicians not only remain abstinent, but learn about living in • nodding off at work, a more balanced way. Recovery from substance use disorders • being caught drinking or self-administering drugs means improved physical, psychological, social, familial, oc- at work, cupational and even spiritual health. It falls to each physician to protect the well-being of their col- leagues, to be watchful for signs of drug and alcohol problems, Intervention and to be prepared to respond. Waiting until a physician with a substance use problem asks for help, if that time ever comes, can have tragic results. We must pay attention to signs of distress in our colleagues, respecting Case resolution our own visceral empathy and formulating an intervention plan The resident’s colleague alerts the chief resident and as soon as possible. At the least, one or two friendly colleagues program director of her concerns discreetly. They can mediately meet with the resident and request that they make time to talk, offer helpful suggestions and resources, and proceed to the emergency room for an assessment. They can do this without needing to know resident complies, and it becomes clear that the resident with certainty just what the problem might be. The physician health program is notifed, and arrangements are made for an urgent assessment. The If this intervention is rejected or proves to be unhelpful, the resident is placed on medical leave. Two or of treatment, the resident is able to return to work, more individuals, respected by the physician and in a position participate in treatment services and health monitoring, of authority, must intervene in a timely, planned and rehearsed and enjoy a full recovery. They should offer their observations of concern, pref- offers to conduct a course for earlier stage intervention as erably in documented form, and frmly request an expert this resident’s condition should have been identifed and clinical assessment—or immediate treatment, if the physician diagnosed by their colleagues sooner. Physician substance abuse and addiction: Time away from clinical duties or other work will often Recognition, intervention and recovery. Ontario Medical Review; be required, both to enable the physician to recover and to October 2002; 43-7. Yet, they provide good physician-patient • describe the inherent challenges of caring for physician relationships and relationship-centred care for their patients. The treating physician and the physician patient can both con- tribute challenges to good care. Perhaps the physician patient in other Case circumstances was their teacher, or has an impressive reputa- A second-year resident is stunned to receive a complaint tion for a particular area of expertise. Physician-providers are about the care offered to a physician patient in the emer- encouraged to draw upon Richard Frankel’s model of com- gency department the week before. The patient had pre- munication in health care and consider the following when sented with chest pain in the context of a recent history of providing care to a colleague (Maier 2008): angina and a strong family history of cardiac disease. Breathe and remember physician patient reported that the resident was abrubt, that an important part of developing rapport is setting the judgemental and dismissive during their encounter. Elicit the patient’s concerns and listen without interrupt- diagnosis brief and the discharge planning suboptimal. As with other patients, the most important The resident remembered the encounter and indicated concern may only be brought up after the third concern that, since the patient was a physician, the resident did is presented. Don’t assume that physician patients need less explana- recommendations as with other patients. Remember that a physician’s knowledge of therapeutics in an area of practice not his or her own Introduction quickly become dated after medical school. Intellectualizing for your own self-comfort or being drawn helping doctors,” or “extending professional courtesy,” caring into talking shop is not in the best service of your pa- for colleagues is an important tradition in medicine.
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