By Y. Mazin. Rutgers University.
Public Attitudes Toward Information and Privacy Are in Flux Genetic privacy was a central preoccupation during the early years of genomics purchase duphalac 100 ml without a prescription, which led to implementation of stringent regulatory procedures to limit the use of genetic data in patient oriented research (Andrews and Jaeger 1991) discount duphalac 100 ml with mastercard. During the ensuing years discount duphalac 100 ml amex, the diffusion of the internet into every corner of our lives is driving massive changes in public attitudes toward privacy buy duphalac 100 ml low price. Research studies of public attitudes reveal deep ambivalence about informational privacy. In the particular arena of genetic information and health records, members of focus groups typically grasp the broad social benefits of sharing data. A consistent theme is that people who contribute their own information to public databases want to be asked for permission, to have a clear explanation of how the data will be used, and to be treated as true partners in the research process (Damschroder et al. Although privacy concerns remain, there is little evidence that the public has the extreme sensitivity toward genetic data that many researchers anticipated 25 years ago. The Proposed Knowledge Network of Disease Could Catalyze Changes in Biology, Information Technology, Medicine, and Society The powerful forces affecting basic biological research, information technology, clinical medicine, and public attitudes toward the privacy of health records and personal genetic information create an unprecedented opportunity to change how biomedical research is conducted and to improve health outcomes. The development of the proposed Knowledge Network of Disease and its associated New Taxonomy could take advantage of these forces to inspire revolutionary change. This Committee regards commitment to the development of these resources as a powerful unifying idea that could harness—and, to an appropriate degree, redirect—the creative energies of the key constituencies to achieve the full potential of biology to improve health outcomes. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease 3 What Would a Knowledge Network and New Taxonomy Look Like? In the previous chapter, the Committee outlined the reasons it concluded that the time is right to develop a Knowledge Network of Disease and New Taxonomy. But what would these resources look like and what implications would they have for disease classification, basic research, clinical care and the health-care system? This chapter describes the Committee’s vision of a comprehensive Knowledge Network of Disease and New Taxonomy that would unite the biomedical-research, public-health, and health-care-delivery communities around the related goals of advancing our understanding of disease pathogenesis and improving health. The Committee envisions that the proposed resources would have several key features: x They would drive development of a disease taxonomy that describes and defines diseases based on their intrinsic biology in addition to traditional physical “signs and symptoms”. The Knowledge Network of Disease Would Incorporate Multiple Parameters and Enable a Taxonomy Heavily Rooted in the Intrinsic Biology of Disease Physical signs and symptoms are the overt manifestations of disease observed by physicians and patients. Physical signs and symptoms are generally also difficult to measure quantitatively. Indeed, in a strict sense, all diseases are presumably asymptomatic for some “latent period” following the initiation of pathological processes. As a consequence, diagnosis based on traditional “signs and symptoms” alone carries the risk of missing opportunities for prevention, or early intervention can readily misdiagnose patients altogether. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease 36 diseases become clinically evident, obtaining optimal diagnostic results can depend on supplementing standard histology with ancillary genetic or immunohistochemical testing to identify specific mutations or marker proteins. Biology-based indicators of disease such as genetic mutations, marker-protein molecules, and other metabolites have the potential to be precise descriptors of disease. They can be measured accurately and precisely–be it in the form of a standardized biochemical assay or a genetic sequence—thus enabling comparison across datasets obtained from independent studies. Particularly when multiple molecular indicators are used in combination with conventional clinical, histological, and laboratory findings, they offer the opportunity for a more accurate and precise description and classification of disease, particularly. Numerous molecularly-based disease markers are already available, and the number will grow rapidly in the future. Amongst the most prominent parameters of disease are an individual’s: x Genome x Transcriptome x Proteome x Metabolome x Lipidome x Epigenome As discussed in Chapter 2, it is increasingly feasible to obtain substantial information about these biological features for each individual patient. The cost of sequencing an individual’s genome is rapidly dropping, and significant advances in the ability to globally and affordably characterize proteomes, metabolomes, lipidomes, epigenomes, and microbiomes of individual subjects will continue, creating the potential for an increasingly rich molecular characterization of individuals in the future. Eventually, it is likely that extensive molecular characterization of individuals will occur routinely as a normal part of health care – even prior to appearance of disease thereby allowing the collection of data on both sick and healthy individuals on a scale vastly exceeding current practice. In addition to providing a new resource for research on disease processes, these data would provide a far more flexible and useful definition of the “normal” state, in all its diversity, than now exists. The ability to make such measurements on both non-affected tissues and in sites altered by disease would allow monitoring of the development and natural history of many disorders about which even the most basic information is presently unavailable. Gene- environment interactions have been implicated in a diverse group of diseases and pathological processes, including some psychological illnesses (Caspi et al.
That said it is possible to remove a tooth with any solid grasping instrument – such a pair of pliers – with the tips wrapped in gauze or in some other way padded – although this is not recommended generic duphalac 100 ml with visa. Thirdly if the tooth’s root(s) breaks (which is more likely with decayed teeth and if the operator is inexperienced) then it can be impossible to remove and the broken root fragment will act as a focus for further infection purchase duphalac 100 ml amex. In some primitive societies when you lost your teeth to chew with then by nature of their diet you died – potentially a problem again buy 100 ml duphalac overnight delivery. Your priority should be to prevent yourself or your families from getting to the point where you have no teeth discount 100 ml duphalac. Porcelain is glorified clay, and is moulded, and then fired to produce a very hard material – there is varying recipes – one recipe consists of one part each of silica, clay, and kaolin, 2 parts of Nepheline syenite, and a small amount of talc. Before this time dentures had been manufactured out many substances including metal, bone, and animal and human teeth. The instrument numbers are considered standard numbers but many companies have their own numbers or variations so check if you are unsure. Note that all of this is obtainable at Wal-Mart, from many pharmacies, or similar stores. Level 2: Basic Dental Kit This is the minimum needed for basic dental work: temporary fillings and extractions. Where possible purchase supplies of high quality, they are reusable and will last for many years with proper care. Level 3: Advanced Dental Surgery Kit This is the advanced kit designed for those with some dental training and can do most needed dental work including fillings and extractions. Note: Extractors 53R & 53L are mirror images of each other if you get the model with the straight handle. If you are nimble with your weak hand and can change sides on the patient you can get by with one or the other of the pair and save money and weight. Note: Forceps # 18, 73, 75, 87, 201, and deep root elevators are of value also if you want to be really complete. This includes both the short and long term as well as the more urgent aspects of immediate care. Whether professionally trained or home-grown the person charged by circumstance or design with providing for the day-to-day care of others needs to be ready to address the ever-changing and continuing needs of their patients. There will also need to be an acceptance from family or group members of a more collective responsibility for caring for the sick and injured, and that delegating all of the care which a sick patient currently receives from trained nursing staff in modern hospital to one person isn’t practical or desirable. Family and friends will need to take a much more active role in helping the “nurse” look after their patient - assisting with companionship, bathing, and feeding the patient. The goal is to provide for the entire range of physical and emotional demands caused by the patient(s) illness or injury. Nursing care begins where urgent or immediate care leaves off once the patient is stabilized and any imminent threats or disabilities are addressed. Because the subject of nursing care per se is so vast it is not the intent of the authors to provide a complete how-to. In keeping with the general philosophy of the book this section is meant to provide an introduction only highlighting some of the factors involved in providing austere nursing care. You will need to be familiar with a large bag of tricks that will make recuperation not only more bearable but also more likely. Often whether or not someone recovers from a traumatic event or a significant illness depends on the care they receive beyond the emergent or acute phases. Without excellent nursing care a person may survive and also recover nearly fully intact from a fractured femur, for instance, only to succumb weeks later to the effects of being kept bedfast. Blood clots in the lower legs caused by inactivity, infected bedsores that result from laying on their back for too long, or even pneumonia resulting from the use of a simple anaesthetic agent such as ether, may claim them long after the fracture has been set and the road to recovery is being well travelled. Simple nursing measures can go a long ways towards preventing any of these from occurring, or addressing them if they should. On a more everyday basis there are also simple considerations to make austere nursing practical: how to properly assess a temperature using an old-fashioned mercury thermometer, how to administer a proper injection, reducing fever with - 144 - Survival and Austere Medicine: An Introduction simple measures that do not include medications, and ensuring proper nutritional support. Defining austere nursing practice Elsewhere in this work we address the various aspects of emergent care when “regular” health care is not available, a la’ where there is no doctor/clinic/emergency facility.
These practi- cae replicated the Arabic encyclopedias in including sections on women’s dis- eases (usually placed after diseases of the male genitalia) discount 100 ml duphalac with visa, yet at the same time they showed considerable originality in devising their own therapeutic pro- grams buy duphalac 100 ml visa. None of these male writers purchase duphalac 100 ml visa, however cheap 100 ml duphalac visa, broke new ground in his catego- rization of gynecological disease. Salernitan anatomical writers did de- vote considerable attention to the anatomy of the uterus and the ‘‘female tes- ticles’’; that these descriptions became increasingly more detailed over time owes not to inspection of women’s bodies, however, but to the assimilation of bits and pieces of anatomical and physiological lore from a variety of other written sources. Nicholaus, the author of the most important text on compound medicines, promised his readers that by dispensing the medicines described in his text, ‘‘they would have an abundance of money and be glorified by a multitude of friends. These men began to style themselves as ‘‘healer and physician’’ (medicus et physicus) and later simply as ‘‘physician. Yet even as cer- tain practitioners were able to enhance their social status through their learn- ing, there continued to exist in Salerno traditions of medical practice that par- took little or not at all in the new learned discourses. It is clear that religious and even magical cures continued to coexist alongside the rationalized prac- tices of physical medicine. There were, moreover, as we shall see in more detail later, some women in Salerno who likewise engaged in medical practice; these women apparently could not avail themselves of the same educational privi- leges as men and are unlikely to have been ‘‘professionalized’’ in the same way as their male counterparts. There was, in any case, no regulation of medical practice in this period (licensing was still a thing of the future),59 so to that degree the ‘‘medical marketplace’’ was open. The context in which the three Salernitan texts on women’s medicine came into being thus was quite expansive and open to a variety of influences and practices. These texts share to varying degrees the characteristics of ‘‘main- stream’’ Salernitan medical writings, Conditions of Women with its attempts to assimilate Arabic medicine, Treatments for Women with its collection of tra- ditional local practices. Women’s Cosmetics is most interesting as an example of how traditional empirical practices could be adopted by learned physicians and deployed as another strategy in re-creating the ideal of the ancient city physician whose success lay largely in the reputation he was able to cultivate. Clearly, women were among the patients whose patronage these practitioners wanted to earn. The Lombard princess Sichelgaita seems to have had her own personal physician, Peter Borda, in the s,60 and there is ample evidence that women regularly figured in the clientele of male practitioners. Neverthe- less, as was noted above, gynecology and obstetrics were areas of medical prac- tice that saw relatively little innovation by male medical writers. Male physi- cians clearly diagnosed and prescribed for gynecological conditions, and they Introduction recommended a wide variety of potions and herbs for difficult birth. But it is doubtful that they ever directly touched the genitalia of their female patients. This limitation of male gynecological and obstetrical practice left room for the existence of female practitioners whose access to the female body was less restricted. As we have seen, women had no higher social position here and they may well have been less literate than women in neighboring areas. Few specialized texts on women’s medicine existed in Arabic, and nonewere translated by Constantine. The larger intellectual currents of Salernitan medicine—the concern to system- atically analyze and explain, the eagerness to incorporate new pharmaceutical products, and, most important, the desire to capture all this new knowledge in writing—provided the spark that would make Salernitan women’s medicine different from anything that had gone before it. Women’s Medicine P-S G Had it been possible to draw up an inventory of European medical writings on women in the third quarter of the eleventh century, that list would have included at least two dozen different texts. But such an inventory would be insufficient to assess the varying im- Introduction portance of these texts, for even though copies might be found in this library or that, an individual text’s usefulness may have been minimal, either because its Latin (often interlarded with Greek terminology) had been corrupted over the course of several centuries of copying or because its theoretical precepts were no longer adhered to or even understood. The gynecological literature in western Europe prior to the late eleventh century represented two ancient medical traditions. First was the Hippocratic tradition, embodied in a corpus of anonymous Greek writings composed be- tween the fifth and fourth centuries . The gynecologi- cal materials of the Hippocratic Corpus constituted as much as one-fifth of that vast collection of writings. The abbreviated translation of Diseases of Women laid out the basic physiology of women (especially as it related to pregnancy), then moved on to alterations of the womb, impedi- ments to conception, disorders of gestation, causes of miscarriage, difficulties of birth, and subsequent problems. The longer version, called by its modern editor On the Diverse Afflictions of Women, addresses questions of etiology, diagnosis, and prognosis, as well as the more routine matters of basic pathology and ther- apy in its ninety-one subheadings. Three other texts (Book on the Afflictions of Women, Book on the Female Affliction, and Book on Womanly Matters) also derive from Diseases of Women ; these are fairly brief and often redundant recipe col- lections rather than organized medical treatises. Just as influential in dissemi- nating Hippocratic views of the female body were the Aphorisms, a collection of pithy verities about the nature of the physician’s craft, the symptoms of dis- ease, prognostic signs, and so forth. The fifth (or in some versions the sixth) of the seven sections of the Aphorisms was devoted primarily to women and their diseases; it was on occasion accompanied by an extensive commentary.
However generic duphalac 100 ml with mastercard, a common chemical name of the active ingredient is dimethyl benzyl ammonium chloride order duphalac 100 ml on line. Use the information on pg 40 to determine if the product meets the criteria for both a sanitizer and/or disinfectant cheap duphalac 100 ml visa. Use test kit daily to monitor the correct concentration of the product used in the food areas (200 to 400 ppm) buy duphalac 100 ml free shipping. Use separate bottles and label each clearly with its intended use with the name of product, date mixed, food/mouthed contact use, or general disinfection. The solution for use on food contact surfaces may differ from that used for general disinfection. For more information about a specific product call the distributor or the company. Scrub the area with soap or detergent and water to remove blood or body fluids and discard paper towels. Disinfect immediately using bleach solution 1 or another appropriate disinfecting product on any items and surfaces contaminated with blood and body fluids (stool, urine, vomit). Spray the area thoroughly with bleach solution 2 or another appropriate sanitizing product. Wipe the area to evenly distribute the sanitizer using single-service, disposable paper towels. Before any new group of children begins an activity at a water play table or water basin, the water play table or basin is washed, rinsed, and sanitized. Any child participating in an activity at a water play table or basin washes his or her hands before the activity. This is acceptable for soaking, cleaning, sanitizing, and disinfecting washable articles. Sink/Basin #1: wash items in hot water using detergent (bottle brushes as needed). If at the end of the cycle when the machine is opened the dishes are too hot to touch, then the items are sanitized. This interest is twofold: first is due to reports about increased allergies, sensitivities, and illness in children associated with chemical toxins in the environment and second, these products tend to cause less damage to the environment. Children are more vulnerable to chemical toxins because of their immature immune systems, rapidly developing bodies, and their natural behaviors. They play on the floor, are very tactile having much body contact with the tables, desks, or play equipment, and have oral behaviors of mouthing toys and surfaces and putting their hands in their mouths. Green sanitizers or disinfectants must be approved by your local public health agency or your childcare consultant. Germs found in the stool can be spread when the hands of caregivers or children contaminate objects, surfaces, or food. Note: The importance of using good body mechanics cannot be over emphasized when changing diapers of larger or older children, as well as infants and toddlers. Equipment Changing surface - The changing surface should be separate from other activities. Check with your childcare health consultant or school nurse to determine which handwashing procedures are appropriate for different age groups of children. Diapers High-absorbency disposable diapers are preferred because cloth diapers do not contain stool and urine as well and require more handling (the more handling, the greater chances for spread of germs). Cloth diaper considerations The outer covering and inner lining must both be changed with each diaper change. Disposable gloves Non-latex gloves without powder should be considered because of possible allergy to latex in staff and children. Disposable wipes A sufficient number of pre-moistened wipes should be dispensed before starting the diapering procedure to prevent contamination of the wipes and/or the container. Parents/guardians or healthcare providers must provide written, signed directions for their use. Plastic bags Disposable plastic bags must be used to line waste containers and to send soiled clothing or cloth diapers home. Waste containers and diaper pails A tightly covered container, preferably with a foot-operated lid, is recommended. Potty chair or commodes (not recommended) Flush toilets are recommended rather than commodes or potty chairs.
For example order duphalac 100 ml with amex, some patients with pulmonary emboli have an indeterminate perfusion–ventilation lung scan showing the distribution of radioactive mate- rial in the lung buy 100 ml duphalac with visa. This means that the results are neither positive nor negative and the clinician is unsure about how to proceed discount 100 ml duphalac with visa. This is more likely to occur if the appendix lies in an unusual location such as in the pelvis or retrocecal area safe duphalac 100 ml. In cases of patients who actually have the dis- ease, if the result is classified as positive, the patient will be correctly classi- fied. If however, the result is classified as negative, the patient will be incorrectly classified. Again the need for blinded reading and careful a-priori definitions of a positive and negative test can prevent the errors that go with this type of problem. Tests that are operator- dependent are most prone to error because of lack of reproducibility. They may perform very well when carried out in a research setting, but when extrapolated to the community setting, the persons performing them may never rise to the level of expertise required, either because they don’t do enough of the tests to become really proficient or because they lack the enthusiasm or interest. When tested in a center that was doing research on this use, they performed very well. Tests initially studied in one center should be studied in a wide variety of other settings before the results of their operating characteristics are accepted. Post-hoc selection of test positivity criteria This situation is often seen when a continuous variable is converted to a dichoto- mous one for purposes of defining the cutoff between normal and abnormal. In studying the test, it is discovered that most patients with the disease being sought have a test value above a certain threshold and most without the disease have a test value below that threshold. There is statistical significance for the difference in disease occurrence in these two groups (P < 0. In some cases, the researchers looked at several cutoff points before deciding on a final one. A validation study should be done to verify this result and the results given as like- lihood ratios rather than simple differences and P values. This problem can be evaluated by using likelihood ratios and sensitivity and specificity and plotting them on the Receiver Operating Characteristics curve for the data rather than using only statistical significance as the defining variables in test performance. Temporal changes Test characteristics measured at one point in time may change as the test is tech- nically improved. The measures calculated from the studies of the newer tech- nology will not apply to the older technology. Look for this problem in the use of newer biochemical or patho- logical tests, as well as in questionnaire tests if the questionnaire is constantly being improved. There may also be problems associated with the technologi- cal improvement in tests. Publication bias Studies that are positive, that find a statistically significant difference between groups, are more likely to be published than those that find no difference. Con- sider the possibility that there may be several unpublished negative studies “out there” when deciding to accept the results of studies of a new test. Ideally, diag- nostic tests should be studied in a variety of clinical settings and with different mixes of patients. Words of caution: the manufacturers of a new test want as many physicians to use the test as often as possible and may sponsor studies that have various of the biases noted above. There is a lot of money to be made in the introduction of a new test, especially if it involves an expensive new technology. These may not be justi- fied based on good objective evidence obtained through well-conducted stud- ies of the technology. As a conscientious physician, you must decide when these expensive technologies are truly useful to your patient. Working with well-done published guidelines and knowing the details of the studies of these new modal- ities can help to put their use into perspective. Studies sponsored by the manufacturer of the test being studied are always open to extra scrutiny. Although this does not automatically make it a bad study, if the authors have a financial stake in the results of the study they often “spin” the results in the most favorable manner. Conversely, a company producing a diagnostic test will resist publication of a negative study, and this may lead to suppression of important medical information.