By M. Jarock. Wheelock College.
Countries that have Sample of countries that have consistently treated citizens dependent on drugs as patients in need of resisted large scale implementation of harm treatment olanzapine 20 mg for sale, instead of criminals deserving of punishment buy olanzapine 2.5 mg on line, have reduction strategies, despite the presence of demonstrated extremely positive results in crime reduction, drug injecting and sharing: health improvement, and overcoming dependence. The consistent implementation researchers in this case also referred to police of this policy has led to an overall reduction in criminal records data. The research shows the number of people addicted to heroin as well that the numbers of charges brought against as a range of other benefts. A key study14 1,476 drug users in the years before and after concluded that: entering treatment reduced by 48 percent. Heavily engaged in Heroin has lost its appeal to the mainstream youth both drug dealing and other forms of crime, they and is considered a ‘dead-end street drug’. The number of problematic heroin users has As these hard-core users found a steady, legal dropped signifcantly and the average age of users means for their addiction, their illicit drug use was has risen considerably. Large-scale, low-threshold reduced as well as their need to deal in heroin drug treatment and harm reduction services and engage in other criminal activities. The heroin substitution program had three effects on the drug market: Medically prescribed heroin has been found • It substantially reduced the consumption among in the Netherlands to reduce petty crime and the heaviest users, and this reduction in demand public nuisance, and to have positive effects on affected the viability of the market. The development and implementation of drug A current example of this process (what may be described policies should be a global shared responsibility, as ‘drug control imperialism’), can be observed with the but also needs to take into consideration diverse proposal by the Bolivian government to remove the political, social and cultural realities. Policies should practice of coca leaf chewing from the sections of the respect the rights and needs of people affected 1961 Convention that prohibit all non-medical uses. As with all multilateral agreements, the However, the idea of shared responsibility has too often drug conventions need to be subject to constant review become a straitjacket that inhibits policy development and modernization in light of changing and variable and experimentation. This analysis strenuously over the last 50 years to ensure that all and exchange of experiences is a crucial element of the countries adopt the same rigid approach to drug policy process of learning about the relative effectiveness of – the same laws, and the same tough approach to their different approaches, but the belief that we all need to have enforcement. As national governments have become exactly the same laws, restrictions and programs has been more aware of the complexities of the problems, and an unhelpful restriction. When these involve a more tolerant approach to drug use, governments have faced international diplomatic pressure to ‘protect the integrity of the Conventions’, even when the policy is legal, successful and supported in the country. These allocation, and implementation have not modernized at negative consequences were well summarized by the the same pace. The growth of a ‘huge criminal black market’, fnanced demonstrated that governments achieve much greater by the risk-escalated profts of supplying international fnancial and social beneft for their communities by demand for illicit drugs. Extensive policy displacement, the result of using scarce investing in supply reduction and law enforcement activities. Geographical displacement, often known as ‘the balloon the punishment of people who use drugs. This structure is premised on the notion that international drug control is primarily a fght against crime and criminals. Unsurprisingly, there is a built-in vested interest in maintaining the law enforcement focus and the senior decisionmakers in these bodies have 4. Drug policies must be pursued in a comprehensive traditionally been most familiar with this framework. The marginalization of the World Health system have been the police, border control and military Organization is particularly worrisome given the fact that authorities directed by Ministries of Justice, Security it has been given a specifc mandate under the drug or Interior. Caitlin Hughes of the University of New strategies will not solve the drug problem, and South Wales and Professor Alex Stevens of the University that the war on drugs has not, and cannot, be won. Hughes and Stevens’ 2010 report detects a slight increase in overall rates of drug use in Portugal in the 10 years since 2. Replace the criminalization and punishment of decriminalization, but at a level consistent with other similar people who use drugs with the offer of health and countries where drug use remained criminalized. Their overall conclusion is that was that the threat of arrest and harsh punishment the removal of criminal penalties, combined with the use would deter people from using drugs. In practice, of alternative therapeutic responses to people struggling this hypothesis has been disproved – many countries with drug dependence, has reduced the burden of drug law that have enacted harsh laws and implemented enforcement on the criminal justice system and the overall widespread arrest and imprisonment of drug users and level of problematic drug use. The researchers wished to examine whether the more repressive policy environment of San Francisco deterred citizens from smoking cannabis or delayed the onset of use. They found that it did not, concluding that: “Our fndings do not support claims that criminalization reduces cannabis use and that decriminalization increases cannabis use. With the exception of higher drug use in San Francisco, we found strong similarities across both cities. We found no evidence to support claims that criminalization reduces use or that decriminalization increases use. Of course, this does not necessarily mean that a period when the use of cannabis was in general decline sanctions should be removed altogether – many drug across the country. However, the researchers found that users will also commit other crimes for which they need this downward trend was the same in Western Australia, to be held responsible – but the primary reaction to drug which had replaced criminal sanctions for the use or possession and use should be the offer of appropriate possession of cannabis with administrative penalties, advice, treatment and health services to individuals who typically the receipt of a police warning called a ‘notice need them, rather than expensive and counterproductive of infringement’. Encourage experimentation by governments unlike the predictions of those public commentators with models of legal regulation of drugs (with who were critical of the scheme, cannabis use in cannabis, for example) that are designed to Western Australia appears to have continued to decline undermine the power of organized crime and despite the introduction of the Cannabis Infringement safeguard the health and security of their citizens. In the 2008 Report of policies and programs that minimize health and social the Cannabis Commission convened by the Beckley harms, and maximize individual and national security.
Hormone therapy Issue Does hormone replacement therapy reduce cardiovascular risk? Evidence On the basis of data from observational studies (400) order olanzapine 20mg line, hormone therapy has been used for pre- vention of cardiovascular disease purchase olanzapine 20 mg line, osteoporosis and dementia. This practice has been called into question following publication of the results of several randomized clinical trials, which showed no coronary protection, and the Women’s Health Initiative (401), which indicated that long-term use of estrogen plus progestin was associated with increased risks of cancer and cardiovascular disease. A Cochrane systematic review (402) of 15 randomized double-blind trials (involving 35 089 women aged 41 to 91 years) examined the effect of long-term hormone replacement therapy on mortality, heart disease, venous thromboembolism, stroke, transient ischaemic attacks, cancer, gallbladder disease, fractures and quality of life. All were placebo-controlled trials, in which perimenopausal or postmenopausal women were given estrogens, with or without progestogens, for at least one year. The only statistically signiﬁcant beneﬁts of hormone therapy were decreased incidences of frac- tures and colon cancer with long-term use. In relatively healthy women, combined continuous hormone therapy signiﬁcantly increased the risk of coronary events and venous thromboembolism (after one year’s use), stroke (after 3 years), breast cancer (after 5 years) and gallbladder disease. Long-term estrogen-only hormone therapy also signiﬁcantly increased the risk of stroke and gall- bladder disease. In relatively healthy women over 65 years taking continuous combined hormone therapy, there was an increase in the incidence of dementia. Global and regional burden of disease and risk factors, 2001: systematic analysis of popula- tion health data. Prevention of recurrent heart attacks and strokes in low and middle income popula- tions. A race against time: the challenge of cardiovascular disease in developing economies. Secondary prevention of non-communicable diseases in low- and middle-income countries through community-based and health service interventions. Risk factors in early life as predictors of adult heart disease: the Bogalusa Heart Study. Combined effects of systolic blood pressure and total cholesterol on cardiovascular disease risk. Joint effects of systolic blood pressure and serum cholesterol on cardiovascular disease in the Asia Paciﬁc Region. Efﬁcacy and safety of cholesterol- lowering treatment: prospective meta-analysis of data from 90,056 participants in 14 randomised trials of statins. Effects of different blood-pressure- lowering regimens on major cardiovascular events: results of prospectively-designed overviews of randomised trials. Age-speciﬁc relevance of usual blood pressure to vas- cular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Effect of statins on risk of coronary disease: a meta-analysis of randomized controlled trials. The effects of blood pressure reduction in older patients: an overview of ﬁve randomized controlled trials in elderly hypertensives. West of Scotland Coronary Prevention Study: identiﬁcation of high-risk groups and comparison with other cardiovascular intervention trials. In: Coronary heart disease: National Service Framework for Coronary Heart Disease – Modern standards and service models. Coronary and cardiovascular risk estimation for primary prevention: validation of the new Shefﬁeld table in the 1995 Scottish health survey population. Primary prevention of heart disease and stroke: a simpliﬁed approach to estimating risk of events and making drug treatment decisions. Prevention of coronary heart disease in clinical practice: recommendations of the Second Joint Task Force of European and other Societies on Coronary Prevention. Validation of the Framingham coronary heart disease prediction scores: results of a multiple ethnic groups investigation. An adaptation of the Framingham coronary heart disease risk function to European Medi- terranean areas. Predictive accuracy of the Framingham coronary risk score in British men: prospective cohort study. Treatment with drugs to lower blood pressure and blood cholesterol based on an individual’s absolute cardiovascular risk. Deﬁnition, diagnosis and classiﬁcation of diabetes mellitus and its complications. American College of Endocrinology position statement on the insulin resistance syndrome. American Diabetes Association Standards of medical care for patients with diabetes mellitus.
Chapter 3: Obstructive lung disorders 109 Incidence Pathophysiology 20% of children cheap olanzapine 10mg, 5–14% of adults discount olanzapine 7.5 mg with visa, increasing in preva- The clinical picture of asthma results from mixed acute lence. With time this repeated stimula- Can present at any age, predominantly in children. They secrete mediators of acute and 2 Intrinsic asthma tends to present later in life. There is chronic inﬂammation including enzymes and oxygen no identiﬁable allergic precipitant. Patients with occupational asthma from the listed causes are entitled to compensation under in- inﬂammation recruiting and activating ﬁbroblasts dustrial injuries legislation in the United Kingdom. They also lead, through r Forall patients, non-speciﬁc irritant trigger fac- mechanisms which are not yet clearly deﬁned, to tors include viral infections, cold air, exercise, bronchialhyperresponsiveness–anexaggeratedbron- emotion, atmospheric pollution, dust, vapours, choconstrictor response to non-speciﬁc insults to the fumes and drugs particularly nonsteroidal anti- airways. The pattern of airway reaction following inhalation of an allergen: i An acute reaction occurring within minutes, peaking Table3. Non IgE related Isocyanates, colophony fumes (from ii A late reaction occurring 4–8 hours after inhalation solder), hardwood dust, complex (the chronic inﬂammatory response). If there is diagnostic difﬁculty in patients with mild symp- Mild–moderate Life-threatening attack Severe attack attack toms or just cough, exercise tests or peak ﬂow diary card r r r recordings as above. Occasionally, a trial of oral corti- Speech normal Unable to Silent chest costeroids for 2 weeks can be used. Skin tests are used complete sentences to identify speciﬁc allergens and serum can be taken for r Pulse <110 r Pulse ≥110 r Cyanosis total and speciﬁc IgEs. An asthma attack is characterised by rapid inspiration, r Allergen avoidance can be advised, e. However these rarely have a major im- tial severity of asthma patients require rapid assessment pact on disease. An acute asthma attack is classiﬁed r Drug therapy includes: short acting β agonists for 2 according to clinical severity (see Table 3. Night-time waking, early phyllines and other agents with additional activities morning wheeze, acute exacerbations in the preceding (see Fig. Once disease control is achieved the steroid dose is reduced under regular review to Complication the minimum dose required to maintain disease Pneumothorax, surgical emphysema due to rupture of control. How- should not be reduced more frequently than every 3 ever, the test may be falsely negative if the asthma is months. Chapter 3: Obstructive lung disorders 111 Step 5: Continuous or frequent oral steroids Daily oral steroids in lowest dose providing adequate control whilst continuing maximal inhaled steroids and use of other steroid sparing agents. Refer patient for specialist care Step 4: Persistent poor control Consider trial of: • Very high dose inhaled steroid • Addition of a fourth drug e. Prognosis Most children and teenagers with asthma improve as Prevalence they get older, although asthma may recur in adult life. Em- All patients should be advised not to smoke and to avoid physematous spaces are found in 50% of smokers aged potential work allergens. Chronic bronchitis and emphysema Sex Deﬁnition M > F Chronicbronchitishasaclinicaldeﬁnitionofcoughpro- ductive of sputum on most days for at least 3 months of Geography the year for more than 1 year. New regression equations for predicting Patients with severe asthma (indicated by need for admission) and adverse peak expiratory flow in adults. Expiratory wheeze and cough are present Virtually conﬁned to cigarette smokers and related to the but the cough is dry. As emphysema be- causes pan-acinar emphysema and accounts for 5% of comesmoresevereothersignsbecomeevidentinclud- patients with emphysema. One in 5000 births have a ho- ing tachypnoea, cachexia, the use of accessory muscles mozygousdeﬁciencyandmostthesegoontodevelopthe of respiration, intercostal recession, pursed lips on ex- lung disease. Patients tend to be young (below 40 years) piration, poor chest expansion (a hyperinﬂated chest especiallyifsmokers,inwhomthediseaseismuchworse. The pink puffer is typical of relatively of airways and luminal narrowing resulting in airway pure emphysema and the blue bloater is typical of rel- obstruction. Mucus respiratory bronchioles whilst the more distal alveolar gland hypertrophy and hyperplasia can be quantiﬁed by ducts and air spaces tend to be well preserved. The theReidindexwhichistheratioofglandtowallthickness alveolar dilatation results from loss of elastic recoil in within the bronchus. Smoking Microscopy also causes glandular hypertrophy (chronic bronchi- Both emphysema and chronic bronchitis are inﬂam- tis) and has an adverse effect on surfactant favouring matory diseases of the lung. In pan-acinar emphysema destruction involves the Eosinophilsarealsoseenespeciallyinchronicbronchitis, whole of the acinus. Theclinicalfeaturesdepend Complications on the degrees of chronic bronchitis and of emphysema Airway obstruction and alveolar destruction eventually contributing to the overall picture. Pulmonary vasculature re- ductive of sputum, expiratory wheeze and progres- sponds to hypoxia by vasoconstriction which increases sive shortness of breath. Symptoms of emphysema the arterial pressure, causing pulmonary artery hyper- are dominated by progressive breathlessness, initially tension, which leads to right heart failure (cor pul- only on exertion but eventually on mild exertion such monale). There may be secondary polycythaemia due Chapter 3: Obstructive lung disorders 115 to hypoxia.
The intake that meets the average energy expenditure of individuals at the reference height order olanzapine 20mg online, weight buy 7.5 mg olanzapine overnight delivery, and age (see Table 1-1). A deficiency of n-6 polyunsaturated fatty acids is characterized by rough and scaly skin, dermatitis, and an elevated eicosatrienoic acid:arachidonic acid (triene:tetraene) ratio. The intake that meets the estimated nutrient needs of half the individuals in a group. The intake that meets the nutrient need of almost all (97–98 percent) individuals in a group. These fatty acids also modulate the metabolism of n-6 polyunsaturated fatty acids and thereby influence the balance of n-6 and n-3 fatty acid-derived eicosanoids. Along with amino acids, they function as enzymes, membrane carriers, and hormones. Amino acids are dietary components of protein; nine amino acids are considered indispensable and thus dietary sources must be provided. The relative ratio of indispensable amino acids in a food protein and its digestibility determines the quality of the dietary protein (see Table S-8). The intake that meets the estimated nutrient needs of half the individuals in a group. The model consists of a systematic series of scientific consider- ations and judgments. The hallmark of the risk assessment model is the requirement to be explicit in all of the evaluations and judgments made. For the first half of pregnancy, the protein requirements are the same as those of the non- pregnant woman. It is thus recommended that saturated fatty acid, trans fatty acid, and cholesterol consumption be as low as possible while consuming a nutritionally ade- quate diet. Like all chemical agents, nutri- ents and other food components can produce adverse effects if intakes are excessive. Therefore, when data are extremely limited or conflicting, extra caution may be warranted in consuming levels significantly above that found in typical food-based diets. A growing body of evidence has shown that macronutrients, particularly fats and car- bohydrate, play a role in the risk of chronic diseases. Although various guidelines have been established that suggest a maximal intake level of fat and fatty acids (e. Further- more, because there may be factors other than diet that may contribute to chronic diseases, it is not possible to determine a defined level of intake at which chronic diseases may be prevented or may develop. If an individual consumes below or above this range, there is a potential for increasing the risk of chronic diseases shown to affect long-term health, as well as increasing the risk of insufficient intakes of essential nutrients. Conversely, interventional studies show that when fat intakes are high, many individuals gain additional weight. Furthermore, these ranges allow for sufficient intakes of essential nutrients, while keeping the intake of saturated fat at moderate levels. The upper boundary corresponds to the highest intakes from foods consumed by individuals in the United States and Canada. This maximal intake level is based on ensuring sufficient intakes of essential micronutrients that are, for the most part, present in relatively low amounts in foods and beverages that are major sources of added sugars in North American diets. When assessing nutrient intakes of groups, it is important to consider the variation in intake in the same individuals from day to day, as well as underreporting. Infants consuming formulas with the same nutrient composition as human milk are consuming an adequate amount after adjustments are made for differences in bioavailability. Highest priority is thus given to studies that address the following research topics: • long-term, dose–response studies to help identify the requirement of individual macronutrients that are essential in the diet (e. It is recognized that it is not possible to identify a defined intake level of fat for maintaining health and decreasing risk of disease; however, it is recognized that further information is needed to identify acceptable ranges of intake for fat, as well as for protein and carbohydrate that are based on prevention of chronic diseases and maintaining health; • studies to further understand the beneficial roles of Dietary and Functional Fibers in human health; • studies during pregnancy designed to determine protein and energy needs; • information on the form, frequency, intensity, and duration of exercise and physical activity that is successful in managing body weight in both children and adults; • long-term studies on the role of glycemic response in preventing chronic diseases, such as diabetes and coronary heart disease, in healthy individuals, and; • studies to investigate the levels at which adverse effects occur with chronic high intakes of specific macronutrients. For some nutrients, such as saturated fat and cholesterol, biochemical indicators of adverse effects can occur at very low intakes. Thus, more information is needed to ascer- tain defined levels of intakes at which onset of relevant health risks (e. A state- ment for health professionals from the Nutrition Committee, American Heart Association. This comprehensive effort is being undertaken by the Standing Committee on the Scientific Evaluation of Dietary Reference Intakes of the Food and Nutrition Board, Institute of Medicine, the National Academies, in collaboration with Health Canada. See Appendix B for a description of the overall process, its origins, and other relevant issues that developed as a result of this new process. Establishment of these reference values requires that a criterion of nutritional adequacy be carefully chosen for each nutrient, and that the population for whom these values apply be carefully defined. A requirement is defined as the lowest continuing intake level of a nutrient that, for a specific indicator of adequacy, will maintain a defined level of nutriture in an individual. The median and average would be the same if the distribution of requirements followed a symmetrical distribution and would diverge if a distribution were skewed.
Early in 2008, Sue Clark brought a handful of epigenetics researchers from Australia together to form the Australian Epigenetics Alliance. The AEpiA has now grown to a membership of nearly 300, with members spanning not only Australasia, but the globe. Last year we hosted our seventh flagship conference, Epigenetics 2017 in Brisbane, QLD, and the WA team are already busy preparing for Epigenetics 2019 – watch this space!
Past Epigenetics meetings: