Additionally generic tenormin 100mg line heart attack 34 years old, we need to initiate comprehensive action to promote healthy diet and physical activity safe tenormin 100mg arterial hypertension; and health services need to be reoriented to accommodate the needs of chronic disease prevention and control discount tenormin 100mg amex arteria oftalmica. I believe that, if existing interventions are used together as a part of a comprehensive integrated approach, the global goal for preventing chronic disease can indeed be achieved and millions of lives saved. All segments of the society must unite across the world to provide a global thrust to counter this global threat. Governments must work together with the private sector and civil society to make this happen. Like so many developing and developed countries around the world, China is facing signiﬁcant health challenges, not just with infectious diseases but now with the double burden of chronic disease. Chronic disease death rates in our middle-aged population are higher than in some high income coun- tries. We have an obesity epidemic, with more than 20% of our 7–17 year old children in urban centres tipping the scales as either overweight or obese. This situation is especially tragic considering that at least 80% of all heart disease, stroke and diabetes are preventable. And our global economies will also suffer severe consequences from societies battling chronic diseases. Currently a national chronic disease control network is being built to comprehensively survey our population. This is the type of comprehensive and integrated action that will achieve success in combating chronic diseases. These programmes represent a long-term investment in our future, in the future of our children. We are committed to implementing the strategies outlined in this report to effectively prevent chronic disease and urge the same scale of commitment from others. The report focuses on the prevention of the major chronic conditions, primarily: » heart disease and stroke (cardiovascular diseases); » cancer; » asthma and chronic obstructive pulmonary disease (chronic respiratory diseases); » diabetes. The nine were chosen on the basis of the size of their chronic disease burden, quality and reliability of available data, and lessons learnt from previous prevention and control experiences. It is vital that the increasing »This growing threat is an under-afﬂ icted is increasing importance of chronic disease is hinders the economic developmentappreciated cause of poverty and anticipated, understood and acted upon of many countries urgently. How will we ensure a healthy future for children likeLuciano and the millions of others facing chronic diseases? It also describes the links between chronic diseases and poverty, This part of the report reveals the extent of the chronic disease pandemic, its relationship to poverty, and its adverse impact on details the economic impact of chronic countries’ macroeconomic development. A new global goal for reducing chronic disease death rates over the next 10 years is also introduced. Thispart Effective interventions for both the of the report provides a summary of the evidence, and explains how interventions whole population and individuals are for both the whole population and individuals can be combined when designing and implementing a chronic reviewed. This part also This part of the report outlines the steps that ministries of describes the positive roles that the health can follow to implement successfully the interventions presented in Part Three. The opportunity exists to make a major contribution to the prevention and control of chronic private sector and civil society can diseases, and to achieve the global goal for chronic disease prevention and control by 2015. Each country has its own set of health functions at national and sub-national levels. While there cannot be a single prescription for implementation, there are core policy functions that should be undertaken at the national level. A national unifying framework will ensure that actions at all levels are linked and mutually supportive. Other government departments, the private sector, civil society and international organizations all have crucial roles to play. How will we ensure a healthy future for children like Luciano and the millions of others facing chronic diseases? This requires a new approach » The chronic disease threat can be overcome using existing knowledge by national leaders who are in a » The solutions are effective – and position to strengthen chronic disease highly cost-effective » Comprehensive and integrated prevention and control efforts, and action at country level, led by governments, is the means to by the international public health achieve success community. Visual impairment and blind- ness, hearing impairment and deafness, oral diseases and genetic Projected gl o disorders are other chronic conditions that account for a substantial portion of the global burden of disease. Injuries * Chronic diseases include cardiovascular diseases, cancers, chronic respiratory disorders, diabetes, neuropsychiatric and sense organ disorders, musculoskeletal and oral disorders, digestive diseases, genito-urinary diseases, congenital abnormalities and skin diseases. These risk factors explain the vast majority of chronic disease deaths at all ages, in men and women, and in all parts of the world. Furthermore, chronic diseases – the gets and indicators to include chronic diseases major cause of adult illness and death and/or their risk factors; a selection of these in all regions of the world – have not countries is featured in Part Two. Health more broadly, including is addressed within the context of international chronic disease prevention, contributes health and development work even in least to poverty reduction and hence Goal 1 developed countries such as the United Republic 1 (Eradicate extreme poverty and hunger). Ten of the most common Notions that chronic dis- misunderstandings are pre- eases are a distant threat sented below. In reality, low and middle income countries are at the centre of both old and new public health challenges. While they con- tinue to deal with the problems of infectious diseases, they are in many cases experiencing a rapid upsurge in chronic disease risk factors and deaths, especially in urban settings. These risk levels foretell a devastating future burden of chronic diseases in these countries. The truth tion to his high blood pressure, nor to his drinking is that in all but the least and smoking habits. He then lost his ability to speak after two consecutive diseases, and everywhere strokes four years later. Roberto used to work as a public transport are more likely to die as agent, but now depends entirely on his family to survive. Moreover, chronic diseases cause substantial financial burden, and can push individuals and house- holds into poverty. People who are already poor are the most likely to suffer ﬁnancially from chronic diseases, which often deepen poverty and damage long-term economic prospects. Much of the family’s Roberto is now trapped in his own body and always income is used to buy the special diapers that needs someone to feed him and see to his most basic Roberto needs. Noemia carries him in and out of the house so check-ups are free of charge but sometimes we he can take a breath of air from time to time. Noemia and four of her brothers and sisters also suffer But the burden is even greater: this family not from high blood pressure. We now know that almost half of chronic disease deaths occur prematurely, in people under 70 years of age. In low and middle income countries, middle- aged adults are especially vulnerable to chronic disease. People in these countries tend to develop disease at younger ages, suffer longer – often with preventable 10 years rose from 23% to 28% between 1995 complications – and die sooner than those and 2003.
No funding is provided for viral-hepatitis testing buy 50 mg tenormin arteria3d review, hepatitis B immunizations discount tenormin 50mg line blood pressure questions, or other services generic tenormin 50mg free shipping heart attack 51. Given that the guide- lines cover three distinct and complex diseases (hepatitis A, hepatitis B, and hepatitis C), they lack the detail necessary to create surveillance practices that are consistent among jurisdictions. As a result of the defciency of resources dedicated to hepatitis surveillance, data are incomplete, variable, and inaccurate. Inconsistency between jurisdictions seriously undermines the validity of the data provided at the state, regional, and national levels. The inability of health departments to track all diagnosed cases also se- riously undermines case-management and prevention efforts. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. They are in Colorado, Connecticut, Minnesota, New York state, New York City, Oregon, and San Francisco. Although the projects focus on surveillance for hepatitis A, hepatitis B, and hepatitis C, they all take differ- ent approaches, including multiple approaches in individual jurisdictions. From those interviews, staff identifed additional program- matic issues that affect reporting. They include resource issues, such as the varied capacity of county and city health departments (which leads to inconsistencies in data collection and data systems, in some instances in the same state); the staffng requirements needed to collect, process, and man- age data; and the staff and time needed to investigate health-care–related outbreaks adequately. Other issues are the need to educate medical provid- ers better on which laboratory tests are needed for appropriate diagnosis (also noted by Fleming et al. State, territorial, or city health-department viral- Copyright © National Academy of Sciences. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Each funding source may require different activities and may provide varied guidance on the receiving unit’s activities. Program Design Variability among jurisdictions is also due to a wide array of program structures. The hepatitis C coordinators’ locations within public health departments may or may not correspond with the health department program responsible for conducting surveillance, which can lead to reduced involvement and oversight by the coordinator of viral hepatitis surveillance activities. However, fewer than two-thirds of the program coordinators reported being able to implement the surveillance components. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. There are signifcant barriers to implementing more comprehensive surveillance activities. Many states do not have the staffng or systems to keep up with such a high volume of informa- tion received and are often unable to follow up with medical providers to address underreporting or to obtain demographic and risk-history informa- tion, such as race, ethnicity, and drug-use details (Klein et al. The lack of funding to hire adequate staff is the fundamental barrier to complete and accurate surveillance. Moreover, the use of the forms is inconsistent among states and local jurisdictions. Paradoxically, efforts to modernize and enhance public-health surveil- lance systems have led to greater inconsistency in data collection. However, the system quickly became dated with advances in information and surveillance technology, such as electronic laboratory reporting and electronic medical records. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Consequently, there is a wide array of state systems with an even wider array of capabilities. The lack of standardization makes it diffcult for states to share information effciently. Four of the 43 states that responded to the recent questionnaire for this committee reported not having any staff to enter data. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Of the 113 study participants who became infected, only two cases of those identifed in the study were picked up by the state’s surveillance system (Hagan et al. Those populations include homeless persons, institutionalized and incarcerated persons, and persons of Asian and Pacifc Island descent. Case Evaluation, Followup, and Partner Services The reporting of a case of hepatitis B or hepatitis C by a public test site or private clinic provides an opportunity for public-health followup. Part of the followup generally involves ensuring that the persons with the reported diagnoses and their partners receive proper medical evaluation, counseling, vaccination, and referrals to support services as needed (Fleming et al. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. There was some success in reaching a small sample of the high volume of infected people, but no funding was available to support the staff. Given the demands on staff, most state health-department surveillance units indicated that they were barely able to keep up with the basics of data collection. Followup can consist of making calls to providers or cases to collect demographic, clinical, or risk-history data and contacting infected people by mail, by telephone, or in person to provide education or referral to medi- cal services. For the most part, even the best resourced surveillance units are able to conduct only very limited case management (Fleming et al. Services include notifying sex or needle-sharing partners of exposure to disease and testing, counseling, and referrals for other services. The Centers for Disease Control and Prevention should conduct a comprehensive evaluation of the national hepatitis B and hepatitis C public-health surveillance system. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. The committee found little published information on or systematic review of viral-hepatitis surveillance in the United States. According to the guidelines, the evaluation should “involve an assessment of system attributes, includ- ing simplicity, fexibility, data quality, acceptability, sensitivity, predictive value positive, representativeness, timeliness, and stability. A compre- hensive review is needed to document the current systems and capacities of public-health jurisdictions. Completion of this task should not delay the implemen- tation of other components of the surveillance-related recommendations in this report. The Centers for Disease Control and Prevention should develop specifc cooperative viral-hepatitis agreements with all state and territorial health departments to support core surveillance for acute and chronic hepatitis B and hepatitis C. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. The committee focused on that surveillance model as an alternative to the current model because of its organization, availability of technical assistance, and provision of detailed guidelines. The strength of the model is in its centralized guidance, mandatory process and outcome standards, and oversight at a national level, all of which provide consistency in data among jurisdictions (Hall and Mokotoff, 2007). The agreements not only provide funding for enough dedicated staff to provide followup directly with providers and to conduct active surveillance but commit states and territories to specifc methods and performance expectations.
One way in which researchers are trying to prevent these reactions purchase generic tenormin pills hypertension what is it,for example in the case of monoclonalantibodies buy cheap tenormin 50mg line arrhythmia books, is via the use of ‘humanised’ therapeutic antibodies generic tenormin 100mg visa blood pressure screening, which are produced by inserting human antibody genes into cultured cells. Higher success rates Overall, the virtues of biopharmaceuticals in terms of their efficacy and safety also mean an economic advantage: The likelihood of successfully developing a new biopharmaceutical is significantly greater than in tradi- tional drug development. Not least because interactions, side ef- fects and carcinogenic effects are rare, 25 percent of biophar- maceuticals that enter phase I of the regulatory process are 36 eventually granted approval. However, the lower risk of failure is offset by an investment risk at the end of the development process. From a medical point of view it seems likely that the current suc- cess of biopharmaceuticals will continue unabated and that these products, especially those used in the treatment of com- mon diseases such as cancer, will gain an increasing share of the market. However, therapeutic proteins are unlikely ever to fully replace their traditional counterparts. Examples in- clude lipid-lowering drugs and drugs for the treatment of type 2 (non-insulin-dependent) diabetes. The future also holds pro- mise for hybrids of conventional and biopharmaceutical drugs. The potential of such ‘small molecule conjugates’ is discussed in the following article along with other major areas of research. Spektrum Akademischer Verlag, Heidelberg, 6th edition 2003 Brüggemeier M: Top im Abi – Biologie. Schroedel, Braunschweig, 2004 Presentations at a media conference: The Roche Group – one of the world’s leaders in bio- tech, Basel, November 2004 http://www. Nevertheless, new discoveries about the molecular causes of diseases and the influence exerted by our genes on the effectiveness of medicines are already leading to the development of specific diagnostic techniques and better targeted treatment for individual patients. Any findings and medical science methods discovered by universities and institutes working in the life sciences usually find their way immediately into the industry’s development laboratories. Just a few ex- amples: T During the 1990s biology was defined by the fields of human genetics and genomics. By deciphering the human genome re- searchers obtained profound new insights into the hered- itary basis of the human body. From the mass of genetic in- formation now available researchers can filter out potential target molecules for new Terms biopharmaceuticals. T Since the late 1990s pro- Chimeric made up of components from two different species or individuals. The technique led to the produc- tion of the first humanised chimeric antibodies, in which variable seg- development. Because pro- ments obtained from mouse antibodies are combined with a constant teins can act either as target segment from a human antibody. Copegus (ribavirin) a Roche product used in combination with molecules or as drug mole- Pegasys for the treatment of hepatitis C. Therapeutic antibodies antibodies used as agents for the treat- and proteins have recently ment of diseases. It Therapeutic proteins proteins used as active substances in has been recognised that drugs. In addition, modifi- cations of therapeutic proteins strongly influence their effi- cacy and stability. T In recent years researchers have succeeded in shedding more light on the key functions of the immune system. These findings have led to various new diagnostic approaches and more refined methods for developing therapeutic antibodies. Research-orientated: development of therapeutic proteins Identification of The number of good molecular targets for new molecular therapeutic proteins is limited targets Assessment Pick the winners; assessment in cellular and animal of available models and new targets Design of therapeutic proteins, e. Most important Modern medical biotechnology uses a wide range drug group: therapeutic of methods to diagnose and treat diseases – from proteins the biotechnological production of simple natu- ral products to gene therapy. The most important group of biotechnological drugs by far, however, are the thera- peutic proteins. Most therapeutic proteins are chemical mes- sengers, enzymes or, especially in recent times, monoclonal an- tibodies. Now these molecules can be produced in genetical- ly modified cells that carry the hereditary information for pro- ducing the human protein. Main avenues of research 41 In addition, new findings from basic research now allow thera- peutic proteins to be coupled with non-protein components to improve their efficacy and duration of action. Since the substance is produced mainly in the kidneys, patients with renal damage are prone to develop anemia. Those affected – often dialysis patients – generally feel weak and tired, because their red blood cells no longer carry sufficient supplies of oxygen to the body. Since the early 1990s recombinant erythropoietin has replaced time-consuming, costly and risky blood transfusions, previous- ly the standard treatment for anemic patients. Because the hor- mone is a glycoprotein (see illustration), it cannot be produced in bacterial or yeast-cell cultures: the erythropoietin molecule has several carbohydrate side chains that slow its breakdown in the body but also modify its intrinsic bioactivity. These side chains can be attached to proteins only by the synthe- Erythropoietin: the molecule sising apparatus found in carbohydrate chain mammalian cells. For this reason, only mammalian cells can be used to produce complex therapeutic pro- teins. In renal clinical trials untreated anemic patients can ex- perience a correction of their anemia with one injection twice a month. Patients who are in maintenance can be managed with a single monthly injection whether they have reached end stage renal disease (chronic kidney disease stage 5) or not (typically chronic kidney disease stages 3 and 4). Less frequent adminis- trations reduce the oscillation in hemoglobin levels outside the optimal range of hemoglobin as defined by best practice guide- lines, which is often seen with existing short-acting compounds (epoetin, darbepoetin). Such excursions are associated with ad- verse events and considered to contribute to further deterio- ration of cardiac and renal functions. It is believed that less fre- quent administrations represent a significant gain in quality of life for patients but also allow overworked nephrologists and nurses to concentrate on the other serious medical conditions affecting many of these patients such as hypertension, diabetes, chronic heart failure and obesity. The principle of Improved efficacy of proteins can be achieved pegylation: Pegasys with the help of specific modifications. It is essential to select the proper moiety that will confer Main avenues of research 43 to the active protein the de- A pegylated protein: Pegasys sired properties. The choice of linker is also very impor- tant as its rigidity (or lack thereof) will influence the ultimate properties of the new medicine. Roche has successfully applied this principle to develop a drug for the treatment of hepati- tis C and B. In this method the drug is enveloped in one or two highly branched molecules of polyethylene glycol. It has been used for de- cades for treating hepatitis C, a widespread infection which causes inflammation of the liver.
Cyclophosphamide is more toxic but may be used in severe diffuse proliferative nephritis or severe neu- Investigations ropsychiatric lupus cheap tenormin 50mg without a prescription arteria descendente anterior. Prognosis Generally a good prognosis buy discount tenormin supine blood pressure normal value, chronic forms of the disease Management are seen tenormin 50 mg online pulse pressure transducer. Patients with renal or neuropsychiatric involve- Anticoagulation with aspirin for mild cases and war- ment have a worse prognosis. During the ﬁrst and third trimester of pregnancy low-molecular-weight heparin is used due to the terato- genicity of warfarin and risks of bleeding in labour. Antiphospholipid syndrome Deﬁnition A disorder characterised by the presence of autoantibod- Systemic sclerosis and scleroderma ies directed against phospholipids or plasma proteins bound to phospholipids. Deﬁnition Sclerosis (hardening due to excessive production of con- nective tissue) of collagen affecting the skin (sclero- Aetiology/pathophysiology derma) and the internal organs (systemic sclerosis). The condition causes a thrombotic ten- Incidence dency due to loss of phospholipid dependent coagula- Rare, 3 per million. Pro-thrombotic stimuli such as preg- nancy, surgery, cigarette smoking, hypertension and Age the use of oral contraceptives further exacerbate this Anyage, mean onset at 40 years. Antibodies include the lupus anti-coagulant (anti-coagulant in vitro but procoagulant in vivo), anti β2glycoprotein-I antibodies and anticardiolipin Sex antibodies. A scleroderma like disor- eration and thickening of the intima and ﬁbrosis of the der is seen following exposure to silica, vinyl chlo- adventitia is seen. Morphoea are patches of sclerotic skin on the trunk r Raynaud’s phenomenon is treated by avoiding cold, andlimbs,whichmaybelocalisedormoregeneralised. Malabsorp- r Limited cutaneous systemic sclerosis begins with tion may require changes in diet. Notreatmenthasbeenshowntoalter r Overlap syndromes have combinations of the features the long-term progression of scleroderma. Diffuse dis- of systemic sclerosis, systemic lupus erythematosus, ease with severe visceral involvement carries the worst dermatomyositis or rheumatoid arthritis. Chapter 8: Connective tissue disorders 369 Nervous system: Cardiovascular system: Ischaemic changes in central and Pericarditis, myocardial fibrosis peripheral nervous system. Peripheral causing a restrictive cardiomyopathy, neuropathy may occur due to conduction tissue fibrosis causes perineural vascular sclerosis. Respiratory system: Pulmonary fibrosis especially in lower Gastrointestinal system: lobes and pulmonary hypertension. Motility disorders including gastro- oesophageal reflux with oesophagitis, ulceration and aspiration pneumonia, malabsorption secondary to bacterial Genitourinary system: overgrowth. Sjogren’s¨ syndrome Pathophysiology There is lymphocytic inﬁltration of salivary glands and Deﬁnition other exocrine glands in the respiratory and gastroin- Achronic inﬂammatory disorder of the lacrimal and testinal tract, the skin and the vagina. Sex 9F : 1M Clinical features Aetiology r Ocular manifestations: Sensation of persistent grit- Sjogren’s¨ syndrome may be primary, or secondary to tiness, photosensitivity, tiredness and an inability to rheumatoid arthritis, systemic lupus erythematosus, produce tears (keratoconjunctivitis sicca). There is r Gastrointestinal system: Lack of saliva (xerostomia) an association with non-Hogkin B cell lymphoma. There 370 Chapter 8: Musculoskeletal system may be oral ulcers, dental caries and ﬁrm non-tender age of 40 years. The skin shows collagenous thicken- phenomenon and an association with other organ ing of the dermis with chronic inﬂammatory cell inﬁl- speciﬁc autoimmune disorders in primary Sjogren’s¨ trates. Occasionally there are systemic features including vasculitis and renal tubu- Clinical features lar defects. Gradual onset of non-speciﬁc systemic features followed by symmetrical, progressive, proximal muscle weakness. Occasionally there is cardiac r Schirmer’s test for keratoconjunctivitis sicca measures involvement leading to heart failure, respiratory involve- tear production. An edge of a strip of ﬁlter paper is ment, including nonspeciﬁc interstitial pneumonia, and placed in the lower eyelid and the length that becomes oesophageal involvement, which may be sufﬁciently se- wetismeasured. Management Sex Acute phases are treated with corticosteroids, which 2F: 1M should be reduced gradually to a low-maintenance dose. Methotrexate, azathioprine or cyclophosphamide are Aetiology/pathophysiology used in resistant cases. Dermatomyositis is associated with malignancy of variable severity, and spontaneous remissions can (e. Chapter 8: Crystal arthropathies 371 Marfan’s syndrome Management r β-blockers have been shown to slow aortic dilata- Deﬁnition tion, and lifelong therapy is recommended by the Inherited condition resulting in abnormalities of con- European Society of Cardiology. The under- r Musculokeletal: Patients have elongated and asym- lyingpathologyisanabnormalityinskin,jointandblood metrical faces with a high arched palate. Some of the reduced upper to lower body segment ratio and an subtypes have been mapped to mutations in the collagen arm span that exceeds the patient’s height. Clinical features r Cardiovascular system: There is degeneration of the There is hyperextensible skin with normal elastic recoil, media of blood vessel walls: hypermobile joints, and fragility of blood vessels causing 1 Dilation of the aortic valve ring producing regurgi- bruising and occasionally aortic dissection and rupture. Hypermobility can lead to early osteoarthritic changes 2 Mitral valve prolapse and associated mitral valve and damage to the joints. The diagnosis is clinical and can be based on clinical cri- r Calcium pyrophosphate causes pseudogout. Once diagnosed patients require periodic r Crystallised injected corticosteroids may result in ia- aortic imaging to detect early dilation. Typically pyrosphosphate crystals are seen Xanthine Hypoxanthine within a phagolysosomal sac, whereas urate crystals are Xanthine Oxidase not conﬁned. Phagocytosis induces Uric Acid cytokine release leading to chemotaxis and further in- ﬂammation. An acute inﬂammatory arthritis resulting from urate An acuteepisodeofgoutmaybeprecipitatedbyasudden crystal deposition secondary to hyperuricaemia. Risk factors include surgery, infection, dehydration, severe illness, Prevalence/incidence starvation, diuretics and alcohol. Pathophysiology r Injointsanacutesynovitismayoccurwhenuratecrys- Age tals have been phagocytosed. Sex r If chronic, the crystals accumulate in the synovium 10M:1F and sites such as the ear cartilage forming lumps termed tophi. Theresultof urate damage is either tubulointerstitial disease (urate Aetiology nephropathy) or acute tubular necrosis. High levels of uric acid cause gout but not all individuals with hyperuricaemia will develop gout. Hyperuricaemia Clinical features is associated with increasing age, male sex and obesity, In 70–90% the initial attack of gout affects the big toe. These features ratesofuricacid production or decreased uric acid make it difﬁcult to distinguish from a septic arthritis. Other joints affected include ankles, knees, ﬁngers, el- r Increased uric acid production may be idiopathic or bowsandwrists. Chronicgoutisunusualbutmaycausea secondary to excessive intake or high turnover as seen chronic polyarthritis with destructive joint damage with in malignancy (especially with chemotherapy). Chapter 8: Metabolic bone disorders 373 Investigations Management Urate levels are often high, although they may fall during The pain of pseudogout is relieved by nonsteroidal anti- an acute attack.
The increase of body weight during a full-term pregnancy averages approximately 16 kg discount tenormin 50mg with mastercard enrique heart attack, which is the median weight gain of 4 purchase tenormin cheap online arrhythmia upon waking,218 women who had good pregnancy outcomes (Carmichael et al buy 100 mg tenormin amex pulse pressure 50-60. Weight gain during pregnancy is made up of both additional fat and new lean tissue (including fetus, amniotic fluid, increased plasma volume, etc. The incremental weight gain at the 50th percen- tile for normal weight individuals with good pregnancy outcomes at the end of the first trimester is 2. The amount of protein to support additional tissue is calculated in Table 10-16 using a factor of 0. While it is recognized that pregnancy lean tissue contains a greater amount of water, correction for assumed differences in body com- position have not been made given the lack of actual data delineating protein maintenance needs in pregnant women. This results in an average total additional need for protein during the last two trimesters of preg- nancy of about 21 g/d over prepregnancy requirements. Burke and coworkers (1943) conducted an observational study of 216 mothers giving birth to single infants in Boston and found a significant correlation between average daily protein intake and birth length and birth weight. They concluded that for practical purposes, a protein intake less than 75 g/d was associated with an infant who would be short and light in weight. Studies from the Montreal Diet Dispensary have also shown a relationship between maternal protein- energy intake and birth weight (Higgins, 1976). This study involved 1,736 low-income pregnant women, 20 years of age or more, whose average maternal protein and energy intakes at various stages of pregnancy were 68 g and 2,249 kcal/d during pregnancy, and were increased to an average of 101 g of protein and 2,778 kcal/d by supplementing the mothers with whole milk and eggs during a subsequent pregnancy. Birth weights were significantly higher for siblings with supplemented mothers compared with their older siblings born to the same mothers when they did not receive the supplementary milk and eggs. These data support the value increased intake of foods high in protein and energy during pregnancy and the additional requirements outlined above. The problem of adolescent pregnancy is that the mother may still be completing her growth (Frisancho et al. In those pregnancies in which the mother’s growth is not yet completed, it appears that there is competition between maternal and fetal growth needs (Hediger et al. The Montreal Diet Dispensary studied the effect of supplementing 1,203 low-income pregnant adolescents with whole milk and eggs and compared them with 1,203 pregnant adolescents who did not receive the additional milk and eggs in their diets (Dubois et al. The adoles- cents in the intervention group increased their protein intake from 73 g/d to approximately 125 g/d in addition to significantly increasing their energy intake. Participation in the intervention resulted in significantly increased mean birth weights and reduced the rate of low birth weights by 39 percent (p < 0. It is composed of two components: the amount needed to maintain the new pregnant tissue and the amount needed for initial depo- sition. The amount of protein deposition is corrected for the efficiency of protein deposition (using the estimate from the slope of 0. Since little weight gain occurs during the first trimester, it is assumed that roughly one-third of the total increase in protein deposition during the 40 weeks of pregnancy (~ 925 g) occurs during the second trimester, with two-thirds occurring during the third trimester. As described above, by the end of the third trimester, ~17 g/d is needed to allow for adequate protein deposition; it can be assumed that roughly half that amount is needed for growth during the second trimester, or 8 g/d (Table 10-16). Given the small amount of protein accretion expected to occur during the first trimester (as demonstrated by Thompson and Halliday  in protein turnover studies during each trimester), the need for additional protein is rather low at this stage. Thus no addi- tional increase in protein requirements is estimated for the first trimester. Since this figure includes the protein needs for the additional tissue deposited, when calculating the amount needed per kilogram of body weight to use with pregnant women, only the amount needed for protein deposition is considered. Pregnant individuals who were studied ranged from 15 to 19 years of age (King et al. For adolescents, the additional need for protein during the second and third trimesters is assumed to be the same as for adult women. Data for the variability of protein deposition in the fetus and mother was not avail- able. Again, in considering the amount needed per kilogram of body weight, only that due to protein deposition is considered. Thus, it is logical to assume that a woman supporting the growth of twins has higher protein needs than a woman having a singleton birth. In a study in which the mothers of twins received nutritional inter- vention (target supplementation was an additional 50 g of protein/d and 1,000 kcal/d) from the 20th week, pregnancy outcome was improved, with a decrease in the low birth weight rate by 25 percent and the very low birth weight rate by 50 percent (Dubois et al. Although this study did not measure the dietary protein or energy intake of the women bearing twins, they gained 2 kg more than the controls. No study could be found that investigated dietary protein intervention in twin pregnancy. On the basis of these data, it seems prudent to provide women carrying twins with protein intakes of an additional 50 g/d beginning in the second trimester, along with sufficient energy to utilize the protein as efficiently as possible. While it appears that the concentration of protein in human milk is not influenced by diet or body composition even in undernourished mothers (Lönnerdal 1986), protein intakes of 1 g/kg of body weight/d promoted the conservation of skeletal muscle in order to maintain good milk production in lactating mothers (Motil et al. Lactating women with these protein intakes appear to adapt by down-regulating protein metabolism (Motil et al. The factorial approach is utilized for determining the protein require- ment during lactation. In this approach, it is assumed that the process of lactation does not alter the maintenance protein requirement of the nonlactating woman and that the protein and amino acid requirements are increased in proportion to milk production. It is important to empha- size that human milk is characterized by a relatively high concentration of nonprotein nitrogenous substances, which contribute approximately 20 to 27 percent of total milk nitrogen (Butte et al. Whether this merely reflects a diversion of urea loss from urine (plus some colonic fermentation) to milk is not known, but in the calculations it is assumed that part of the increased nitrogen needs of the lactating woman will of necessity be derived from her dietary protein. The additional protein requirement for lactation therefore is defined as the output of total protein and nonprotein nitrogen in milk. This table shows the factorial estimate of the increase in protein requirement associated with lactation and assumes that the incremental efficiency of nitrogen utilization of 0. It is assumed that the cost of making protein for maintenance requirements is the same as that for growth and lactation. When the absolute increase was converted to weight-specific intakes by using the reference weights of adolescent girls 14 to 18 years (54 kg) and adult women 19 to 50 years (57 kg) from Chapter 1 (Table 1-1), the numbers were quite close, so the highest value (that for the 14- to 18-year-old category) is provided as the overall recom- mendation. Adding the average requirement for additional protein needed is calculated as +21. Again, given the closeness of the values, one value is recommended for all age groups. Whether or not this is true has significance not only for athletes, but also for those with muscle wasting who wish to preserve muscle mass by training, such as elderly or immobile adults, or those suffering from muscle-wasting dis- eases. The available literature includes studies of both resistance (body- building) and endurance training. Endurance training does not result in muscle building, which would increase muscle protein deposition, but it is well recognized that endurance exercise is accompanied by an increase in the oxidation of branched chain amino acids (Lemon et al. However, these were acute studies performed around the time of the exercise itself, and did not take into account the remaining part of the day. An examination of leucine oxidation over a 24-hour period, including exercise during each of the fed and fasting periods, showed that the increase in oxidation, although statistically significant, was small in relation to the total daily amount of oxidation (4 to 7 percent) (El-Khoury et al.
In family medicine buy tenormin 50mg fast delivery blood pressure terms, much of our ability to diagnose and ad- Rules for patients to get along with their doctor: vise is based on a trusting relationship with our patients that • Rule 1: Your doctor can’t do it alone proven 50 mg tenormin pulse pressure 62. As in all relationships buy tenormin once a day blood pressure chart symptoms, there must be doctor does not mean you should not ask support and resolve to permit the relationship to grow. As one commentator has written, for there to be a justifed trust between patient and doctor, “the consultation must be distractible. Case resolution • Rule 5: They want to know what is going to be The resident used the services available through her local done and when. I am a good patient, that the patient must always agree with the physician’s recom- believe it or not. Because one shoe doesn’t patient fnd concordance on an approach to care in illness and ft all: a repertoire of doctor–patient relationships. Objectives that only 14 per cent of the participants consumed the recom- This chapter will mended six to eight glasses of water per day, and the majority • describe some of the barriers to adequate nutrition in the (60 per cent) snacked less than once a day (Winston 2008). A workplace, qualitative study in which physicians were interviewed about • discuss how inadequate nutrition can affect physicians their workplace nutrition habits reported that 19 of the 20 par- personally and professionally, and ticipants expressed that they sometimes have diffculty eating • suggest ways in which individual physicians can infuence and drinking during work hours (Lemaire et al 2008). In particular the usual attention to healthy What is the impact of inadequate nutrition on physi- nutrition has been gradually eroded by long sessions in cians? Poor nutrition for physicians during the work day has the operating room and lengthy work days. The resident signifcant consequences, both for the individual physician and regards the nutrition choices at the hospital as unaccept- for the workplace. Physicians have previously described how able and fnds they are missing meals, losing weight and their inability to eat and drink properly during work hours is generally feeling awful on most days. When considering physicians’ nutrition in the For physicians: workplace, the solution should be simple—just make time to • Eat breakfast. However, the issue is not so straightforward, and • Carry healthy and convenient snacks with you. Nutrition in the health care workplace To improve nutrition in the workplace, physicians and health For health care organizations: care organizations must enhance their awareness and under- • Improve the quality and variety of foods available standing of the impact of inadequate nutrition and the barriers in the workplace. Without this knowledge, there will be little • Improve access to nutritious food (e. For example, one study provided a description of some eat, drink and store food from home. They also Case resolution felt that inadequate nutrition had a negative impact on both The resident is facing an issue common to most physi- their ability to complete their work and on their interactions cians—diffculty obtaining adequate nutrition during the with patients, colleagues and other health care professionals. The resident consumed adequate nutrition during a work day had better becomes more aware of the link between nutrition and cognitive function than those who neglected their nutritional well-being. Physicians have identifed several baked rice or whole grain crackers, juice boxes, yogurt practical barriers to healthy eating in the work environment. The resident identifes clean and secure These include lack of time to stop and eat, mostly as a result storage areas on the units where they work and also keeps of staff shortages and workload issues, lack of scheduled a few snacks in their lab coat pocket and locker. The breaks, lack of convenient access to food, poor food choices resident makes time for a healthy balanced breakfast daily. In addition to these practical barriers, physicians have room and ward work schedule. The resident encourages also described how certain attributes of medical professional- the other members of the team to do the same. The ism may in fact hinder their workday nutrition (Lemaire et al resident lobbies the health care organization to improve 2008). For example, doctors have expressed how their strong access to and quality of available nutrition, and to provide work ethic and sense of professionalism discourages them designated, convenient spaces for nutrition breaks. Changing the status quo Many physicians are aware of healthy nutritional choices and Winston J, Johnson C, Wilson S. To overcome these barriers, there needs to be advocacy for ad- equate nutrition in the workplace. Education and dialogue will guide physicians and health care organizations to an increased awareness of the doctors’ nutrition patterns, a facilitation of positive change, and an appreciation of the link between physician nutrition and work performance. As physicians and health care organizations promote the benefts of improved nutrition and workplace wellness, everyone will beneft, given the important link between physician wellness and quality of patient care. Summary Various personal and workplace factors can make it diffcult for physicians to ensure adequate nutrition during their work day. Physicians and health care organizations share a responsibility to improve workplace nutrition by raising awareness, changing nutrition practises and improving access to nutritious food in the workplace. It begins for The medical student most people with deciding sometime during the undergraduate Admission to medical school is a tremendous accomplish- years of university to pursue studies in medicine. There is the delight of achievement, the pride of family is the frst step toward a professional career that is rich in per- and friends, and the promise of a rewarding future. The memory of this joy will serve taken lightly, as the years of training are demanding and require successful candidates in good stead during their transition to self-discipline and dedication. This transition is not meant to be easy, but it preparation, followed by many years of practice, along with brings great potential for personal and academic growth. Medical school admission Medical school can present challenges to one’s personal life. Applicants are expected to have mitment required can challenge relationships: not everyone had a breadth of life experience, as demonstrated in volunteer will fnd it easy to accommodate the medical student’s new work, job experiences, extracurricular activities, a proven ability schedule and its demands. Added to these stresses is the fnan- to assume responsibility, an altruistic nature and good interper- cial burden of tuition, which may create or add to an existing sonal skills. This standardized examination has four sections focusing on physical sciences, This combination of challenges tests everyone at some point biological sciences, verbal reasoning and writing. Medical students are at risk of develop- these daunting requirements are the fnancial implications of ing unhealthy lifestyle habits. All of these factors—poor coping strategies that arise in re- sponse to stress and constraints of time—can quickly lead to further diffculties. It is important to be aware that medical schools have devel- oped a wide range of personal and professional resources to provide support for their students. These resources can be readily accessed through the institution’s undergraduate medi- cal education offce. Physicians who are graduated physicians lived within the hospital to further their satisfed with their career are not only disciplined, effective and clinical training and hone their skills. The term lives on, al- productive: they also take pleasure in the work—but not at though the times have changed. It therefore from two to six years in duration—are instrumental for the requires considerable commitment to proactively manage one’s development of expertise in a chosen specialty. The years of training are preparation for a way of the same issues that existed in medical school persist, new of being. It is important for residents to pursue medicine in challenges will come with increased responsibility for patient a fashion that is in keeping with who they are as individuals.