Mark Corson

I. Lee. Dean College.

The transfer of patient dorsed by local clinicians and their appropri- records to a third-party service supplier has been ate professional bodies and patient one of the major concerns put forward by the associations buy 30 caps ashwafera fast delivery. Arrangements for risk-sharing in the event of ate care protocols used to be seen by many as its unplanned-for changes 30 caps ashwafera otc, and formulae for the unique point of advantage discount 30caps ashwafera amex. The cost of means that guideline-based medicine is likely to staffing will very likely be the highest com- become a permanent feature in the healthcare land- ponent of operating costs. First, it is neces- Conclusions that extrapolate beyond the range sary to discuss the ethics and desirability of pub- of available data are as inappropriate in scientific lishing clinical trials, and the biases that may be publications as they are in regulatory documents involved with that process. Omissions of details in ceutical physicians may benefit from some discus- methods and results pursuant to a concise presen- sion of classic parts of an orthodox clinical trial tation will always be subjective, and there is a close report in a peer-reviewed journal, and some clues link between the appropriateness of this subjectiv- for effective oral presentations. The scope of this chapter is whether writing him/herself or when guiding spe- strictly formal publications: regulatory documents cialist medical writers, are many, sometimes con- (which are typically not published and are a differ- trary to common standards of integrity, and often ent form of clinical trials reporting)and marketing emanate from powerful people who lack the materials are dealt with elsewhere. In some way or another, the pharmaceutical used by journalists, the diligent application of com- physician will interpret his/her data to reach con- plete ignorance, and the forced fit of technical in- clusions, and will want to urge some change in the formation to a predetermined political position. These changes The publication of clinical trials, then, is one might include prescribing habits, healthcare re- example where the pharmaceutical physician source utilization, public health policy, or regula- (acting as publicist or medical writer)may become tory practices. Even when Whatever the form of publication, the only tools he/she acts solely as a medical writer, the pharma- available to persuade people to make these behav- ceutical physician must understand the ethical re- ioural changes are the well-created document, sponsibility to represent the material in a fair, audiovisual presentation, press release, etc. If this under-reporting is suboptimal, then those Regulators controlling promotional practices need who publish clinical trials must take their share of only satisfy themselves that the publication accur- the blame. Marketing depart- publish negative data that are making the most ments can use these publications for promotional noise about how unsatisfactory is the performance purposes, knowing that the data is cast-iron, the of the pharmaceutical industry in failing to publish message is unarguably positive, and that the self- it (e. This evident benefits of the drug will be understood by author cannot agree with Dickersin et al (1992), the most sceptical clinician meeting the least adept who wrote: `Contrary to popular opinion, publica- salesperson. Lastly, senior management can bask in tion bias originates primarily with investigators, the glory of its contribution to the public health, not journal editors. Two Lastly, some good studies are less than ideal publi- large pharmaceutical companies have taken an ini- cation candidates solely because the manuscript tiative to register their own clinical trials (e. All too often the primary objective should identify the target journal before putting of the trial is not achieved: the authors then select- pen to paper, and judge whether the quantity of ively publish a few of the many secondary end- material supports a whole paper, a brief report, or points that did support their hypothesis. Clinical trials are a an independently-prepared summary of the proto- specific case of this general, perennial problem, to col, with its prospective objectives and complete list which Rafal (1991)has provided a somewhat of end-points, perhaps in mini-type, at the end of humourous guide. The principal investigator(s)is(are)authors, cists, medical writers, and those who control unless so numerous as to require a team desig- journal content. The statistician(s)who personally accept(s)re- structing meta-analyses from published studies sponsibility for the statistical analysis in the should beware. All named authors should be able to personally The publication of clinical trials in peer-reviewed defend the paper after publication, and be fa- journals normally follows the same format as for miliar with (but not necessarily have personally any other paper: title, authors, sponsorship, ab- performed)all the methods employed in the stract, introduction, methods, results, discussion, clinical trial. All journals publish guidelines describing the The acknowledgments can then list all those formats for the often diverse types of article that who took part (e. A hybrid vari- academic meetings with: (a)disorganized speech ant is also sometimes used, where a one (or a few) (due to disordered thought processes and/or acute lead author(s)are named and stated to represent episodic dysarthria); and (b) an inability to control the rest of the team (e. This ineptitude is displayed by all advantages of this tactic are that there is at least medical specialties (including pharmaceutical phys- one person who accepts responsibility for defense icians and clinical trialists), by most other non- of the paper after publication. Some hosts make the talk more challen- multisite studies: the protocol can state that the ging by impishly providing slide projectors with investigator who recruits the most completed pa- various diseases (Fox 2000). You exclusion criteria in most clinical protocols alone should have the following three things sine qua non: exceed the word limit of most isolated abstracts. An understanding of the audience and the vo- is a criterion used by companies to justify the time cabulary needed to communicate with them and expense of sending staff to a conference: (the general public, a patient advocacy group, authors then generate and submit unimportant ab- an academic society, and an in-house depart- stracts, principally for use as tickets to venues that ment seminar all require very different ap- attract them for ulterior reasons. A look at the venue and the various pieces of published in full sometimes can make a isolated equipment that will be at your disposal; think abstract, provided the full reference is provided, about how to match your speaking volume to and an educated audience at, say, an academic the open air or to the microphone (if any), and conference, will be aware of the potential biases where to stand so that you can see your slides of this technique. But For the actual talk itself, one useful checklist is as these are minor exceptions to the general principle follows: that, in order to assess the validity of a clinical trials report, far more detail is needed than can be pub- 1. Create slides to be self-supporting: if you gave the central question be answered for that clinical your set of slides to someone equipped with a trial: would electronic publication make these data projector, could they, without any further ex- more easily available to the audience that can best planation, more or less work out your subject use them (Geddes 1999)? Practice search times, and has lower production and ship- showing one slide before wrongly loading all ping expenses, but requires readers to have access of them. Epidemiological patient population included 30% adolescents studies, where huge numbers of patients are often because this group represents a relevant frac- studied, may be especially suited to this form of tion of the whole population with type I dia- publication. The most common form at present is briefly review the data that you have pre- probably the distribution of electronic facsimiles of sented in their support, and then interpret printed papers, usually in. Access to these fac- similes is usually restricted to those who also have a Most people are in an altered psychological state subscription to the paper version of the journal, shortly after giving a talk, whether or not it seemed and thus represents a duplication of, or extension to go well. Pharmaceutical physicians may often want to Song et al (1999)have suggested that electronic avoid involvement in the drafting of press releases journals can reduce publication bias (see above), altogether. Altman (1999)have even proposed that not only The best advice on press releases may be two- will publication bias be reduced, but also the intrin- fold. However, this enlarged was the case, then state clearly the implications volume of publications also mandates a different of these data to the clinical development plan: if peer-review system, or even no peer-review at all. It it needs redirection, then state what that redirection is possible that electronic publications may come to is, and the implication for the registration time- be suspected as both providing higher quantities of line. This protection of the right to exploit companies will only very rarely be exposed to the a publication is central to the promotion of pub- need for press releases concerning their clinical lishing per se, and thus an incentive to disseminate trials. First, for a fee, the protected publica- ination of the results of such a clinical trial to the tion can be registered with the national office of appropriate audience (shareholders and investment copyright. Second, the copyright holder can simply community)is legally required when material to the assert in the publication ownership of copyright prospects of a small, public company.

Quality of life was synaptic function discount 30 caps ashwafera with amex, eventually improved spatial memory cognition buy ashwafera 30 caps on-line. Social participation was measured using the So- cial Profle (Donohue purchase 30 caps ashwafera with amex, 2013) at the end of each session as repeated 170 measures. Three main themes emerged that supported participants’ 1 1 quality of life were well-being, peace of mind, and relationships. Chen Conclusion: Community-based program has positive effects on so- The Second Hospital of Hebei Medical University, Department of cial participation in older adults. In achieving good quality of life Rehabilitation, Shijiazhuang, Hebei, China while aging, it is important to maintain relationships with family and friends, and fnding time to support and help others in need. Results: The expression of Bcl-2 in the perihema- of studies have analyzed the infuence of lower limb amputation on tomal area in 1. A total of 160 patients of trans-tibial amputation were fol- with control group and 1. The aim of present study was to clarify the basis of answers to a fve point questionnaire which included risk factors for dysphagia in patients with acute exacerbation of their social, economic and psychological aspects. Material and Methods: This study used a cross-sectional de- were correlated to assess the infuence of functional recovery on the sign. Clinical inter- of them felt increased level of depression and anxiety after amputa- views, blood chemistry analysis, electrocardiography, echocardiog- tion. According to previous studies, patients were divided into a also social, economical and psychological factors. An amputee with better performed, and then variables with signifcant difference between ambulation level fares better economically, psychologically and so- groups were entered into a multivariate model. Results: Among the cially in comparison to an amputee with poor ambulatory outcome. The key words “cerebral palsy”, 175 “aging” and “health care programs” were adressed. Moreover there are age related conditions and sec- Xinger Li, Jianping Chen, Yuanyuan Guo, Xi Qing, Ya- ondary factors associated with adulthood and aging in cP patients. The Future care for this group should include well organised interdisci- treatment process and ending event were reported and the related plinary health care programs aiming at improving health and well literatures were reviewed. There were sinus under the bedsore which were surrounding with a lot of pu- rulent secretions (Fig. All treatment methods includ- ing revascularization had been tried with no signifcant effect and 174 the patient had been asked to accept amputation. How- Internal Medicine and Rehabilitation Science, Sendai, Japan, 2Sen- ever, the evidence is not strong enough and larger, randomized, dai Medical Center, Department of Rehabilitation, Sendai, Japan, double blind, placebo-controlled, and multicenter trials are needed. This could be attributed to comple- 4 mentary role of electrodiagnostic studies to imaging studies, where neering, Taipei, Taiwan, Chang Gung University, Department of electrodiagnos is as a physiologic evaluation compared to imaging Physical Therapy and Graduate Institute of Rehabilitation Science, studies as anatomic/structural evaluation. Conclusion: This study was the frst to demon- nerve damage and brain trauma as well. Based on our results, brain injury may alter the mented with psychosocial approach for patients and their caretakers. Data of demographic characteristics, etiology and origin of more than 13,000 islands. Due to geographical conditions and dis- referral, and fnal diagnose and payment methods were gathered. Results: Result, in about one third (31%) of cases was rial and Methods: A 3-year-old girl sustained multiple fexor and normal. The most common roots involved in lumbosacral and cer- extensor tendon rupture and median nerve injury of left hand in a vical radiculopathies were L5 (49. All the muscle strength, and sensory), and how to do gentle stretching and doctors were general duty doctors or residents in their respective massage. The areas covered were Rahim Yar Khan, Rojan, Dera the instructions for therapy and supervision were done by text mes- Ghazi Khan, MuzaffarGarh, Rajanpur, Nowshehra, Charsadda and sage and messenger applications with mobile phone. The Doctors reached the food area between instructions how to make hand orthoses from local materials. Re- 1–4 weeks and spent an average of 30 days in the food affected sults: After 16 weeks of the telerehabilitation, there was improve- areas. Gastrointestinal, respiratory and skin Conclusion: Telerehabilitation programs can be delivered even if infections were the commonest ailments followed by conjuncti- there was no sophisticated technology. Hasnan1 rehabilitation services are required in initial days of foods, general 1University of Malaya, Rehabilitation Medicine, Kuala Lumpur, duty doctors trained in common food related ailments are suff- Malaysia cient, however evacuation of previously disabled person residing in the area should be catered for. Conclusion: Higher self-effcacy and independence level evacuees living in temporary housing, and to identify whether the are associated with higher ftness level. It is therefore important amount of physical activity was related to physical ftness and qual- that rehabilitation interventions include strategies to promote and ity of life. Material and Methods: Sixty-four residents of temporary improve self-effcacy and independence. These measures may lead housing in Minamisoma city, aged ≥65 years participated in the to higher physical activity and ftness level. The average daily steps of each participant were measured using a triaxial accelerometer to be representative of the daily phys- ical activity. No relationship was observed between the amount of Aqil, Pakistan physical activity and physical ftness and health-related quality of life except for “physical function”.

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Hyperparathyreoidismus - definition; classification; diagnosis; clinical picture, treat- ment. Hypermineralocorticismus - definition, clinical picture; treatment of Conn adenoma. Pheochromocytoma – diagnosis; differential diagnosis; clinical picture; treatment. Daibetes mellitus – etiology, pathogenesis, types; diagnosis, clinical characteristics. Acute metabolic complications of diabetes – hypoglycaemia, ketoacidosis, nonketotic hyperosmolar coma. Harrison’s Principles in Internal Medicine In Bulgarian:  Раздел „Ендокринология” в В “Клиника и терапия на вътрешните болести. It will be of use to those working in both new and more developed nuclear medicine Manual centres. Its principal objective is “to accelerate and enlarge the contribution of atomic energy to peace, health and prosperity throughout the world’’. The copyright has since been extended by the World Intellectual Property Organization (Geneva) to include electronic and virtual intellectual property. Proposals for non-commercial reproductions and translations are welcomed and will be considered on a case by case basis. Functional imaging using nuclear medicine procedures has become an indispensable tool for the diagnosis, treatment planning and management of patients. This manual sets out the prerequisites for the establishment of a nuclear medicine service, including basic infrastructure, suitable premises, reliable supply of electricity, maintenance of a steady temperature, dust exclusion for gamma cameras and radiopharmacy dispensaries. It offers clear guidance on human resources and training needs for medical doctors, technologists, radiopharmaceutical scientists, physicists and specialist nurses in the practice of nuclear medicine. The manual describes the requirements for safe preparation and quality control of radiopharmaceuticals. In addition, it contains essential requirements for maintenance of facilities and instruments, for radiation hygiene and for optimization of nuclear medicine operational performance with the use of working clinical protocols. The result is a comprehensive guide at an international level that contains practical suggestions based on the experience of professionals around the globe. This publication will be of interest to nuclear medicine physicians, radiologists, medical educationalists, diagnostic centre managers, medical physicists, medical technologists, radiopharmacists, specialist nurses, clinical scientists and those engaged in quality assurance and control systems in public health in both developed and developing countries. Administration of radionuclides to women of child bearing age or pregnant patients. The present Nuclear Medicine Resources Manual offers guidance on human resources and training needs in the practice of nuclear medicine for medical doctors, physicists, technologists, technicians and nurses. Nuclear medicine physicians must be able to interpret the wishes of their clinical colleagues and demonstrate how clinical practice can be improved by the use of nuclear medicine techniques. It is, of course, imperative to achieve a certain standard of clinical practice before it can benefit from nuclear medicine. The introduction of complex nuclear medicine techniques for imaging or treating cancer with radiolabelled antibodies and peptides is only useful where there is an existing cancer service with qualified nuclear medicine staff at all levels. The present manual sets out the prerequisites for the establishment of a nuclear medicine service. Basic infrastructure should include suitable premises, a reliable supply of electricity, air-conditioning, temperature control and dust exclusion for gamma cameras and other equipment. Local government and customs officials must be familiar with the properties of radiopharmaceuticals and be prepared to expedite customs clearance procedures since radiopharma- ceuticals decay if they are delayed in customs. The manual also contains details of the required instrumentation as well as instructions on maintenance and optimization of performance. There is also a section on practical clinical protocols and, unlike traditional textbooks where the emphasis is on outlining why protocols should be followed, this manual describes how they should be followed. It also stresses the importance of an accurate interpretation of results and describes pitfalls likely to be encountered. There are five parts in a nuclear medicine report: (1) The patient and demographic data; (2) The details of the test undertaken and the patient’s response; (3) A description of the findings; (4) A conclusion based on these findings; (5) The clinical data and request, and clinical advice as a result of the study. Nuclear medicine permits: (a) Investigations that establish a specific diagnosis, as in thyroid disease, pulmonary embolism or exercise induced stress fracture; (b) Investigations that aim to exclude a particular diagnosis, such as myocardial perfusion imaging (presence of significant ischaemic heart disease) or renography (presence of functionally significant renovascular disorder); (c) Follow-up investigations such as myocardial perfusion imaging after angioplasty or coronary bypass surgery, and the identification of tumour recurrence or metastasis using increasingly specific imaging agents. The range of applications and the clinical efficacy of internally targeted radionuclide therapy are growing.

Bhugra ea (2007) suggest that they be viewed as symptom complexes cheap 30 caps ashwafera mastercard, modified by culture purchase ashwafera 30 caps online, occurring in response to stressful circumstances 30 caps ashwafera. Race, culture and ethnicity may falsely appear to explain research findings when factors such as economics (poverty, debt, education, etc) are not examined. One of the points against someone having a delusion is that they share their belief with their culture. Nevertheless, psychopathology causes considerable personal and socio-economic disability across cultures. A discussion of cultural influences on schizophrenia is to be found in the chapter on schizophrenia. Although not universally corroborated, ethnic minorities may tend to express distress through somatic complaints. According to Bhugra (2008) a culture may be: Pathogenic – causing symptoms Pathoselective – effecting groups in different ways Pathoplastic – modifying symptom presentation Pathoelaborating – reinforced by culture Pathofacilitative – some cultures are prone to certain disorders Pathodiscriminating – culture defines what is deviant Some key terms require definition. Acculturation is the assumption of characteristics of the larger or more advanced society. Assimilation (a bigger step than acculturation) involves total absorption in the larger society. Examples of maladaptation to a host culture include ‘over-identification’ (decry old culture in favour of host practices) and ‘hyper-identification’ (decry host culture in favour of culture of origin). A more comfortable adaptation is represented by ‘inside-outside split’ (private practice of culture of origin 166 and public practice of host culture). Ethnography consists of the examination of written records, folk tales, myths, language, key informants, life histories, questionnaire surveys, psychological tests, and participant observation, all aimed at studying cultural forms. The Hmong of Southeast Asia believe that the 168 soul is always in danger from opportunistic spirit thieves called dabs and that shamans (tvix neebs) who are skilled in spirit rescue oppose such forces; medical interventions break sacred Hmong taboos and the Hmong will only seek medical help as a last resort and with little tolerance for lack of results. Diviners read oracles, interpret dreams, and communicate with the spirit world (incl. African Americans with bipolar or psychotic mood disorders are at increased risk of being misdiagnosed as having schizophrenia, i. Americas Ataque de nervios (Puerto Rican syndrome) is found among Latin American Hispanics, especially older females with relatively little education. It is a socially sanctioned expression of grief or conflict consisting of anxiety and aggressiveness leading on to paresis, loss of consciousness or blanking out of the mind, hyperventilation, shouting and swearing, striking out at others, falling, convulsive movements or lying as if dead, and amnesia. Bilis (muina, colera) is considered to be due to disturbed relationships between bodily hot and cold and between spirit and soma as a result of anger or rage in Latinos. Acute tenseness, screams, shakes, headache, and upset stomach are common, whereas some cases appear to lose consciousness. Bouffée délirante is found in Haiti and West Africa and may resemble brief psychotic disorder. Sudden onset of agitation, aggression, excitement, and confusion characterise his phenomenon, with some cases experiencing hallucinations and paranoid thinking. Evil eye (mal de ojo), mainly found in Latin America (particularly children), refers to illness induced by the stare of a jealous person. By way of comparison, ancient Ireland had its Cailleach, an old hag who was able to transfer mental illness from one person to another. Falling out (blacking out, indisposition) is a dissociative state found among excited or fearful black Americans, Bahamians and Haitians in Miami, consists of sudden collapse, paralysis, and an inability to see or speak. Hearing and understanding are, however, intact, and no evidence is uncovered to suggest an epileptic origin. Ghost sickness among American Indians involves preoccupation with death and the dead. Sufferers may report nightmares, weakness, dread/anxiety/suffocation/futility, confusion, loss of consciousness/faintness/dizziness, anorexia, and hallucinations. The symptoms include headache, anxiety, irrational anger directed towards nearby people, and aimless running and falling. Locura171 of Latin America is a chronic, severe psychosis attributed to heredity or life’s problems in which there are agitation, visual and auditory hallucinations, incoherent speech, inability to adhere to societal rules, and with the potential for violence. Piblokto or pibloktoq (running syndrome) occurs in ‘hysterical’ Eskimo females who may run away or jump into cold water; she is at risk of killing either herself or others, and she has no memory for the event once it is over; it is viewed as representing a dissociative fugue. Susto (chibih, espanto, pasmo, perdida del alma, tripa ida) occurs in the High Andes and takes the form of a sustained melancholia due to worries that the soul may vacate the body. Tabanka is found in Trinidad among males who become depressed and suicidal once deserted by their wives. Some tribesmen, during periods of economic hardship, believe that they have become this ghoul, and they have been known to murder and eat their brethren. Africa172 Amariko, an Ugandan colouration of post-partum psychosis, involves a wish on the mother’s part to eat her baby! Brain fag syndrome (Ori ode or Ode ori in Nigeria) is a prevalent form of somatised anxiety and depression found in association with education in West Africa. It is characterised by a rich variety of somatic symptoms, particularly related to the head (e. It has been suggested that the condition may be a response to excessive expectations in, and cost of, education. The health and wellbeing of a person can be influenced by the actions of a distant other person. Treatment is through the ministrations of a traditional healer (or priest if the victim is Christian) who lifts the curse. Instead one should discover the personal and communal meaning of the experience; the relatives should be interviewed, using an interpreter as necessary. Sangue dormido173 among the Portuguese-speaking Cape Verde islanders (or emigrants from these Atlantic islands) consists of numbness, pain, tremor, stroke, blindness, infection, heart attack, and, in pregnant women, miscarriage.