By A. Domenik. Quincy University.
This chapter covers three types of viruses that could potentially be employed as bio-terrorism agents: smallpox best 100 mcg fluticasone, alphaviruses (e cheap fluticasone 100mcg visa. Prophylaxis: Immediate vaccination or revaccination should be undertaken for all personnel exposed fluticasone 250 mcg visa. Isolation and Decontamination: Droplet and Airborne Precautions for a minimum of 17 days following exposure for all contacts generic 100mcg fluticasone amex. Patients should be considered infectious until all scabs separate and quarantined during this period. If quarantine is not possible, require contacts to check their temperatures daily. Any fever above 38° C (101° F) during the 17-day period following exposure to a confirmed case would suggest the development of smallpox. The contact should then be isolated immediately until smallpox is either confirmed or ruled out and remain in isolation until all scabs separate. Acute systemic febrile illness with encephalitis develops in a small percentage (4% children; < 1% adults). Generalized malaise, spiking fevers, shaking chills, severe headache, pain in the eyes with exposure to light, and muscle pain for 24-72 hours may be seen. Patients who develop encephalitis may require anticonvulsants and intensive supportive care to maintain fluid and electrolyte balance, ensure adequate ventilation, and avoid complicating secondary bacterial infections. Malaise, muscle pain, headache, vomiting, and diarrhea may occur in any of the hemorrhagic fevers. Significant numbers of personnel with a hemorrhagic fever syndrome should suggest the diagnosis of a viral hemorrhagic fever. Antiviral therapy with ribavirin may be useful in several of these infections (available only as Investigational New Drug under protocol). This chapter will cover four toxins considered to be among the most likely to be used against U. This is followed by symmetrical descending flaccid (weak, soft) paralysis, with generalized weakness and progression to respiratory failure. Symptoms begin as early as 12-36 hours after inhalation, but may take several days after exposure to low doses of toxin. A bioterrorism attack should be suspected if multiple casualties simultaneously present with progressive descending flaccid paralysis. Toxin is not dermally (skin) active and secondary aerosols are not a hazard from patients. Airway necrosis and pulmonary capillary leak resulting in pulmonary edema would likely occur within 18-24 hours, followed by severe respiratory distress and death from hypoxemia (low blood oxygen) in 36-72 hours. Diagnosis: Acute lung injury in large numbers of geographically clustered patients suggests exposure to aerosolized ricin. The rapid time course to severe symptoms and death would be unusual for infectious agents. Treatment: Management is supportive and should include treatment for pulmonary edema. Gastric lavage and cathartics (emetics) are indicated for ingestion, but charcoal is of little value for large molecules such as ricin. Prophylaxis: There is currently no vaccine or prophylactic antitoxin available for human use. Ricin is non-volatile, and secondary aerosols are not expected to be a danger to health care providers. Patients may also present with nausea, vomiting, and diarrhea if they swallow the toxin. Artificial ventilation might be needed for very severe cases, and attention to fluid management is important. Effects on the airway include nose and throat pain, nasal discharge, itching and sneezing, cough, shortness of breath, wheezing, chest pain and bloody sputum. Severe intoxication results in prostration, weakness, ataxia, collapse, shock, and death. Diagnosis: Should be suspected if an aerosol attack occurs in the form of "yellow rain" with droplets of variously pigmented oily fluids contaminating clothes and the environment. Soap and water washing, even 4-6 hours after exposure can significantly reduce dermal toxicity; washing within 1 hour may prevent toxicity entirely. Prophylaxis: The only defense is to prevent exposure by wearing a protective mask and clothing (or topical skin protectant) during an attack. Isolation and Decontamination: Outer clothing should be removed and exposed skin decontaminated with soap and water. Secondary aerosols are not a hazard; however, contact with contaminated skin and clothing can produce secondary dermal exposures. Environmental decontamination requires the use of a hypochlorite solution under alkaline conditions such as 1% sodium hypochlorite and 0. However, the general principles outlined within this chapter hold true regardless of the agent used. Refer to the guidelines in the bioagent section above for a generic approach to assessment. Additionally, decontamination procedures for chemical agents are analogous to the procedures followed for a suspected biological agent. Exposure may cause skin burns and necrosis, eye burns with ulceration and possible perforation, airway disease with shortness of breath, wheezing, and chest pain and suppression of the immune system. Severe intoxication results in prostration, weakness, seizures, collapse, shock, and death. Diagnosis: Should be suspected if an aerosol attack occurs in the form of a vapor with symptoms as outlined above or contact with an oily yellow to brownish liquid is encountered. Treatment: Skin: Soothing creams to burns, analgesics, antibiotics to treat/prevent infection. Eyes: Soothing eye drops, topical mydriatics, topical antibiotics, and sunglasses. Prophylaxis: The only defense is to prevent exposure by wearing a protective mask and clothing (or topical skin protectant) during an attack. Isolation and Decontamination: Outer clothing should be removed and exposed skin decontaminated with soap and water. Environmental decontamination requires the use of a hypochlorite solution under alkaline conditions such as 5% sodium hypochlorite or 0. The primary effect is to disrupt the normal function of nerve endings creating a number of symptoms that can lead to death. These agents operate on the same mechanisms as many commercially available insecticides and are often referred to as pesticides for humans. Severe intoxication results in prostration, weakness, seizures, collapse, shock, and death. Diagnosis: Should be suspected if an aerosol attack occurs in the form of a vapor with symptoms as outlined above. Continue using atropine at 2 mg every 5-10 minutes until secretions are drying up and respiratory symptoms have improved. Prophylaxis: The only defense is to prevent exposure by wearing a protective mask and clothing (or topical skin protectant) during an attack. Isolation and Decontamination: Outer clothing should be removed and exposed skin decontaminated with soap and water. Environmental decontamination requires the use of a hypochlorite solution under alkaline conditions such as 5% sodium hypochlorite or 0. The primary effect is to disrupt the normal function of the cells ability to utilize oxygen that can lead to death. Signs and symptoms: Exposure causes a brief increase in respirations followed by respiratory distress. Severe intoxication results in prostration, weakness, seizures, collapse, shock, and death. Diagnosis: Should be suspected if an aerosol attack occurs in the form of a vapor with symptoms as outlined above. Isolation and Decontamination: Outer clothing should be removed and exposed skin decontaminated with soap and water. Environmental decontamination requires the use of a hypochlorite solution under alkaline conditions such as 5% sodium hypochlorite or 0. However, until reliable detectors are available in sufficient numbers, usually the first indicator of a biological or chemical attack in unprotected people will be those who become ill. Decontamination involves either disinfection, sterilization or removal to reduce microorganisms or chemical agents to an acceptable level on contaminated articles, thus rendering them suitable for use. Disinfection is the selective reduction of undesirable microbes to a level below that required for transmission. Decontamination methods have always played an important role in the control of infectious diseases. However, we are often unable to use the most efficient means of rendering microbes or chemicals harmless (e. Though some sophisticated methods of decontamination may not be available underway, some fairly simple tools are available. Biological and chemical terrorism agents can be decontaminated by mechanical, chemical and physical methods: Mechanical decontamination involves measures to remove but not necessarily neutralize an agent. An example is the filtering of drinking water to remove certain water-borne biologic agents (e. Dracunculus medinensis), or in a bioterrorism context, the use of an air filter to remove aerosolized anthrax spores, or water to wash an agent from the skin. Chemical decontamination renders biological and chemical terrorism agents harmless by the use of disinfectants or decontaminants that are usually in the form of a liquid, gas or aerosol. Some of these products are harmful to humans, animals, the environment, and materials. Dermal (skin) exposure to a suspected biological or chemical terrorism aerosol should be immediately treated by soap and water decontamination. Careful washing with soap and water removes nearly all of the agent from the skin surface. Hypochlorite solution or other disinfectants are reserved for gross biological contamination (i. In the absence of chemical or gross biological contamination, these will confer no additional benefit, may be caustic, and may predispose to colonization and resistant superinfection by reducing the normal skin flora. Chemically or grossly biologically contaminated skin surfaces should be washed with a 0. The 5% solution can be made by adding eight 6-ounce ampules of calcium hypochlorite to five gallons of water. These solutions evaporate quickly at high temperatures so if they are made in advance they should be stored in closed containers. Also the chlorine solutions should be placed in distinctly marked containers because it is very difficult to tell the difference between the 5% chlorine solution and the 0. However, this solution may be instilled into non-cavity wounds and then removed by suction to an appropriate disposal container. Within about 5 minutes, this contaminated solution will be neutralized and nonhazardous. Subsequent irrigation with saline or other surgical solutions should be performed.
Overall purchase fluticasone 100 mcg without prescription, this example suggested that tern of deviation over short time intervals within a country deviation patterns in groups of similar countries may be or across countries in the same mortality stratum 250mcg fluticasone fast delivery, it is pos- similar purchase fluticasone 100mcg online, allowing predictions of cause of death patterns in sible to use the observed cause of death pattern in a refer- countries where registration data are not available but for ence population to estimate the cause of death pattern for which neighboring countries do have data generic fluticasone 100 mcg visa. Some examples of applications simple spreadsheet program called CodMod (Salomon and would be Murray 2001a). Note that as described earlier, the CodMod was also used to develop regional patterns of results reported here are tabulated by underlying disease deviation from predicted cause compositions, which were cause or external cause of injury. Total attributable deaths then used to estimate mortality by broad causes for countries for some diseases that increase the risk of other diseases or for which no registration data were available. Chapter 4 estimates deaths attrib- the case of the Sub-Saharan Africa region, where good utable to 26 global risk factors. For other countries in that region, regional models were based on weighted death rates using Egyptian Worldwide, one death in every three is from a Group I cause. For the Paciﬁc islands, a regional pattern was 2 percent of Group I deaths in 1990, it accounted for 44 per- based on data available from islands reporting death regis- cent of Group I deaths in 2001. Virtually all the Group I cause of death model for 12 causes of death to estimate deaths are in low- and middle-income countries. Of these child deaths, 99 percent occurred Group I 36% in low- and middle-income countries. Those age 70 and over accounted for 70 percent of deaths in high-income countries, compared with 30 percent in other countries. In these countries, 30 percent of 54% 87% all deaths occur at ages 15 to 59, compared with 15 percent Source: Authors’ calculations. The causes of death at these ages, as well as in childhood, are thus important in assessing Figure 3. Murray Children (ages 0–14) ulations with high mortality and low incomes than in the High-income countries high-income countries. Europe and Central Asia Latin America and the Caribbean Leading Causes of Death Middle East and North Africa Table 3. Europe and Central Asia Whereas lung cancer, predominantly due to tobacco Latin America and the Caribbean smoking, remains the third leading cause of death in high- Middle East and North Africa income countries, reﬂecting high levels of smoking in previ- East Asia and Pacific ous years, the increasing prevalence of smoking in low- and middle-income countries has not yet driven lung cancer into South Asia the top 10 causes of death for these countries. High-income countries Lower respiratory infections, conditions arising during Europe and Central Asia the perinatal period, and diarrheal diseases remain among Latin America and the Caribbean the top 10 causes of death in low- and middle-income coun- Middle East and North Africa tries. In 2001, these three causes of death together account- East Asia and Pacific ed for nearly 60 percent of child deaths globally. Leading causes Sub-Saharan Africa of death are generally similar for males and females, 0 1,000 2,000 3,000 4,000 although road trafﬁc accidents appear in the top 10 only for Death rate per 100,000 people males and diabetes appears only for females. Although notable success has been Age Group, 2001 achieved in certain areas, for example, polio, communicable diseases still account for 7 out of the top 10 causes and are responsible for about 60 percent of all child deaths. These results show that premature countries, conditions arising during the perinatal period, mortality from noncommunicable diseases is higher in pop- including birth asphyxia, birth trauma, and low birthweight, The Burden of Disease and Mortality by Condition: Data, Methods, and Results for 2001 | 69 Table 3. Murray have replaced infectious diseases as the leading cause of the single most important contributor to the burden of dis- death and are now responsible for 21 to 34 percent of ease among adults in this age group. Deaths from measles have declined The risk of death rises rapidly with age among adults age modestly, although more than half a million children under 60 and over in all regions. Regional than a million child deaths per year or nearly 11 percent of variations in the risk of death are smaller at older ages than all deaths of children under ﬁve. Historical data from countries such as Australia and ages 15 to 59 worldwide in 2001. The Burden of Disease and Mortality by Condition: Data, Methods, and Results for 2001 | 71 Table 3. In low- and middle-income regions except Sub-Saharan Eastern Europe from 1990 onward, Hungary and Poland Africa, where they are eighth and seventh, respectively. The tables in annex 3B show total deaths by age, sex, and South Asia (mainly India) and Latin America and the cause for each of the regions and the world. Lower respiratory infections, primarily pneumonia, and high-income countries (table 3. South Asia is the only other region This section provides an overview of the methods, software where suicide is in the top 10 causes of death. In particular, given differences in cause, it is important to ensure that the disability weight the way the data for incidence, prevalence, and mortality are and the population incidence and prevalence data relate to collected, it is almost inevitable that observations are inter- the same case deﬁnitions. Second, model incidence and duration from estimates of prevalence, because the various epidemiological variables are causally remission, case fatality rates, and background mortality. For most disease and injury groups, rele- of different epidemiological estimates and ensure that the vant experts were consulted during the development and estimates used were internally consistent. For certain condi- developed with a number of additional features (Barendregt tions for which weights were not available from the original and others 2003). As well as calculating solutions when the three calculations quantify societal preferences for different health states. These weights do not represent the lived experience of any disability or health state or imply any societal value of the person in a disability or health state. Thus, for example, Population m Deaths from without disease All other other causes disability weights of 0. It rate i rate r m also means that, on average, a person who lives three years Cases of Cause-specific with paraplegia followed by death is considered to experi- deaths disease Case fatality ence more equivalent healthy years than a person who rate f has one year of good health followed by death (3 years Source: Barendregt and others 2003. In other words, for most and sex were then added for all countries in each region to conditions the combination of incidence, case fatality, and provide regional estimates for 2001. The effect of discounting compli- speciﬁcratesformortality,incidence,andprevalencefor2000 cates this, however, with low incidence and long duration and 2002 and applying them to population data for 2001. These included the relative risk of mortality for those with diabetes com- pared with those without diabetes (Roglic and others 2005), • Disease registers. Disease registers record new cases of dis- and the assumption that remission rates are zero. For some causes, the only counts available were of calculations than self-reported interview surveys. In particular, longitudinal stud- there is huge variability in the information content across ies of the natural history of a disease have provided a studies or data sets, and that small epidemiological studies wealth of information about incidence, average duration, are counted equally in table 3. That said, it is striking that of the more than 8,000 data • Health facility data. Furthermore, one-quarter of the system is virtually total, facilities-based data will be data sets relate to populations in Sub-Saharan Africa and based on biased samples that do not reﬂect the preva- around one-ﬁfth to populations in high-income countries. Likewise, hospital deaths are unlikely to be use- tions and to Sub-Saharan Africa is not entirely surprising, ful because of the same problems of selection bias. Noncommunicable diseases Malignant neoplasms Incidence 11 8 11 10 2 14 25 81 Survival 3 4 1 0 1 0 15 24 (Continues on the following page. Injuries 3 1 1 0 0 6 7 18 Totall 1,155 914 1,239 590 522 1,955 1,735 8,096 Source: Authors’ compilation. Note: The data sources include population-based epidemiological studies, disease registers, and surveillance and notiﬁcation systems, but exclude death registration data (see tables 3. Where possible, regional and global totals refer to numbers of separate studies, or country-years of reported data from surveillance or notiﬁcation systems. Global totals may include global review studies not counted in regional subtotals. Totals refer to numbers of countries for which data were available, not to total data sets or country-years. Country-years of surveillance reports (approximate, minimum estimate for Latin America and the Caribbean). Actual numbers of studies used exceed the minimums shown here, based on summed table entries for speciﬁc causes regardless of whether counts were of data sets or of countries. Because different countries may be in has drawn on more than 10,000 data sets or studies, making different phases of the epidemic, the relationship between it almost certainly the largest synthesis and analysis of global prevalence and mortality may vary across countries. To estimate the incidence of diarrheal diseases in children under ﬁve in developing and developed Communicable Diseases and Maternal, Perinatal, countries, 357 community-based studies and population and Nutritional Conditions surveys were used (Bern 2004; Murray and Lopez 1996d). This section gives an overview of data sources and methods Point prevalences were estimated assuming an average dura- for speciﬁc Group I causes and references to more detailed tion of six days per episode. The The methods used to estimate incidence for childhood-cluster methods and data used to estimate incidence and mortality diseases were summarized earlier. Country-speciﬁc estimates of duration were weighted for the proportion of Hepatitis B and C. Malaria prevalence was based on regional preva- of syphilis, chlamydia, and gonorrhea. The methodology is lence rates for acute symptomatic episodes estimated by described in detail elsewhere (Gerbase and others 1998; Murray and Lopez (1996d). Regional incidence and prevalence rates for lep- mate country-speciﬁc prevalence rates. The baseline regional and subregional preva- ered to be endemic in these countries. Prevalence studies in the Middle East and North Africa and Sub-Saharan estimates were based on regional prevalence rates for cases Africa. As the prevalence of blinding trachoma declines with of hydrocele or lymphodaema caused by infection with socioeconomic development even in the absence of a specif- ﬁlariae. For this rea- son, both nationally reported data and speciﬁc criteria for a Onchocerciasis. Following the continued were then applied to countries that have reported cases of success of the Onchocerciasis Control Program in western blinding trachoma (Shibuya and Mathers 2003). African countries and the introduction of population-wide administration of ivermectin in other endemic areas, the Intestinal Nematode Infections. Therefore, the prevalence of community-based, cross-sectional surveys for subnational blindness from onchocerciasis was reestimated by taking administrative regions (Brooker and others 2000; de Silva into account the declining trends in prevalence and the cov- and others 2003). In areas without comprehensive data, pre- erage and duration of onchocerciasis control programs dictions of the distribution of soil-transmitted helminths (Alley and others 2001). However, prevalence studies of Chan and others (Bundy and others 2004; Chan 1997). Prevalence and incidence the estimated prevalence may not be generalizable to the estimates for lower respiratory infections were based on an country as a whole. For this reason, the current prevalence analysis of published data on the incidence of clinical pneu- of blindness due to onchocerciasis was estimated by monia from 95 community-based studies published since nationally reported data, if available, and extrapolation 1961 (Rudan and others 2004). Most of the studies were lon- from 1993 estimates using trend analysis of onchocerciasis gitudinal and conducted over long enough periods to control programs in each endemic country (Shibuya and account for seasonal variation. The database compiles information for all popula- tion of deliveries occurring in hospitals (Dolea and tion groups, especially preschool-age children and women AbouZahr 2003a, 2003b; Dolea, AbouZahr, and Stein 2003; of childbearing age, and includes information on the preva- Dolea and Stein 2003). The incidence of unsafe induced lence of xerophthalmia, including night blindness and abortion was estimated at the country level using 156 pub- serum retinol distributions. Incidence rates for low birthweight, prevalence rates for mild, moderate, and severe anemia. The program is currently preparing registration systems in high-income countries and from a comprehensive database of country-speciﬁc prevalence mothers participating in nationally representative household estimates of both clinical and subclinical iron deﬁciency surveys (such as the U. For countries for which no studies were available,the regional Protein-Energy Malnutrition. Regional survival models were epidemiological characteristics were used (Stein 2002c). Country- country (Mathers, Shibuya, and others 2002; Shibuya and speciﬁcestimatesforgoiterrateswereobtainedandusedtocal- others 2002).
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From 2004 to 2013 a conversion ratio of opium to morphine/heroin of 7:1 was used, based on interviews conducted with Afghan morphine/heroin “cooks”; based on an actual heroin production exercise conducted by two (illiterate) Afghan heroin “cooks”, documented by the German Bundeskriminalamt in Afghanistan in 2003 (published in Bulletin on Narcotics, vol. The ratio was modified to 18:5 kg of opium for 1 kilogram of 100 per cent pure white heroin hydrochloride, equivalent to a ratio of 9. The estimates of the export quality of Afghan heroin are based on the average heroin wholesale purities reported by Turkey. For countries other than Afghanistan, a “traditional” conversion ratio of opium to heroin of 10:1 is used. Figures in italics are preliminary and may be revised when updated information becomes available. Purification of coca paste yields cocaine (base (fifth edition) of the American Psychiatric Association, or and hydrochloride) the International Classification of Diseases (tenth revision) of the World Health Organization “crack” cocaine — cocaine base obtained from cocaine hydrochloride through conversion processes to make it people who suffer from drug use disorders/people with drug suitable for smoking use disorders — a subset of people who use drugs. People with drug use disorders need treatment, health and social cocaine salt — cocaine hydrochloride care and rehabilitation. Dependence is a drug use new psychoactive substances — substances of abuse, either disorder in a pure form or a preparation, that are not controlled prevention of drug use and treatment of drug use disorders under the Single Convention on Narcotic Drugs of 1961 — the aim of “prevention of drug use” is to prevent or or the 1971 Convention, but that may pose a public health delay the initiation of drug use, as well as the transition threat. There is a lot of information available, and new methods for treating cancer are always being tested, so it may be Many Choices hard to know where to start. You have many choices to make before, This brochure may help you understand what during, and after your cancer treatment. The most important message of this brochure is to talk to your doctor before you try anything new. Consumers may use the One example is using acupuncture to help with side terms “natural,” “holistic,” “home remedy,” or “Eastern effects of cancer treatment. 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Thechnologies for data capture and manage- shown in parentheses below and Annex A) clustered un- ment and development of high quality databases will der fve challenges. Translational research infrastruc- the beneft of patients, citizens and society as a whole (see tures and data harmonisation of structured, semi-struc- the paragraph Looking Forward below). This starts with the integration of all ‘omics’ data to Innovation’ approach (27). A Europe-wide process to evaluate and validate biomarkers, together with longitudinal and Challenge 5 – Shaping Sustainable in-depth studies to further characterise diseases and their Healthcare progression would support on-going eforts towards this integration and re-classifcation (18,19). Patients and the citizen will play an increasingly important role in adopting and controlling the use of data from electronic health records and in developing Challenge 4 – Bringing Innovation prospective surveillance and monitoring systems for per- to the Market sonal health data (30,32). Alto- funding agencies, public health agencies, policy makers, gether 27 organisations from 14 countries across Europe industry, regulatory authorities, health insurers and, cruci- and beyond have contributed directly to this document, ally, the citizen. Specifying the chal- of molecularly defned tumour subgroups to specifc inhi- lenges and obstacles that will be faced by researchers, bitors. In comparison to chemotherapy a substantially im- industry, policy makers and healthcare providers will faci- proved outcome is described in an increasing number of litate the development of strategies and the identifcation cancer entities with this approach. An additional beneft is that an difer widely, depending on factors such as scientifc evi- innovation-driven healthcare system is one of the biggest dence, the particular professional context, personal experi- driving forces not only for a competitive healthcare indus- ence or values, and difering applied quality standards. In addition, key Europe- nal high-level stakeholders participants were introduced an organisations and institutions have published reports, to the topic and made familiar with the results of the ana- guidelines and roadmaps. From this analysis an inventory of the sessions were presented and discussed with the of recommendations was prepared and grouped into key entire audience to ensure that cross-sectoral issues were areas. These stakeholders were invited to the PerMed work- shops and/or participated in semi-structured interviews. Interviews were conducted either fa- PerMed webpage) ce-to-face or over the phone. In total 35 experts from the following four areas were interviewed: (1) basic research Dialogue platform exclusively for funding organisa- and new technologies, (2) translational research, (3) regu- tions – ‘Round Table PerMed’: As part of the dialogue lation and reimbursement, and (4) healthcare systems in platform the PerMed ‘Round Table PerMed’ was set up. All fnal interview summaries were approved by Round Table is a forum for ministries and funding organi- the respective experts. Key issues include: the establishment of a strong ‘Personalised Medicine refers to a medical model culture of collaboration between all relevant research using characterisation of individuals’ phenotypes and areas in a true public–private partnership, the adaptation genotypes (e. On the other hand, diseases that display rather dife- using omics and related technologies (e. These developments are occur- wider populations and individuals, it will become possible ring alongside a growing involvement of patient and ci- to better predict the best course of treatment or preventi- tizen interests, the increased role of patient advocacy and on for each citizen, thereby introducing a radically diferent support groups, the ubiquitous availability of information approach to healthcare on a broad scale. The approach has through the internet and the consequent rise in health li- the potential to ofer medium- and long-term gains – to teracy of patients and citizens. These trends are likely to patients and to society – and should signifcantly outweigh change the way that healthcare clients and providers in- the required initial investment. This can being defned as the entire range of research along the only be achieved when standard protocols with regard to healthcare value chain. This includes not only basic and diagnostic tests and treatment are used in treatment cent- translational research, but also research relating to regu- res; these centres can then serve as partners jointly execu- latory aspects, new fexible health technology assessment ting a particular trial. Furthermore, there are manifold interrelations between the fve challenges; these have not been indicated in order to keep the clearness of the fgure. This is not meant to imply that the particular recommendation may not be equal- Recommendations on biomedical, health-related ly relevant to other challenge areas. All recommendations ces research have been colour-coded according to the activities re- ferred to, which are grouped into three broad areas. In these cases, the recommendation has 11 4) Challenges for the further implementation of Personalised Medicine Challenge 1 – Developing Aware- tive Pathways to Patients) represents a frst and welcome ness and Empowerment step in this direction. Instead of lenges in the areas of patient information, data protection merely treating a disease, a shift to a more holistic appro- and data ownership. In order to do this, it will be patients feel more ‘left alone’, becoming responsible them- fundamental to establish shared practices and a com- selves for managing complex treatment regimens, which munication network. Furthermore, a move towards more preventive approaches to healthcare Empowerment – Providers in the health sector, citizens, is expected and needed. Networks of stake- challenges, and are capable and willing to support its im- holders, researchers, clinicians and patients/citizens who plementation. In addition, the stu- dy of genomics can provide information about an individu- 1. Provide further evidence for the beneft deli- al’s reaction to a particular pharmaceutical product. Once clinical and personal utility cons of this option will support decision-makers in this as well as economic sustainability are proven in a precisely sensitive feld. These developments should be supported defned indication, a strategy for the communication and in the light of a holistic approach carefully avoiding the dissemination of the possibilities, challenges and potenti- risk that the citizen might only be seen as a ‘sum of data’. One example could be feasibility studies on health data cooperatives with an assessment of ethical, legal and soci- 2. Develop and promote models for individual al implications comparing diferent European healthcare responsibility, ownership and sharing of per- system settings. An appropriate data ownership framework for ment pathways and track the safety and efec- patients will therefore be needed, especially given that tiveness of these interventions. For this reason, issues relating interfaces is needed to enable the use of smartphones, to data ownership, storage, handling, editing, sharing, tablets, other mobile services, ‘smart home’ and tele-he- controlling and access regulations have to be addressed. The implementation of this recommen- ethical basis for integrating data generated about and by dation 2 and 3 will strengthen the fnality for the patients’ users into health information collected by medical profes- beneft. Additionally, a framework for the management and communication of predictive information derived 4. For this rea- data silos of national healthcare systems and so improve son fexible and adaptable guidelines will be needed to interoperability. Personal and economic benefts evolve and incorporate lessons from experiences of the 13 various stakeholders; so for example the efect in terms tient advocacy organisations; 3) supporting lifelong lear- of justice and fairness in healthcare is difcult to predict ning and skills to promote good health. Improve communication and education stra- althcare system and increase the patient’s role tegies to increase patient health literacy.