By M. Mine-Boss. Saint Louis Christian College.
Provincial/territorial medical associations offer physician with disabilities to promote and enhance the interests of the health programs for their members purchase erectafil 20 mg without prescription. Association s Centre for Physician Health & Well-being is an excellent resource for all physicians buy generic erectafil 20 mg line. Case resolution Disabilities infuence to varying degrees a resident or practising The program director asks the resident to meet to dis- physician s ability to continue in their feld discount 20mg erectafil otc. A mild disability cuss the resident s needs should the resident be allowed may have minimal or no adverse functional effect on a phy- to resume training quality 20 mg erectafil. A severe disability, such as a major brain injury, may the area of work modifcation. At the meeting the resi- make it impossible for that trainee or physician to return to dent requests to be permitted to use a separate clean their training or practice. The resident demonstrated the ability to stand However, the trainee or physician may encounter situations and balance quite well with the bilateral long leg braces in which co-workers are less than sympathetic toward their that had already been prescribed during rehabilitation. These modifcations were found to be acceptable, and the resident was able to rejoin training on a trial basis under The Canadian Human Rights Act stipulates that employers supervision. Under the Act, employers are expected to exhaust all Key references reasonable avenues of accommodation, including workplace Graves L. Physicians who wish to return to training or practice after acquiring a disability and can do so competently and safely, working with or without the use of functional aids and es- sentially on par with their fellow physicians, should be able to do so. They should be given every possible assistance on the part of program directors, colleagues and administrators to facilitate their return to training or practice. Their high levels of debt may be correlated with a received during residency, or the effects of poor spending lack of budgeting by residents. Given the already overloaded schedule of a resident residents do require more teaching around fnancial planning. Many residents good fnancial planning can help to alleviate money worries are either too exhausted to consider managing their fnances and secure a better future after residency training. The rel- or procrastinate until the end of their training, hoping that life evance of fnancial health to physician health and well-being is will work itself out. In part, this may be a way of avoiding discussed, basic terms and concepts in fnancial management the stress of dealing with fnancial concerns. However, it may are outlined, and particular attention is given to budgeting and also be fair to say that many programs and medical schools set debt management. By giving adequate attention to personal f- their residents up for this stress by not organizing seminars on nancial management, residents can help to prepare the ground fnancial management, not properly advertising or making the for a secure future. Myths about fnances Read a self-help book on basic personal fnances In considering or not considering their fnancial well-being, and fnancial planning. American Journal fnancial planning should be considered in much the same way of Surgery. Work habits and specialty choice have been shown to be af- fected by residents fnancial situations. Those with heavy debt often moonlight to supplement their income; however, this extra workload can exacerbate physical and mental stress. This is a compilation of This chapter will your current assets and liabilities; the difference describe the key components and benefts of comprehen- between them represents your equity or net worth. This highlights your cash in outline key components of debt management, and fows (sources of income) and outfows (expenses). This analysis of your resources and discretionary spending may help you to fnd ways to improve your fnancial position. This analysis A fourth-year resident would like to lease a new car but allows you to assess whether your life and disability doesn t know if they can afford it. The resident has made insurance coverage is meeting your goals in securing a budget, but has trouble sticking to it. The resident feels a source of income replacement for your loved ones that they do not have a good grasp of where their money in the event of your death, or for you and your de- goes. The resident would like to have a better understand- pendants in the event that through accident or illness ing of the basics of fnancial planning so that they can you become unable to earn an income. Goals and objectives Comprehensive fnancial planning With the help of your fnancial planner, you will formulate An evaluation of their current and potential fnancial resources fnancial goals and objectives in relation to a measurable time can help individuals develop a plan that will help them to frame. This will mean analyzing existing restrictions on short- and mid-term goals and long-term aspirations. Comprehensive fnancial planning can be broken down into six basic steps: Recommendations 1. Implementation and follow-up Current situation The steps and activities included in your fnancial plan should You will share with the fnancial consultant certain personal be described and prioritized to help you to understand and fol- information (e. You will be asked for other relevant by the professional and personal events that unfold in your information, such as your banking institution and the contact life. To reach your long-term goals and have a secure fnancial information of your accountant and lawyer. Cash 0 To purchase a desirable home within the frst Medical library 1,500 fve years after residency. Computer 2,500 To sell the resident s old car (which is barely Used car 5,000 working) and use the money to decrease the Total 9,000 monthly payment on a new car lease. Liabilities ($) In reviewing the cash fow statement, the resident realizes Credit card debt 500 that by spending less on clothing and restaurant meals Line of credit 50,500 they would be able to reach these objectives sooner. The Total 51,000 resident obtains written fnancial recommendations and plans to start implementing them in the near future. The Net worth $(-42,000) fnancial consultant and the resident have a follow-up meeting in three months to evaluate progress and to ad- Because of the signifcant debt they accrue during their dress any questions that arise. The purpose of the Summary resident s net worth statement is to take a snapshot of their Because of the need to simultaneously manage debt, create current fnancial position that will provide a starting-point cash fow and prepare for the future, professional fnancial for subsequent planning. Ideally, an application for a line of credit or an increase to a line of credit should be Case discussed beforehand with a fnancial planner. A resident who will be completing training in six months and their spouse, who is also in the last year of residency, The interest rate on unsecured loans offered to medical stu- don t have any children yet and live in a condominium dents and residents can be as low as the prime lending rate if owned by the resident s in-laws. Interest rates on secured lated $60,000 in debt (on a personal line of credit) during liabilities such as a car loans are usually higher, ranging from training and has $20,000 in student loans. Here, interest rates can vary from 16 to 24 per cent of the balance, depending on the Introduction client s credit rating. Paying down a credit card balance by using In 2007, the average debt of Canadian medical residents at a personal line of credit can save 11 to 19 per cent of the the end of training was reported as $158,728 (Kondro 2007). Indeed, given rising tuition costs, debt during medical training has become a necessary evil for most residents. However, not Pros and cons of student loan consolidation all debt is the same, and proper debt management can lower All physicians can claim a federal tax credit (15 per cent in overall interest payments and help to speed up repayment. Interest paid are: for any other indebtedness, such as bank loans or lines of Canada and provincial student loans, credit, are not eligible for this credit. However, residents who are carrying with federal and/or provincial student loan authorities. This a signifcant debt load and are faced with a limited cash fow debt tends to be relatively favourable in terms of after-tax rates may wonder about the relative merits of paying down their and repayment options. Several fnal decision may be a matter of personal preference and of Canadian provinces have therefore pioneered programs to risk tolerance. Learning how different fnancial management defer interest on the provincial portion of medical resident practises can best ft a residents personal level of comfort and loans. The interest rates on federal and provincial student loans may be as high as two or three percentage points above the prime Negotiating with fnancial institutions lending rate. However, the interest paid on these loans has been Residents can save precious time and avoid unnecessary frustra- claimable as a federal tax credit since 1998. Most provinces tion by working with a fnancer who is familiar with physicians provide such tax credits as well. In consolidating all debts to the bank, the resi- from terms that are more advantageous than those normally dents will forfeit both federal and provincial tax credits. A fnancial consultant can provide If the student loans stay outside of the loan consolida- their physician clients with some useful advice in preparation tion, the residents will realize an after-tax interest rate of for a meeting with a fnancial institution s account manager. A credit rating is based mainly on an individual s history of debt repayment, The fnancial planner gave three alternatives to the resi- his or her current fnancial position (assets and liabilities) and dents on their debt management process. Because banks often place more emphasis on current credit rating than on future income potential, it is Focus on savings: If they both purchase $13,000 of crucial to maintain an excellent credit rating. Because credit ratings are based on a seven-year cycle, any late interest payments or failures to pay bills will have a negative Focus on reducing debt: After four years of practice impact on an individual s credit rating for some time. A fnancial consultant can provide advice on maintaining a good credit Combine strategies: By combining these strategies, rating. Trainees should be approach their fnancial institutions to consolidate their proactive with their money by negotiating with fnancial loans into a line of credit or term loan. Through appropri- ratings, they can negotiate a line of credit at interest rates ate fnancial planning all residents can secure fnancial as low as the prime lending rate. Tax Tips for the Medical However, caution should be used when considering con- Student, Resident and Fellow. The bank offers the resident and spouse the prime rate of four per cent on a line of credit to consolidate their indebtedness including their student loans, on which they have been paying prime plus three per cent. The bank s offer seems to be attractive, but after a closer look, the actual after-tax savings would be approximately 1. Logan C, Director Disability Services, Homewood Employee Health: personal conversation Canadian Medical Association. In Creating a Healthy Culture in Medicine: a Report From the 2004 Quality Worklife Quality Healthcare Collaborative. College of Family Physicians of Canada, Canadian Medical Association, Royal College of Physicians and Surgeons of Rich P. Global Business pdf and Economic Roundtable for Mental health College of Family Physicians of Canada, Canadian Medical 1-E. Promoting healthy partnerships in medical Intelligence: Key Readings on the Mayer and Salovey Model. Leadership in academic psychiatry: the vi- sion, the givens, and the nature of leaders. Balancing family and career: addressing the description of deans and students perceptions. Is that your pager or Stressful incidents, stress and coping strategies in the pre- mine: a survey of women academic family physicians in dual registration house offcer year. Inside/Outside: A Physician s Journey With Reading our way to more culturally appropriate care. Health problems and the use of health services among physicians: a review article with particular emphasis on 4-C. Physical activity and public health: Updated Faugier J, Lancaster J, Pickles D, Dobson K. Barriers to recommendation for adults from the American College of Sports healthy eating in the nursing profession: Part 2.
For many deterministic epidemiology models order erectafil 20mg online, an infection can get started in a fully susceptible population if and only if R0 > 1 erectafil 20mg sale. Thus the basic reproduc- tion number R0 is often considered as the threshold quantity that determines when an infection can invade and persist in a new host population purchase erectafil 20 mg with amex. Section 2 introduces epidemiology modeling by formulating and analyzing two classic deterministic mod- els trusted erectafil 20mg. This model demonstrates how exponential population growth aects the basic reproduction number R0. These epidemiologic models are based on the demographic models in section 4 with either continuous age or age groups. The two demographic models demonstrate the role of the population reproduction numbers in determining when the population grows asymptotically exponentially. New general expressions for the basic reproduction number R0 and the average age of infection A are obtained. The theoretical expressions in section 6 are used in section 7 to obtain estimates of the basic reproduction number R0 and the average age of infection A for measles in Niger, Africa. In section 8 estimates of the basic reproduction number R0 and the contact number (dened in section 2. Because pertussis infectives with lower infectivity occur in previously infected people, the contact number at the endemic steady state is less than the basic reproduction number R0. Section 9 describes results on the basic reproduction number R0 for previous epidemiology models with a variety of structures, and section 10 contains a general discussion. Epidemic models are used to describe rapid outbreaks that occur in less than one year, while endemic models are used for studying diseases over longer periods, during which there is a renewal of susceptibles by births or recovery from temporary immunity. The horizontal incidence shown in Fig- ure 1 is the infection rate of susceptible individuals through their contacts with infec- tives. This form of the horizontal incidence is called the standard incidence, because it is formulated from the basic principles above [96, 102]. The parameter has no direct epidemiological interpretation, but comparing it with the standard formulation shows that = N, so that this form implicitly assumes that the contact rate increases linearly with the population size. This strongly suggests that the standard incidence corresponding to v = 0 is more realistic for human diseases than the simple mass action incidence corresponding to v =1. This result is consistent with the concept that people are infected through their daily encounters and the patterns of daily encounters are largely independent of community size within a given country (e. The standard incidence is also a better formulation than the simple mass action law for animal populations such as mice in a mouse-room or animals in a herd , because disease transmission primarily occurs locally from nearby animals. Vertical incidence, which is the infection rate of newborns by their mothers, is sometimes included in epidemiology models by assuming that a xed fraction of the newborns is infected vertically . See  for a survey of mechanisms including nonlinear incidences that can lead to periodicity in epidemiological models. It has been shown  that these terms correspond to exponentially distributed waiting times in the compartments. For ex- ample, the transfer rate I corresponds to P(t)=et as the fraction that is still in the infective class t units after entering this class and to 1/ as the mean wait- ing time. For measles the mean period 1/ of passive immunity is about six to nine months, while the mean latent period 1/ is one to two weeks and the mean infec- tious period 1/ is about one week. Another possible assumption is that the fraction still in the compartment t units after entering is a nonincreasing, piecewise contin- uous function P(t) with P(0) = 1 and P() = 0. Then the rate of leaving the compartment at time t is P (t), so the mean waiting time in the compartment is t(P (t))dt = P(t)dt. These distributed delays lead to epidemiology models 0 0 with integral or integrodierential or functional dierential equations. If the waiting time distribution is a step function given by P(t)=1if0 t, and P(t)=0 if t, then the mean waiting time is, and for t the model reduces to a delay-dierential equation . Each waiting time in a model can have a dierent distribution, so there are many possible models . The basic reproduction num- ber R0 has been dened in the introduction as the average number of secondary infections that occur when one infective is introduced into a completely susceptible host population . Note that R0 is also called the basic reproduction ratio  or basic reproductive rate . It is implicitly assumed that the infected outsider is in the host population for the entire infectious period and mixes with the host population in exactly the same way that a population native would mix. The contact number is dened as the average number of adequate contacts of a typical infective during the infectious period [96, 110]. An adequate contact is one that is sucient for transmis- sion, if the individual contacted by the susceptible is an infective. Some authors use the term reproduction number instead of replacement number, but it is better to avoid the name reproduction number since it is easily confused with the basic reproduction number. Note that these three quantities R0,, and R in Table 1 are all equal at the beginning of the spread of an infectious disease when the entire population (except the infective invader) is susceptible. In recent epidemiological modeling literature, the basic reproduction number R0 is often used as the threshold quantity that determines whether a disease can invade a population. Although R0 is only dened at the time of invasion, and R are dened at all times. For most models, the contact number remains constant as the infection spreads, so it is always equal to the basic reproduction number R0. In these models and R0 can be used interchangeably and invasion theorems can be stated in terms of either quantity. But for the pertussis models in section 8, the contact number becomes less than the basic reproduction number R0 after the invasion, because new classes of infectives with lower infectivity appear when the disease has entered the population. The replacement number R is the actual number of secondary cases from a typical infective, so that after the infection has invaded a population and everyone is no longer susceptible, R is always less than the basic reproduction number R0. Also, after the invasion, the susceptible fraction is less than 1, so that not all adequate contacts result in a new case. Thus the replacement number R is always less than the contact number after the invasion. Combining these results leads to R0 R, with equality of the three quantities at the time of invasion. This model uses the standard incidence and has recovery at rate I, corresponding to an exponential waiting time et. Since the time period is short, this model has no vital dynamics (births and deaths). Most of the unvaccinated cases were people belonging to a religious denomination that routinely does not accept vaccination. Here the replacement number at time zero is so, which is the product of the contact number and the initial susceptible fraction so. Ifso > 1, then i(t) rst increases up to a maximum value imax = io + so 1/ [ln(so)]/ and then decreases to zero as t. The susceptible fraction s(t) is a decreasing function and the limiting value s is the unique root in (0, 1/) of the equation (2. Note that the hallmark of a typical epidemic outbreak is an infective curve that rst increases from an initial Io near zero, reaches a peak, and then decreases toward zero as a function of time. The susceptible fraction s(t) always decreases, but the nal susceptible fraction s is positive. The epidemic dies out because, when the susceptible fraction s(t)goesbelow1/, the replacement number s(t) goes below 1. The results in the theorem are epidemiologically reasonable, since the infectives decrease and there is no epidemic, if enough people are already immune so that a typical infective initially replaces itself with no more than one new infective (so 1). But if a typical infective initially replaces itself with more than one new infective (so > 1), then infectives initially increase so that an epidemic occurs. The speed at which an epidemic progresses depends on the characteristics of the disease. The equilibrium points along the s axis are neutrally unstable for s>1/ and are neutrally stable for s<1/. Observe that the threshold result here involves the initial replacement number so and does not involve the basic reproduction number R0. Here the contact number remains equal to the basic reproduction number R0 for all time, because no new classes of susceptibles or infectives occur after the invasion. For this model the threshold quantity is given by R0 = = /( + ), which is the contact rate times the average death-adjusted infectious period 1/( + ). If 1 or io =0, then solution paths starting in T approach the disease-free equilibrium given by s =1and i =0. If>1, then all solution paths with io > 0 approach the endemic equilibrium given by se =1/ and ie = ( 1)/. If R0 = 1, then the replacement number s is less than 1 when io > 0, so that the infec- tives decrease to zero. However, after the infective fraction has decreased to a low level, the slow processes of the deaths of recovered people and the births of new susceptibles grad- ually (over about 10 or 20 years) increase the susceptible fraction until s(t) is large enough that another smaller epidemic occurs. This process of alternating rapid epi- demics and slow regeneration of susceptibles continues as the paths approach the en- demic equilibrium given in the theorem. At this endemic equilibrium the replacement number se is 1, which is plausible since if the replacement number were greater than or less than 1, the infective fraction i(t) would be increasing or decreasing, respectively. Notice that the ie coordinate of the endemic equilibrium is negative for <1, coincides with the disease-free equilibrium value of zero at = 1, and becomes positive for >1. This equilibrium given by se =1/ and ie = ( 1)/ is unstable for <1 and is locally asymptotically stable for >1, while the disease-free equilibrium given by s = 1 and i =0is locally stable for <1 and unstable for >1. Thus these two equilibria exchange stabilities as the endemic equilibrium moves through the disease-free equilibrium when = 1 and becomes a distinct, epidemiologically feasible, locally asymptotically stable equilibrium when >1. The following interpretation of the results in the theorem and paragraph above is one reason why the basic reproduction number R0 has become widely used in the epidemiology literature. If the basic reproduction number R0 (which is always equal to the contact number when the entire population is susceptible) is less than 1, then the disease-free equilibrium is locally asymptotically stable and the disease cannot invade the population. But if R0 > 1, then the disease-free equilibrium is unstable with a repulsive direction into the positive si quadrant, so the disease can invade in the sense that any path starting with a small positive io moves into the positive si quadrant where the disease persists. The latter condition is used to obtain expressions for R0 in age-structured models in sections 5 and 6. This unrealistically short average lifetime has been chosen so that the endemic equilibrium is clearly above the horizontal axis and the spiraling into the endemic equilibrium can be seen. They unrealistically assume that the population is uniform and homoge- neously mixing, whereas it is known that mixing depends on many factors including age (children usually have more adequate contacts per day than adults). Moreover, dierent geographic and social-economic groups have dierent contact rates. By using data on the susceptible fractions so and s at the beginning and end of epidemics, this formula can be used to estimate contact numbers for specic diseases . Using blood samples from freshmen at Yale University , the fractions susceptible to rubella at the beginning and end of the freshman year were found to be 0.
A short history The origin of the technology goes back to the Curies purchase 20 mg erectafil visa, who frst discovered the piezoelectric effect generic erectafil 20mg on line. Attempts to use ultrasound for medical purposes startet in the 1940s when they used a contineous ultrasonic emitter to obtain images from a patient`s brain cheap erectafil 20mg overnight delivery. The use of Ultrasonics in the feld of medicine had nonetheless started initially with it s applications in therapy rather than diagnosis cheap erectafil 20mg, utilising it s heating and disruptive effects on animal tissues. The transducer is coupeled to the body by a gel and the pulse of ultrasound goes into the soft tissuse (speed of about 1500 m per second). The transducer will then sense the refected, weaker pulses of ultrasound and transform them back into electrical signals. These echoes from different organs are amplifed and processed by the receiver and sent to the computer, which keeps track of the return times and amplitudes. You can see how arms and legs of a fetus move, or see the heart valve open and close. Computer Receiver A lot of technology is involved in the different parts Transducer of the ultrasound technique. Let us shortly mention that the transducer, that trans- mits and receives the ultrasound energy into and from the body is a key component. It is built up of hundreds of transducers in order to take a high reso- The main components of ultrasound lution real-time scan. The many transducers create a wavefront and the angle of the wavefront can be altered by fring the transducers one after another. By changing the angle of the wavefront, a three-dimensional image can be built up over a large area. Doppler ultrasound The velocity of the blood can be measured by the Doppler effect i. Side effects Current evidence indicates that diagnostic ultrasound is safe even when used to visualize the embryo or fetus. In this connection we would like to mention that research in the beginning of 1980s showed that use of clinical ultrasound equipment could result in water radicals (H. Furthermore, in work with cells in culture exposed to ultrasound resulted in damage (simi- lar to those known from ionizing ra- diation). In the fgure to the right is given the world average use of radiation for medical imag- ing. New techniques and methods have been added with the result that the total dose (the collective dose) has increased. Since the 1950s it has been a goal to keep the doses for each examination as low as pos- sible in order to prevent any deleterious ef- fects of radiation. Year The fgure shows the use of x-rays for imaging It may be of interest to attain some infor- since the start in 1895 mation about the radiation exposure from diagnostic medical examinations. The Committee concluded that medical applications are the largest man-made source of radiation exposure for the world s population. The doses are in general small and are justifed by the benefts of accurate diagnosis of possible disease conditions. This implies that the effective doses to patients undergoing different types of medical diagnostic have been obtained. From this per capita annual doses can be obtained by averaging the collective doses over the entire pupolation (in- cluding non-exposed individuals). There is no direct evidence that diagnostic use of radiation ever causing any harm to the public. It is evident that the dose to certain groups of patients may be relatively large, for example for a number of patients with tuberculosis where chest fuoroscopy was used through 2 5 years. Signifcant doses has also been the result after the use of thorotrast in the period 1930 1950. According to this hypothesis it is possible to claim that about 250 fatal cancers per year would be the result for Norway with a population of 4. The old use of Thorotrast and the use of fuoroscopy in combination the the pneumatorax treatment for tuberculosis. Thorotrast is retained by the re- ticuloendothelial system, with a biological half-life of several hundred years, so that such patients suffer lifetime exposure to internal radiation. Some of the decay products, principally the radium isotopes Ra 228 and Ra 224, escape from the colloidal particles and deposit in the skeleton. The bio- logical end-points include liver cancer and leukemia and it can be concluded that Thorotrast increased the carcinogenic risk. Tuberculosis and chest fuoroscopy In the period 1930 1960 a large number of patients with tu- berculosis were treated by pneumathorax air was flled in the cavity of the chest and the lung was forced to collapse. In order to control the air flling the patient was x-rayed both before and after the flling and fuoros- copy was the method. A treatment could last for a number of years and consequently the number of x-ray examinations could be up to 100 and more. First of all the dose determination is highly uncertain can probably vary by a factor 2. Second, no information excist about the doses received in the time elapsed since the last examination i. Despite of these weak points, the data show a surprising decrease in cancer for those who received low doses (34 percent and 16 percent at the dose points of about 15 and 25 centi-Gray). This is done in order to controll the collapse of the lung as shown in the illustration. Straus The objective of medicine is to address people s unavoidable such as cardiovascular diseases, diabetes, hypertension, needs for emotional and physical healing. The discipline has depression, and use of tobacco and other addictive sub- evolved over millennia by drawing on the religious beliefs and stances. Public health and for the development of future health care strategies for the medical practices have now advanced to a point at which developing world. In the We refer to medical practices that evolved with indigenous industrial nations, a surprisingly large proportion of people peoples and that they have introduced to other countries opt for practices and products for which proof as to their safety through emigration as traditional medicine. The advancing human health through the further dispersion of terms complementary and alternative describe practices and effective and economical medical practices. With globalization, the pattern of disease in developing Endless varieties of practices are scientifically unproven and countries is changing. For the sake of organ- ble diseases dominated, now 50 percent of the health burden izing an agenda for research into these approaches, the in developing nations is due to noncommunicable diseases, U. An example of the former is Reiki ther- as many as 60 percent of those living in France,Germany,and the apy, which aims to realign and strengthen healthful energies United Kingdom consume homeopathic or herbal products. Second, the limited data on drugs; cyclosporine A; birth control cost-effectiveness may not be applicable in the case of those Valerian Sedatives countries. Although that herbals are highly variable in quality and composition, economic factors play a role in this choice, the underlying with many marketed products containing little of the intended incentives are not always predictable. A few herbals are banned because they are cheaper alternatives to conventional medical outright in several countries. John s wort, which affects the metabolism of nearly At least one study has shown that financial considerations 50 percent of all prescription drugs (Markowitz and others are rarely the primary factor in choosing a traditional healer, 2003). The cumulative data on the pharmacological and poten- ranking behind such reasons as confidence in the treatment, tial adverse effects of herbal supplements now dictate that ease of access, and convenience (Winston and Patel 1995). In patients discuss their use of supplements with knowledgeable the United States, the average cost of a single visit to a Navajo practitioners before initiating treatment. The high cost of using a healer was cited as the most compelling, but they are sufficient to generate hypotheses that common barrier to seeking care from this source. The same survey found that outcomes tended to be bet- ter when patients went to government clinics (67. Survey respondents in Ghana reported that the Complementary and Alternative Medicine | 1283 Table 69. Nonetheless, this strategy may be difficult to apply to the larger Another common misconception is that the poor are more health care system. At least one study shows that this may not be Furthermore, patients tend to seek care from traditional true. Of through prepaid health plans or government insurance 28,254 individuals in the sample, 10,033 had consulted a health reduces the overall costs of health care and found that it does care provider in the four weeks preceding the survey. An outpatient survey found that, system, as the investigators reasoned that this would enable of 246 patients who had been receiving conventional treatment them to evaluate their follow-up. Overall, the investigators from the Royal London Homeopathic Hospital since the onset found that complementary medicine was between 53 and of care, a third had halted their conventional treatment and 63 percent less expensive than conventional medicine for another third had reduced their intake of conventional med- achieving equivalent levels of effectiveness. However, this study was not randomized, conventional care, but this is also common in developing and patients had to have failed first-line drug treatment before nations. For instance, Mwabu (1986) provides evidence from being offered the choice of second line-treatment, either with Kenya that patients are likely to use more than one type of acupuncture or with Western medicine. Evidence indicates that the cost of homeopathic patients illness, condition, socioeconomic status, and educa- medication is lower than the average cost of allopathic prod- tion. If an initial visit to one kind of provider did not resolve ucts, which would be an economic factor in favor of its use if the disease satisfactorily, a follow-up visit was made to a differ- homeopathy were proven to be effective. Finally, the quality of care including National Health Service in the United Kingdom found that the efficiency of service and waiting time at government and pri- drug costs associated with homeopathy were lower than those vate clinics is an important determinant of whether patients of allopathic practitioners (Swayne 1992). However, the study overharvesting of endangered species for medicinal purposes is was not randomized and failed to control for the inclination of also a concern. The possible extinction of medicinal plants is of less expensive than conventional treatments for episodes of concern not only to developing countries but also to industrial back pain. One nonrandomized study found that the cost of countries, as in the cases of poaching of American ginseng and chiropractic treatment over a five-year period, including both overharvesting of native saw palmetto. In such instances, promoting conventional treatments significant differences in either the mean costs of care or the that do not depend on endangered species may bring impor- outcomes between the physical therapy and chiropractic tant benefits to society. A number of surveys show that as the time costs of practicing them, are so low relative to con- local pharmacies are the primary source of treatment for many ventional medicine that evidence of their clinical effectiveness ailments, especially in rural areas where government or private might suffice to justify their use on economic grounds. Training traditional healers is substantially less expensive than Blumenthal and others (2002) find significant declines in coro- training doctors or nurses. Indigenous people will seek the help of tradi- additional training, traditional healers can serve as primary tional healers because of proximity, familiarity, and trust. Including the traditional healer as part of the health care Ndubani and Hojer 1999). One way to do this is by supporting local ulated, and herbal products typically differ from source to production of safe and effective herbals such as artemisia at source and from batch to batch in terms of their component affordable prices. National nongovernmen- those with proven efficacy and safety should be made available tal organizations, such as the Accreditation Commission for for therapeutic use. In both settings, relatively little evidence integrated them into medical school curricula to differing supports this view. Chinese scientists determined the active shown results comparable to those achieved with nonsteroidal, ingredient of the herbal in the 1970s, and Western pharmaceu- anti-inflammatory drugs in alleviating back pain (Straus 2004). Randomized clinical trials have shown that one such drug, Homeopathy dihydroartemisinin-piperaquine, is effective against drug- Homeopathy is a success in terms of its broad appeal and use, resistant Plasmodium falciparum malaria (Hien and Dolecek not because of the strength of evidence supporting it. Another artemisinin derivative, artesunate, was shown few conventional scientists and physicians find homeopathy to to increase parasite clearance and reduce the gametocyte count be plausible.
Both false-negative and false-positive skin test results may occur because of improper technique or material erectafil 20mg online. Improperly prepared or outdated extracts may contain nonspecific irritants or may not be physiologic with respect to pH or osmolarity erectafil 20 mg amex, and therefore produce false-positive results order 20 mg erectafil with visa. The injection of an excessive volume can result in mechanical irritation of the skin and false-positive results discount erectafil 20 mg on-line. Interpretation of skin tests Population studies have demonstrated that asymptomatic individuals may have positive skin test results ( 37,38). A positive skin test result only demonstrates the presence of IgE antibody that is specifically directed against the test antigen. A positive result does not mean that a person has an allergic disease, or that an allergic person has ever had a clinically significant reaction to the specific antigen. The number and variety of prick tests performed depend on clinical aspects of the particular case. The antigens used may vary because of the prevalence of particular antigens in any geographic location. Satisfactory information usually can be obtained with a small number of tests if they are carefully chosen. With inhalant antigens, correlating positive skin tests with a history that suggests clinical sensitivity may strongly incriminate an antigen. Conversely, a negative skin test and a negative history exclude the antigen as being clinically significant. Interpretation of skin tests that do not correlate with the clinical history or physical findings is much more difficult. If there is no history suggesting sensitivity to an antigen, and the skin test result is positive, the patient can be evaluated again during a period of maximal exposure to the antigen. At that time, if there are no symptoms or physical findings of sensitivity, the skin test result may be ignored. A three-year study of college students demonstrated that asymptomatic students who were skin test positive were more likely to develop allergic rhinitis 3 years later than skin test negative asymptomatic students. Patients with a history that strongly suggests an allergic disease or clinical sensitivity to specific antigens may have negative skin test results for the suspected antigens. It is difficult to make an allergic diagnosis in these cases because, when properly done, negative results indicate that no specific IgE antibody is present. These patients may be requestioned and reexamined, and the possibility of false-negative skin test results must be excluded. Because there is no normal limit for IgE concentrations, measuring total IgE is not of diagnostic significance and rarely provides useful information ( 43,44). Total serum IgE determinations are indicated in patients suspected of having allergic bronchopulmonary allergic aspergillosis, both in the diagnosis and monitoring of the course of the disease (45). High IgE concentrations in infants may predict future allergic diseases and occasionally are checked in infants with frequent respiratory infections. IgE concentrations are also necessary in the evaluation of certain immunodeficiencies such as hyper-IgE syndrome. Skin testing is the diagnostic test of choice for IgE-mediated diseases and is generally reported to be more sensitive and specific than in vitro tests (46). The same clinical problems observed in skin testing are present when the results of in vitro tests are interpreted. In addition, there are a number of technical problems over which the clinician has no control that can influence the test results. Both in vitro testing and skin testing can yield false-negative, false-positive, or equivocal results, depending on a number of variables. If performed optimally, both methods detect specific IgE antibody accurately and reproducibly. Some patients may not be able to omit medications that interfere with skin testing. Because no medications interfere with in vitro testing, it may be useful in these patients. In vitro tests would avoid the possibility of anaphylaxis or even uncomfortable local reactions. In contrast to skin testing, dermographism and widespread skin diseases, do not interfere with in vitro testing, and therefore may be useful in patients with these problems. Commercial firms and individual physicians may misrepresent the value of any testing method. The results of any tests must correlate with the production of allergic symptoms and signs by a specific antigen to have any meaning. Consequently, the history and physical examination personally performed by the physician remain the fundamental investigative procedure for the diagnosis of allergic disease. Ultrastructural changes in human skin mast cells during antigen-induced degranulation in vivo. An assessment of the role of intradermal skin testing in the diagnosis of clinically relevant allergy to timothy grass. Appraisal of skin tests with food extracts for diagnosis of food hypersensitivity. Effect of distance between sites and region of the body on results of skin prick tests. Duration of the suppressive effect of tricyclic antidepressants on histamine-induced wheal-and-flare reactions in human skin. A controlled study of the effects of corticosteroids on immediate skin test reactivity. Prolonged treatment with topical corticosteroids results in an inhibition of the allergen-induced wheal-and-flare response and a reduction in skin mast cell numbers and histamine content. Decrease of skin and bronchial sensitization following short-intensive schedule immunotherapy in mite-allergic asthma. The development of negative skin tests in children treated with venom immunotherapy. Influence of the pollen season on immediate skin test reactivity to common allergens. Seasonal variation of skin reactivity and specific IgE antibody to house dust mite. Inhibition by prednisone of late cutaneous allergic response induced by antiserum to human IgE. Late onset reactions in humans: correlation between skin and bronchial reactivity. Antigen provocation to the skin, nose, and lung in children with asthma: immediate and dual hypersensitivity reactions. Arthus-type reactivity in the nasal airways and skin in pollen sensitive subjects. Association of skin reactivity, specific IgE, total IgE, and eosinophils with nasal symptoms in a community based population study. Development of asthma, allergic rhinitis and atopic dermatitis by the age of five years. Serum IgE levels, atopy, and asthma in young adults: results from a longitudinal cohort study. Reference values of total serum IgE and their significance in the diagnosis of allergy among the young adult Kuwaiti population. Age-related serum immunoglobulin E levels in healthy subjects and in patients with allergic disease. The use of in vitro tests for IgE antibody in the specific diagnosis of IgE-mediated disorders and in the formulation of allergen immunotherapy. Comparison of skin testing and three in vitro assays for specific IgE in the clinical evaluation of immediate hypersensitivity. Comparison of three in vitro assays for serum IgE with skin testing in asthmatic children. Noninfectious rhinitis is characterized by clear (watery or mucoid) discharge that often contains eosinophils. The noninfectious group can be subdivided into seasonal allergic rhinitis, perennial allergic rhinitis, and perennial nonallergic rhinitis. Classification of rhinitis Perennial nonallergic rhinitis comprises a heterogeneous group consisting of at least two subgroups ( 2). This subdivision of patients with nonallergic rhinitis may not always be possible in a particular case and therefore may not be an entirely suitable system for clinical routine. These symptoms are periodic in nature and occur during the pollinating season of the plants to which the patient is sensitive. Incidence Although allergic rhinitis may have its onset at any age, the incidence of onset is greatest in children at adolescence, with a decrease in incidence seen in advancing age. Although it has been reported in infants as young as 6 months of age ( 3), in most cases, an individual requires two or more seasons of exposure to a new antigen before exhibiting the clinical manifestations of allergic rhinitis ( 4). One community study of allergic rhinitis reported that 75% of patients resided inside the city ( 5), but other studies have not reported variation in the prevalence of allergic rhinitis based on geographic location ( 6). In addition, there does not appear to be any correlation between socioeconomic status or race and the prevalence of allergic rhinitis ( 6). Boys tend to have an increased incidence of allergic rhinitis in childhood, but the sex ratio becomes even in adulthood. Although the prevalence of allergic rhinitis has been estimated to range from as low as 4% to more than 40% ( 5,7,8), an accurate estimate of the incidence of allergic rhinitis is difficult to obtain. Some obstacles in obtaining accurate estimates of allergic disease include variability in geographic pollen counts, misinterpretation of symptoms by patients, and inability of the physician to recognize the disorder. Epidemiology studies suggest that the prevalence of allergic rhinitis in the United States and around the world is increasing ( 9). However, contributing factors may include higher concentrations of airborne pollution, such as diesel exhaust particles ( 10); rising dust mite populations ( 11); less ventilation in homes and offices; dietary factors ( 12); and a trend toward more sedentary lifestyles ( 13). With the increased prevalence of allergic rhinitis, the disorder has increased in importance, and the suffering and annoyance that many experience should not be underestimated. In allergy-specific questionnaires ( 14,15), subjects with allergic rhinitis consistently reported lower quality of life than nonallergic controls. In a large health outcomes study of patients with moderate to severe allergic rhinitis symptoms, 70% of untreated patients reported being embarrassed or frustrated by their allergy symptoms, and 98% reported being troubled by practical problems ( 15). Considerable expenditures are involved in medications, physician fees, and economic loss secondary to absenteeism and inefficient performance at work. Ross estimated that the cost of decreased productivity in the United States labor force due to allergic rhinitis totaled $2. Conservative estimates report that prescription medication costs are greater than $1 billion per year, and over-the-counter medications are at least twice that amount (17). The severity of symptoms, however, may vary from year to year depending on the quality of pollen released and patient exposure during the specific pollinating seasons. Occasionally, the disease undergoes a spontaneous remission without specific therapy. Etiology Pollen and mold spores are the allergens responsible for seasonal allergic rhinitis ( Table 9.
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