By B. Altus. University of North Texas.

Capacity If there is serious doubt about the patient’s capacity to give consent buy discount bimat 3ml on line, it should be assessed as a matter of priority generic bimat 3 ml with visa. The patient’s general practitioner or other responsible doctor may be sufficiently qualified to make the assessment, but in serious or complex cases involving difficult issues about the future health and well-being, or even the life of the patient, the issue of capacity to consent should be assessed by an independent psychiatrist (in England, ideally, but not necessarily, one approved under section 12 of the Mental Health Act of 1983) (9). If after assessment serious doubts still remain about the patient’s competence (e. Understanding Risks and Warnings A signature on a form is not, of itself, a valid consent. For a valid, true, or real consent in law, the patient must be sufficiently well informed to under- stand that to which he or she is asked to give consent. To defend a doctor against a civil claim alleging lack of consent based on a failure to warn adequately, it is necessary to have more than a signature on a standard consent form. Increasingly, in medical negligence actions, it Fundamental Principals 41 is alleged that risks were not explained nor warnings given about possible adverse outcomes. Therefore, it is essential for the doctor or any other healthcare professional to spend adequate time explaining the nature and purpose of the intended investigation, procedure, or treatment in terms that the patient can understand. The patient’s direct questions must be answered frankly and truthfully, as was made clear in the Sidaway case (11), and thus the discussions should be undertaken by those with adequate knowledge and experience to deal with them; ideally, the clinician who is to perform the operation or procedure. Increasingly, worldwide the courts will decide what the doctor should warn a patient about—applying objective tests, such as what a “prudent patient” would wish to know before agreeing. For example, in the leading Australian case (12), the court imposed a duty to warn about risks of remote (1 in 14,000) but serious complications of elective eye surgery, even though professional opinion in Australia at the time gave evidence that they would not have warned of so remote a risk. In the United States and Canada, the law about the duty to warn of risks and adverse outcomes has long been much more stringent. In the leading case (13), the District of Columbia appeals court imposed an objective “prudent patient” test and enunciated the following four principles: 1. Every human being of adult years and sound mind has a right to determine what shall happen to his or her body. Consent is the informed exercise of choice and that entails an opportunity to evaluate knowledgeably the options available and their attendant risks. In the leading Canadian case (14), broad agreement was expressed with the propositions expressed in the American case. The prac- titioner is not required to make an assessment based on the information to be given to an abstract “prudent patient;” rather, the actual patient being con- sulted must be assessed to determine what that patient should be told. How- ever, the Sidaway and Bolitho (15) cases make clear that doctors must be supported by a body of professional opinion that is not only responsible but also scientifically and soundly based as determined by the court. The message for the medical and allied health care professions is that medical paternalism has no place where consent to treatment is concerned; patients’ rights to self-determination and personal autonomy based on full dis- closure of relevant information is the legal requirement for consent. A doctor must be satisfied that the patient is giving a free, voluntary agreement to the pro- posed investigation, procedure, or treatment. Express consent is given when the patient agrees in clear terms, verbally or in writing. A verbal consent is legitimate, but because disputes may arise about the nature and extent of the explanation and warnings about risks, often months or years after the event, it is strongly recommended that, except for minor matters, consent be recorded in written form. In the absence of a contemporaneous note of the discussions leading to the giving of consent, any disputed recollections will fall to be decided by a lengthy, expensive legal process. The matter then becomes one of evidence, with the likelihood that the patient’s claimed “per- fect recall” will be persuasive to the court in circumstances in which the doctor’s truthful concession is that he or she has no clear recollection of what was said to this particular patient in one of hundreds of consultations undertaken. A contemporaneous note should be made by the doctor of the explana- tion given to the patient and of warnings about risks and possible adverse outcomes. It is helpful to supplement but not to substitute the verbal explana- tion with a printed information leaflet or booklet about the procedure or treat- ment. The explanation should be given by the clinician who is to undertake the procedure—it is not acceptable to “send the nurse or junior hospital doc- tor” to “consent the patient. How- ever, in circumstances in which the procedure has a forensic rather than a therapeutic content and the doctor is not the patient’s usual medical attendant but may be carrying out tasks that affect the liberty of the individual (e. If no assumptions are made by the doctor and express agree- ment is invariably sought from the patient—and documented contemporane- ously—there is less chance of misunderstandings and allegations of duress or of misleading the individual. Adult Patients Who Are Incompetent Since the implementation of the 1983 Mental Health Act in England and Wales (and the equivalent in Scotland) no parent, relative, guardian, or court can give consent to the treatment of an adult patient who is mentally incompe- tent (16). The House of Lords had to consider a request to sterilize a 36-yr-old woman with permanent mental incapacity and a mental age of 5 years who had formed a sexual relationship with a fellow patient. The court held that no one, not even the courts, could give consent on behalf of an adult who was incompetent. Age of Consent In England, section 8 of the Family Law Reform Act 1969 provides that any person of sound mind who has attained 16 year of age may give a valid consent to surgical, medical, or dental treatments. For those under 16 years of age the House of Lords decided (18) that valid consent could be given by minors, provided that they understood the issues. The case concerned the provision of contraceptive advice to girls younger than 16 years in circumstances in which a parent objected.

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Uterine Fibroids • The majority are without symptoms but may be associated with vague feelings of discomfort purchase bimat 3 ml, pressure buy bimat 3 ml on-line, congestion, bloating, and heaviness; can include pain with vaginal sexual activity, urinary frequency, backache, abdominal enlargement, and abnormal bleeding • Abnormal bleeding in 30% of women with fibroids Uterine fibroids are bundles of smooth muscle and connective tissue that can be as small as a pea or as large as a grapefruit. However, because they disrupt the blood vessels and glands in the uterus, they can cause bleeding and loss of other fluids. Uterine fibroids are classified according to their location, as follows: • Submucosal (just under the lining of the uterus) • Intramural (within the uterine muscle wall) • Subserosal (just inside the outer wall of the uterus) • Interligamentous (in the cervix between the two layers of the broad ligament) • Pedunculated (on a stalk, either submucosal or subserous) Causes Increases in local estrogen (specifically estradiol) concentration within the fibroid itself are thought to play a role in the development and growth of fibroids. Concentrations of estrogen receptors are higher in fibroid tissue than in the surrounding tissue. In addition to an excess of estrogen production within the body, a strong case can be made for the role of the most significant environmental factor assaulting female hormonal health—compounds known as xenoestrogens. These compounds are also known as endocrine or hormone disrupters, environmental estrogens, hormonally active agents, estrogenic substances, estrogenic xenobiotics, and bioactive chemicals. Examples of xenoestrogens include phthalates (used in plastics), pesticides, tobacco smoke by-products, and various solvents. Xenoestrogens enhance or block the effects of estrogen in the body by binding to estrogen receptors. They also promote a shift from healthy estrogen breakdown products to cancer-causing estrogen metabolites. Therapeutic Considerations Reducing the size as well as the symptoms of uterine fibroids with natural medicines is easily accomplished in most cases. Unfortunately, this statement is supported more by the clinical experiences of naturopathic physicians than by scientific evidence, though the approach is scientifically rational—that is, if uterine fibroids are caused by an excess of estrogen produced in the body as well as the effects of xenoestrogens, it makes sense that reducing estrogenic influences should shrink uterine fibroids. Keep in mind that as women pass through menopause there is less estrogen and so there will also be a tendency for the fibroid to shrink on its own. Diet The most important dietary recommendations are to eat a high-fiber diet rich in phytoestrogens (plant estrogens) and to avoid saturated fat, sugar, and caffeine. These simple changes can dramatically reduce circulating estrogen levels and reduce estrogen’s influence on the fibroid. One study looked at what happened when women switched from the standard American diet (40% of calories from fat; only 12 g fiber per day) to a healthier diet (25% of calories from fat; 40 g fiber). That’s a good thing, because when phytoestrogens occupy the receptors, estrogen can’t affect cells. By competing with estrogen, phytoestrogens cause a drop in estrogen effects, and are thus sometimes called antiestrogens. Great sources of phytoestrogens include soy and soy foods, ground flaxseed, and nuts and seeds. These dietary recommendations have extreme significance not only in treating uterine fibroids but also in reducing endometrial cancer. Women with uterine fibroids have a fourfold increase in the risk of endometrial cancer. In a case-control study of a multiethnic population (Japanese, white, Native Hawaiian, Filipino, and Chinese) examining the role of dietary soy, fiber, and related foods and nutrients in the risk of endometrial cancer, 332 women with endometrial cancer were compared with women in the general multiethnic population, and all women were interviewed by means of a dietary questionnaire. Similar reductions in risk were found for greater consumption of other sources of phytoestrogens, such as whole grains, vegetables, fruits, and seaweed. The researchers concluded that plant-based diets low in calories from fat, high in fiber, and rich in legumes (especially soybeans), whole grain foods, vegetables, and fruits reduce the risk of endometrial cancer. These dietary associations may explain at least in part the lower rates of uterine cancer in Asian countries than in the United States. Soy isoflavones appear to be selective in terms of the tissues in which they have an estrogenic effect and the tissues in which their effect is antiestrogenic. Soy phytoestrogens do not appear to have an estrogenic effect on the human uterus and may in fact help shrink uterine fibroids due to an antiestrogenic effect. We recommend moderate but not excessive soy consumption in the range of 45 to 90 mg soy isoflavones per day. See the chapter “Menopause” for more information on the isoflavone content of soy foods. Nutritional Supplements Historically, naturopaths have used lipotropic factors such as inositol and choline to support the healthy detoxification of estrogen. Lipotropic supplements usually are a combination of vitamins and herbs designed to support the liver’s function in removing fat, detoxifying the body’s wastes, detoxifying external harmful substances (pesticides, flame retardants, plastics, etc. These lipotropic products vary in their formulations depending on the manufacturer, but they are all similar and are meant for the same uses. Many now contain anticancer phytonutrients found in vegetables from the brassica family, such as indole-3-carbinol, di-indoylmethane, and sulforaphane. Research has shown that these compounds help to break down cancer-causing forms of estrogens to nontoxic forms, making them especially important for women with uterine fibroids. However, their activity is certainly less than the effects of dietary phytoestrogens such as soy and flax. Newer, nonsurgical techniques such as high-intensity focused ultrasound are also now available.

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Lagasse and Johnstone – in a thoughtful review – de¿ne pay for performance order bimat 3ml overnight delivery, or value purchasing purchase bimat 3 ml amex, as “the use of incentives to encourage and reinforce the delivery of evidence- based practice and health care systems’ transformation that promotes better outcomes as ef¿ciently possible” [61]. This de¿nition provides some insight into the current status of pay for performance by describing its driving force more clearly than it does any particular incentives. In other words, the driving forces pay for performance are quality improvement and cost reduction. Gullo A (2005) Professionalism, ethics and curricula for the renewal of the health system. Gullo A, Santonocito C, Astuto M (2010) Professionalism as a pendulum to pay for performance in the changing world. World Health Organization (2000) World health report 2000 – Health systems: improving performance. Regional overview of social health insurance in south-east Asia, World Health Organization and overview of health care ¿nancing (2006) Retrieved August 18. Kohn L, Corrigan J, Donaldson M, eds (2000) To Err Is Human: Building a Safer Health System. Commonwealth Fund International survey (2005) Taking the pulse of health care systems. New Zealand Ministry of Health (2001) Adverse events in New Zealand public hospital: principal ¿ndings from a national survey. World Health As- 30 Professionalism, Quality of Care and Pay-for-Performance Services 361 sembly. Agency for Healthcare research and Quality: The National Guidelines Clearing- house http://www. Fiorentini G, Iezzi E, Lippi Bruni M et al (2010) Incentives in primary care and their impact on potentially avoidable hospital admissions. Grumback K, Osmond D, Vranizan K et al (1998) Primary care physicians experi- ences of ¿nancial incentives in managed-care systems. Coleman K, Hamblin R (2007) Can pay-for-performance improve quality and re- 362 A. Spooner A, Chapple A, Roland M (2001) What makes British general practitioners take part in a quality improvement scheme? Campbell A, Steiner A, Robinson J et al (2005) Do personal medical services con- tracts improve quality of care? Peterson L, Woodard L et al (2006) Does pay-for-performance improve the quality of health care? Snyder L, Neubauer R, for the American College of Physicians Ethics, Profession- alism and Human Rights Committee (2007) Pay for performance principles that promote patient-centered care: an ethics manifesto. Ethics in practice: managed care and the changing health care environment medicine as a profession managed care ethics working group statement. American College of Physicians (2007) Linking physicians payment to quality of care. American College of Physicians (2007) The use of performance measurements to improve physician quality of care. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required. The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work. Readers are encouraged to confirm the information contained herein with other sources. For example and in particular, readers are advised to check the prod- uct information sheet included in the package of each drug they plan to administer to be certain that the information contained in this work is accurate and that changes have not been made in the recommended dose or in the contraindications for administration. This recommendation is of particular importance in connection with new or infrequently used drugs. Associate Professor Department of Pathology Quillen College of Medicine Johnson City, Tennessee Student Reviewers Sara M. Nesler University of Iowa College of Medicine Iowa City, Iowa Class of 2002 Misha F. Haque Baylor College of Medicine Houston, Texas Class of 2001 Joseph Cummings University of Iowa College of Medicine Iowa City, Iowa Class of 2002 Harvey Castro University of Texas—Galveston School of Medicine Galveston, Texas Class of 2002 McGraw-Hill Medical Publishing Division New York Chicago San Francisco Lisbon London Madrid Mexico City Milan New Delhi San Juan Seoul Singapore Sydney Toronto McGraw-Hill Copyright © 2002 by The McGraw-Hill Companies. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be repro- duced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher. Rather than put a trademark symbol after every occur- rence of a trademarked name, we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of the trademark.

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:

2005 – Canberra, ACT
2007 – Perth, WA
2009 – Melbourne, VIC
2012 – Adelaide, SA
2013 – Shaol Bay, NSW
2015 – Hobart, TAS
2017 – Brisbane, QLD