By Q. Vatras. William Woods University.

Pneumonic Plague (Yersinia pestis) Symptoms: Fatigue discount 60 mg pyridostigmine fast delivery, fever pyridostigmine 60 mg visa, cough buy generic pyridostigmine 60mg, shortness of breath, and malaise. Fleas on rodents also transmit plague zoonotically – keep the rat population under control and there will be fewer rats to spread the fleas. Botulism Symptoms: Blurry vision, difficulty speaking and swallowing, sore/dry throat, dizziness, and paralysis. Smallpox Symptoms: Fever, rigors (uncontrolled shaking), malaise, headache, and vomiting. As a rule in primitive conditions assume all suspected cases are highly contagious. Brucellosis (Brucella melitensis) Symptoms: Fever, headache, sweating, chills, back pain Primitive treatment: Doxycycline + rifampicin Usually nonfatal. Second line biological agent due to low kill potential but has the potential to overwhelm medical services due to epidemic outbreaks. Encephalomyelitis Symptoms: Fever, headache, severe photophobia (aversion to light). Meliodosis and Glanders (Burkholderia pseudomalleri) Symptoms: Pneumonia with associated septicaemia. Primitive treatment: Ceftazidime for acute infection, doxycycline to prevent recurrence. Psittacosis (Chlamydia psittaci) Symptoms: Atypical pneumonia with fever and cough. Primitive treatment: Doxycycline or Chloramphenicol Human transmission usually from inhaled dust infected with placental tissue or secretions from infected sheep, cows, or goats. Typhus fever (Rickettsia prowazekii) Symptoms: Fever, headaches, chills, generalised pain and rash. Second line bio agent Ricin (technically a chemical agent) Symptoms: Block protein synthesis within the body. This is the support of the body’s organ systems (heart, brain, liver, kidneys) to help them continue to function following damage but is not specifically aimed at treating the underlying injury or disease. It is usually delivered in an intensive care unit and consists of treatments such as oxygen, ventilation, dialysis, fluid therapy, nutrition, and using medications to maintain blood pressure. In an austere situation your ability to deliver supportive care will be minimal and potentially a massive drain on limited resources. Since it is likely any exposure would be the result of a terrorist attack it may be difficult to avoid. If dealing with a patient of suspected chemical agent poisoning ensure you are protected and that the patient is decontaminated. Where - 123 - Survival and Austere Medicine: An Introduction formal decontamination is not possible – remove and dispose of their clothes and wash them down with soap and water. If you suspect a chemical attack try and stay up wind from the location and on the high ground. Chemical agents will be carried by the wind and as most are heavier than air the chemicals will settle in low lying areas. Inside try and find a room with minimal windows (ideally an interior room with no windows), tape cracks around doors and windows and place a wet towel around the base of the door Equipment The single most important piece of equipment is a protective facemask and appropriate filters for all the members of your family. Ensure your filters meet the standard for both biologicals, and organic chemicals, and that you have spares. The following is the Australian commercial standard for mask filters which is the most appropriate for this application: A2B2E2K2 Hg P3. A protective over-suit protects you from liquid and dense vapour contamination on your skin. Usually liquid does not spread over a wide area while vapour can disperse over wide distances. Vapour is poorly absorbed from the skin but it can be if the vapour is dense enough but this is only likely close to the release point. For most people the priority is the purchase of appropriate gasmasks before considering over-suits. If you are unable to afford commercial chemical protective suits consider purchasing those recommended for spraying agricultural chemicals; they do offer the same level of protection but are cheaper, and many nerve agents are based around organophosphate agricultural sprays. Medical preparations In an austere situation Tincture of green soap (or another mild soap) is still the recommended low-tech decontamination agent for suits and bodies. They cause their effects by blocking the breakdown of acetylcholine – a communication chemical between nerves and muscles. When the enzyme, which breaks it down, is blocked, it accumulates, and causes the symptoms of nerve agent poisoning. Treatment: Pre-treatment: This consists of the administration of medication prior to exposure to a nerve agent to minimise the effect of the agent. This binds reversibly to the same receptors to which the nerve agents bind irreversibly helping to reduce their effects. This was tolerated for prolonged periods by troops during Gulf War 1 with minimal minor side effects. If exposure occurs then pre-treatment combined with post-exposure treatment significantly reduces the death rate. Post-exposure treatment: This should be administered immediately upon suspicion of exposure to nerve agents (i. Large amounts of atropine may be required, but the indications and administration are beyond the scope of this book. The dose is titrated against signs of atropinization: dry mouth, dry skin, and tachycardia > 90 min. In the complete absence of medical care and confirmed nerve agent exposure atropine can be continued to maintain atropinization for 24 hours (usually 1-2 mg Atropine 1-4 hourly). Atropine effects are essentially peripheral and it has only a limited effect in the central nervous system 2. Oxime treatment: While atropine minimises the symptoms it does not reverse the enzyme inhibition caused by the nerve agent. By administering oximes this encourages the reactivation of the enzymes required to breakdown the acetylcholine. Different oximes work better with different nerve agents usually a mix of Pralidoxime and Obidoxime is given. Anticonvulsants: In severe exposures there is the risk of seizures leading to serious brain injury. Patients with severe exposures may also require assisted ventilation and suctioning of their airways. If you are able to get access to military autoinjectors then this is ideal first aid/initial therapy. If the patient survives the initial contact then it is likely that the patient will survive. The spectrum of symptoms runs from weakness, dizziness, and nausea through seizures and respiratory arrest.

In a mixed-race drug market in Seattle buy pyridostigmine 60mg amex, Beckett and her colleagues found that 4 percent of drug deliveries involved a black seller discount pyridostigmine 60 mg without a prescription, but 32 percent of drug delivery arrestees were black (Beckett order genuine pyridostigmine online, Nyrop, and Pfingst 2006). Disproportionate drug arrests of minority suspects also reflect political and legal considerations. William Stuntz observed, “the law of search and seizure disfavors drug law enforcement operations in upscale (and hence predominantly white) neighborhoods: serious cause is required to get a warrant to search a house, whereas it takes very little for police to initiate street encounters” (Stuntz 1998, p. Residents of middle- and upper-class white neighborhoods would also most likely object vigorously if they were subjected to aggressive drug law enforcement and, unlike low-income minority residents, they possess the economic resources and political clout to force politicians and the police to pay attention to their concerns. The bottom line is that it is “much more difficult, expensive, and politically sensitive to attempt serious drug enforcement in predominantly white and middle-class communities” (Frase 2009, p. Subscriber: Univ of Minnesota - Twin Cities; date: 23 October 2013 Race and Drugs A self-fulfilling prophecy may be at work. If police target minority neighborhoods for drug arrests, the drug offenders they encounter will be primarily black or Hispanic. Darker faces become the faces of drug offenders, which may also contribute to racial profiling. Extensive research shows that police are more likely to stop black drivers than whites, and they search more stopped blacks than whites, even though they do not have a valid basis for doing so. Similarly, blacks have been disproportionately targeted in “stop and frisk” operations in which police searching for drugs or guns temporarily detain, question, and pat down pedestrians (Fellner 2009). Although police generally find drugs, guns, or other illegal contraband at lower rates among the blacks they stop than the whites, the higher rates at which blacks are stopped result in greater absolute numbers of arrests (Tonry 2011). Race becomes one of the readily observable visual clues to help identify drug suspects, along with age, gender, and location. There is a certain rationality to this—if you are in poor black neighborhoods, drug dealers are more likely to be black” (1998, p. Katherine Beckett and her colleagues showed that drug arrests in Seattle reflected racialized perceptions of drugs and their users (Beckett et al. Although the majority of those who shared, sold, or transferred serious drugs were white, almost two-thirds (64. Black drug sellers were overrepresented among those arrested in predominantly white outdoor settings, in racially mixed outdoor settings, and even among those who were arrested indoors. Three- quarters of outdoor drug possession arrests involving powder cocaine, heroin, crack cocaine, and methamphetamines were crack-related even though only one-third of the transactions involved that drug. The disproportionate pattern of arrests resulted from the police department’s emphasis on the outdoor drug market in the racially diverse downtown area of the city, its lack of emphasis on outdoor markets that were predominantly white, and, most important, its emphasis on crack. Crack was involved in one-third of drug transactions but three-quarters of drug delivery arrests; blacks constituted 79 percent of crack arrests. The researchers could not find racially neutral explanations for the police emphasis on crack in arrests for drug possession or sale, or for the concentration of enforcement activity in the racially diverse downtown area rather than predominantly white outdoor areas or indoor markets. These emphases did not appear to be products of the frequency of crack transactions compared to other drugs, public safety or public health concerns, crime rates, or citizen complaints. The researchers concluded that the choices reflected ways in which race shapes police perceptions of who and what constitutes the most pressing drug problems. Blacks are disproportionately arrested in Seattle because of “the assumption that the drug problem is, in fact, a black and Latino one, and that crack, the drug most strongly associated with urban blacks, is ‘the worst’” (Beckett et al. In 2010, as Table 4 shows, cocaine (including crack) and heroin arrests accounted for 22. Blacks were more likely than whites to report using heroin, but the percentages are quite low: 1. The proportion of drug arrests for cocaine and heroin thus seem to bear only a slight relationship to the prevalence of their use. Boyum, Caulkins, and Kleiman (2011) observe that the enforcement of laws criminalizing cocaine accounts for “about 20 percent of the nation’s law enforcement, prosecution, and corrections” (p. Subscriber: Univ of Minnesota - Twin Cities; date: 23 October 2013 Race and Drugs Table 4 Arrests by Type of Offense, Drug, and Race, 2010 White Black Native American Asian Total Sales Cocaine/Heroin 34,787 45,635 346 351 81,119 42. All other things being equal, one would expect the racial distribution of prisoners sentenced for particular crimes to reflect the racial distribution of arrests for those crimes. Blumstein showed in 1982 that about 80 percent of racial differences in incarceration in 1979 could be accounted for by differences in arrest (Blumstein 1982). In the case of drug offenses, there was a significant difference between the racial breakdowns of arrests and incarceration. Racial disparities in imprisonment for drug crimes are even greater than disparities in arrest. There are significant racial differences at different decision points in criminal justice processing of cases following arrest. Those differences compound, ultimately producing stark differences in outcomes (Kochel, Wilson, and Mastrofski 2011; Spohn 2011). In Illinois, for example, even after accounting for possible selection bias at each stage of the criminal justice system, nonwhite arrestees were more likely than whites to have their cases proceed to felony court, to be convicted, and to be sent to prison (Illinois Disproportionate Impact Study Commission 2010). After controlling for other variables, including criminal history, African Americans in Cook County, Illinois were approximately 1. Subscriber: Univ of Minnesota - Twin Cities; date: 23 October 2013 Race and Drugs Spohn 2011). Young African-American men in Ohio had lower odds of pretrial release on their own recognizance, had higher bond amounts, and higher odds of incarceration relative to other demographic subgroups (Wooldredge 2012). The exercise of federal prosecutorial discretion with respect to charging decisions, motions for mitigated sentences based on substantial assistance by the defendant in the prosecution of others, and plea bargaining has led to racial disparities that affect sentences (Baron-Evans and Stith 2012, pp. Rehavi and Starr (2012) found that federal prosecutors were more likely to charge more serious offenses against black than white arrestees, including for offenses carrying mandatory minimum penalties. Ulmer and his colleagues found racial differences in downward departures under the federal guidelines, whether initiated by prosecutors or judges (Ulmer, Light, and Kramer 2011). Researchers concluded that the defendant’s race influenced the likelihood of incarceration in 15 studies of drug offender sentencing. All else considered, white felony drug offenders in North Carolina received less severe punishment than blacks or Hispanics (Brennan and Spohn 2011). The effects of race on sentencing decisions is particularly notable when the studies take account of age, gender, or socioeconomic status (Spohn and Hollerman 2000; Doerner and Demuth 2010; Spohn 2011). Doerner and Demuth’s study of sentencing decisions in federal courts found that young black and Hispanic males receive the harshest sentences of all racial/ethnic/gender-age subgroups and that the effects of race and ethnicity were larger in drug than in nondrug cases (Doerner and Demuth 2010, p. In 2003, the United States Sentencing Commission reported that black drug defendants were 20 percent more likely to be sentenced to prison than white drug defendants (U. In its annual report for 2010, the United States Sentencing Commission reported that black (30. Blacks had higher average sentences than whites or Hispanics for powder and crack offenses, regardless of whether they were sentenced under the mandatory minimum provisions (U. Much of the research on racial disparities in case outcomes has sought to tease out the extent to which racial differences reflect the influence of legally irrelevant factors such as race, gender, and age. Yet research also shows that ostensibly race-neutral, legally relevant factors such as prior criminal records yield racial disparities.

This can be compounded by poor communication between patients and providers and inaccurate perceptions of cancer treatment purchase pyridostigmine 60 mg mastercard. Misconceptions can be exacerbated by differences in religion purchase pyridostigmine 60mg fast delivery, gender generic pyridostigmine 60mg with amex, class and belief systems between the patient and the health-care team (39). In addition, patients may not understand or not be given clear instructions on the recommended facility and time for evaluation at the treatment facility. Results from the situation analysis can assist with the development of strategic priorities to address the common barriers. Potential interventions to strengthen to early diagnosis Step 1 Step 2 Step 3 Awareness Clinical and evaluation, Access to accessing diagnosis and treatment care staging Diagnostic Awareness of symptoms, Accurate clinical Referral for Accessible, high-quality testing and seeking and accessing care diagnosis treatment treatment staging Interventions: Intervention: Intervention: Interventions: Intervention: • empower and engage people and • improve provider • strengthen • develop • improve access to treatment communities capacity at frst diagnostic referral by reducing fnancial, • improve health literacy and contact point and mechanisms geographic, logistical and reduce cancer stigma pathology and sociocultural barriers services integrated • Facilitate access to primary care care • Provide supportive counselling and people- centred care Leadership and governance to improve access to care Leadership and governance in cancer control involve development and implemen- tation of strategic frameworks combined with effective oversight, coalition-building and multisectoral engagement, regulation, resource allocation, attention to system design and accountability. Careful consideration should be made for how distribution of resources impacts access and equity (7). Accreditation and standards can improve the availability and readiness of key interventions at each level of the health system. Similarly, multisectoral action through effective partnership can facilitate early diagnosis and promote access to cancer care (40). Step 1: Awareness and access to care Empower and engage people and communities Empowering and engaging people and communities enable timely clinical presen- tation by improving health literacy, reducing stigma and facilitating access to care. Important objectives of engaging with communities are to improve knowledge and awareness of cancer, to listen to what they report as their major barriers to seeking earlier diagnosis for cancer symptoms and to use their knowledge to develop solu- tions. Feedback from the community can include the location of services, opening times of health facilities, costs of care, provider behaviour or addressing other prac- tical issues such as transport. Improve health literacy and reduce cancer stigma Specifc strategies to improve health literacy and reduce stigma depend on predom- inant sources of information and can include printed media, radio, television, social media and other online tools. Interventions used to promote public awareness about cancer should be culturally appropriate and consistent at all levels of the health sys- tem. Key messages include awareness of “alarm” or “red fag” symptoms that may represent cancer, how to seek evaluation for these symptoms and awareness that timely evaluation and treatment can increase the likelihood of a cure. Awareness of highly predictive cancer symptoms includes knowing how to self-identify changes and to understand that specifc symptoms may represent cancer without excessive fear or denial (Table 3). Guide to cancer early diaGnosis | 23 Table 3. Common symptoms and signs that may be due to cancera Site of cancer Common symptoms Breast lump in the breast, asymmetry, skin retraction, recent nipple retraction, blood stained nipple discharge, eczematous changes in areola Cervix Post-coital bleeding, excessive vaginal discharge Colon and rectum change in bowel habits, unexplained weight loss, anaemia, blood in the stool (rectal cancer) Oral cavity White lesions (leukoplakia) or red lesions (erythroplakia), growth or ulceration in mouth Naso-pharynx nosebleed, permanent blocked nose, deafness, nodes in upper part of the neck Larynx Persistent hoarseness of voice Stomach upper abdominal pain, recent onset of indigestion, weight loss Skin melanoma Brown lesion that is growing with irregular borders or areas of patchy colouration that may itch or bleed Other skin cancers lesion or sore on skin that does not heal Urinary bladder Pain, frequent and uneasy urination, blood in urine Prostate diffculty (long time) in urination, frequent nocturnal urination Retinoblastoma White spot in the pupil, convergent strabismus (in a child) Testis swelling of one testicle (asymmetry) a These common symptoms may be due to cancer or due to a different medical condition. Mass media are an important platform for awareness raising, although messaging strategies need to be carefully designed and tested to reach population groups most in need (17). Social networks can also be used to improve health-seeking behaviour and health literacy (41). Cancer survivors and advocates play an important role in reducing stigma and promoting public awareness that cancer can be a curable dis- ease, and can be paired with the professional community for further leveraging (12). Community health workers and civil society can help improve public awareness and facilitate health-seeking at local health centres. A pilot study of early diagnosis in Malaysia engaged community nurses to hold health educational talks. Facilitate access to primary care Health education and community mobilization can ensure populations engage with the health sector. Addressing determinants of health and obstacles to primary care 24 | Guide to cancer early diaGnosis can have additional benefcial effects in reducing cancer delays, improving equity, increasing adherence to diagnosis and treatment and improving overall health par- ticipation (35). Public awareness about cancer should not only include symptom awareness but also counselling on how and where to present for care, with consider- ation for facility capacity, accessibility and direct and indirect costs. Step 2: Clinical evaluation, diagnosis and staging Improve provider capacity at frst contact point The primary care level has an important role in cancer control that includes education and health literacy in cancer prevention, early identifcation of cancer, diagnostic tests, counselling and care after diagnosis and follow-up care after treatment, including palli- ative and supportive care (19). Additional cancer-related interven- tions include: (i) counselling on risk reduction such as behavioural modifcation (e. Improving capacity at the primary care level or frst contact point in the health system can result in more effective and timely cancer diagnosis (Table 4). Providers should receive appropriate knowledge and clinical assessment skills through pre-service education and continuing professional development. Guide to cancer early diaGnosis | 25 Table 4. Sample interventions to improve early diagnosis capacity at the primary care level Building capacity in primary care Impact develop protocols for clinical assessment (e. Factors that enable primary care providers to diagnose cancer include allowing suffcient time to assess individual patients, ensuring availability of diagnostic tools (e. Care protocols should be developed and utilized to avoid unnecessary health expen- ditures such as expensive diagnostic or staging studies for localized cancer. Strengthen diagnostic and pathology services Basic cancer diagnostic tests such as ultrasound, X-ray, cytology and biopsy capabil- ity should be available at the secondary care level, and also available at the primary care level where resources permit, to successfully implement cancer early diagnosis programmes (44). Diagnostic algorithms should be developed according to available resources and provider capacity and coordinated between facilities. Quality assurance mecha- nisms should also be developed to ensure that diagnostic and pathology services are accurate, that the appropriate standards are employed and that results are commu- nicated in a timely manner. Develop referral mechanisms and integrated care The health system architecture required to provide core cancer services varies by setting and cancer type. In some regions and for certain cancers, clinical and patho- logic diagnosis can be provided during an initial clinic visit. Other settings and some cancer types require multiple referrals to complete cancer diagnosis, staging and ini- tiate treatment. The overall goal is to minimize delays in care and provide integrated, 26 | Guide to cancer early diaGnosis people-centred care through: (i) coordinated, effcient referral systems that facilitate access, improve communication and reduce unnecessary visits; (ii) linking primary care and outpatient specialty care to advanced diagnostic and treatment services; and (iii) effective communication between patients, families and providers, encour- aging patient participation and shared decision making. The types of services provided at the secondary and tertiary care levels depend on health system organization (Figure 9). The package of services in various facilities should be documented and known to health planners and providers to enable timely referral and prompt diagnosis. Referral and counter-referral guidelines should be established to deliver time-sensitive services without fragmentation or duplication and be readily available at all levels, developed according to provider and facility capacity. A direct link should be developed between primary care facilities and higher levels of care by establishing criteria for referral and counter-referral and improving infor- mation transfer between providers (e. A medical records system should be available at all levels of care, allowing providers to properly document diagnostic and staging information, management plans and status at each follow-up visit (45). Interventions can be designed to improve coor- dination between providers and patients, such as tumour boards, multi-disciplinary review or an integrated electronic medical record system. Sample organization of cancer interventions by care level Community engagement Primary care level Secondary care level Tertiary care level and empowerment Key functions Diagnosis Diagnosis Diagnosis • cancer awareness • recognition of cancer signs • cytology, biopsy, routine • cytology, biopsy, histopa- • community leaders and symptoms histopathology thology, prognostic markers, and cancer advocates • appropriate clinical • X-ray, ultrasound, endoscopy immunochemistry engagement evaluation Treatment • X-ray, ultrasound, endoscopy, • addressing cancer stigma • early referral of suspicious • Moderately complex surgery computerized tomography • Facilitating health-seeking cases • outpatient chemotherapy Treatment behaviour Treatment • radiotherapy • identifcation of barriers to Additional functions • Basic procedures (e. Guide to cancer early diaGnosis | 27 and fragmentation of care, when possible, all staging should be done at the facility with the requisite staging and treatment capacity. Routine post-treatment follow-up after discharge from a higher level of care may be available at the primary care level (such as suture removal). Survivorship care, including surveillance for recurrence and sequelae from treatment, may be provided at various care levels and should be coordinated with the patient’s treatment team of primary and specialized providers. Patients with metastatic disease who are not can- didates for treatment or who have completed treatment at a higher-level facility may receive palliative care services at, or coordinated by, an adequately equipped pri- mary care facility (46). Provide supportive counselling and people-centred care A preliminary diagnosis of cancer can be overwhelming for the patient.

Integrating disease management within the management plan reduces the likelihood of new activities being incorporated which are at odds with disease control objectives discount pyridostigmine amex. As such plans are used to inform budgetary requirements for a site order pyridostigmine with a visa, incorporation of disease management objectives increases the likelihood that these activities will be routinely funded buy pyridostigmine with a mastercard. As such plans are used to inform personnel workplans for a site, to incorporating disease management increases the likelihood that the required activities will be routinely scheduled into work planning. As such plans are used to inform training requirements for a site, incorporation of disease management increases the likelihood of investment in building capacity and maintaining appropriate expertise. Wetlands provide the interface for wildlife and domestic stock: managing the diseases of both should form part of an integrated site management plan (Sally MacKenzie). How to integrate disease management into management plans When integrating disease management into wetland management plans, the following practical aspects should be included: What: Ensure the disease management objectives are clearly defined (e. The management plan should specifically describe those diseases of known concern or with potential for emergence. It is also important to specify which activities should be avoided or amended if the disease management objectives are to be met. Who: Within the management plan, ensure it is clear who is responsible for each disease management activity, both in terms of project management and implementation. Also, it is important to highlight which stakeholders are involved in activities with key roles to play in disease prevention and control (e. How: The management plan should describe the specific disease management practices required. The logistics and practicalities of their implementation should be explicit or sources of this information should be provided. When: The timing of disease management activities should be described, both in terms of when to be implemented and their duration. For example, specific disease management activities may be required to coincide with seasonal use of the wetland by domestic livestock or migratory wild animals, or in response to ‘seasonal’ diseases. Similarly it should be explicit when to cease or reduce other activities which might have a negative impact on disease prevention or control. For example, during periods where there is a high risk of disease outbreak, anthropogenic stressors should be reduced or restricted to less sensitive areas of a site. Staff awareness and training The outbreaks are seasonal in nature (in response to factors including hot weather) hence a training presentation is provided to all grounds staff (i. Training includes information about the disease, recognising disease signs in the field, principles of disease control and the annual action plan. All appropriate staff with a role to play in the prevention and/or control of outbreaks are, therefore, aware of the actions to be taken and their responsibility for their Figure 3-6. Summary of management actions During the next eight weeks (or whatever period is considered appropriate i. Prevent environmental conditions that can lead to an outbreak Keep water levels stable. Environmental factors Maintain water pump in ‘South Lake’ (area of high risk and previous disease outbreak). Keep high volume of water moving through the ‘South Lake’ (replace in-flow pipe with one of larger diameter). The pipe bringing water from the canal to the ‘Swan Lake’ to be continued to be kept clear, including regular clearing of grids at either end. Care to be taken when strimming/cutting vegetation to prevent organic matter entering water bodies. Carcase and maggot removal Vegetation at water’s edge will be strimmed/cut to allow easier searches for sick and dead animals. Active searches for carcases of all species (including fish) to begin immediately, with extra searches in priority areas. Searches to be done early in the morning to reduce effects of the disturbance on visitors. All grounds staff and volunteers to be extremely vigilant – looking for any birds showing early stages of paralysis, obviously sick birds and carcases. Double bagging to collect carcases (a single bag can be knotted, inverted and knotted again to create double bag). Recording: details of species, ring number and location of sick and dead birds to be recorded. Bags containing carcases, maggots and substrate containing maggots to be put into freezer to kill maggots. Consideration given to scaring techniques in case birds need to be scared from specific sites. If the need arises, one half of isolation area to be set up to as a hospital unit for sick birds. The aim is to consider possible emergency disease scenarios and to integrate rapid cost effective response actions that allow outbreaks to be controlled and prevented in the future. Contingency plans should be considered, ‘bought into’ and agreed upon by all major stakeholders, and have appropriate resources and legislative backing where necessary. Regular simulation exercises will also serve to highlight any modifications required in contingency plans where aspects are subject to change such as incorporating new staff, new emerging disease threats and legislation and regulations [►Section 3. Plans should include clear objectives and guidelines and be written in language that is understandable to all relevant stakeholders. Above all, plans should provide sufficient information to allow the relevant authorities and managers to make informed decisions on appropriate policies and measures used to control a disease outbreak. It is advisable to develop contingency plans for specific high-risk/high priority diseases which incorporate generic standard operating procedures that may be common to several different specific plans. These should be supported by additional financial and resource plans and supportive legislation to ensure enforcement of contingency plans when needed. Technical contingency plan Specific disease contingency plans detail the management measures that should follow detection of an outbreak in order to control spread. These documents are likely to need to make reference to generic operating procedures for activities and programmes that may be common to several or all disease management strategies, such as modes of internal and external communication and organised public awareness campaigns [►Section 3. Reference may also be made to manuals that provide zoosanitary guidelines for enterprises deemed at risk of a disease outbreak (e. The contingency plan should clearly identify assigned roles and responsibilities of personnel taking part in the response to a disease outbreak. A contingency plan should be developed for each of the diseases that have been identified as being of high risk in a particular wetland site [►Section 3. An epidemiological investigation will help determine the impact of a disease and understand the infection risks to others and the environment. Outcomes will help determine the extent of infected areas/zones and guide disease prevention and control measures in each area/zone. Potential consequences for people, wildlife and livestock, including food security and poverty alleviation, production losses, trade losses and public and animal health. Surveillance strategies during different phases of a disease management programme.

Library facilities and e-textbooks Library facilities will be provided electronically through the University of Edinburgh Library Online 60 mg pyridostigmine otc. Students will also have access to the physical library buildings if they do wish to access these in Edinburgh cost of pyridostigmine. The University library will allow access to most journals and online e-textbooks related to the course generic 60mg pyridostigmine fast delivery. Computer requirements Computer and broadband A computer and internet access (preferably broadband) are required to participate in the course. A webcam is very useful for full participation in tutorials but a microphone and headphones will allow ‘voice-only’ participation. Software / computer configurations We will ask you to download some free software and to run configurations to ensure your computer is set up to run some of the e-learning resources (e. You will be given full details of this prior to commencing the course—see below for further details: Flash player Check you have the latest Flash Player (Version 9 or above) How do I know what version of Flash Player I have? Two ways of doing this, either: a) Right-click any flash object in a web browser b) Click on Start> Control Panel >Add/Remove Programs. A dialogue appears that tells you the version of Flash Player currently installed. Wimba Classroom Ensure that your computer is configured to run Wimba (the online tutorial software) before starting the course. Please use the ‘wizard’ to check that your computer and headset are set up for Wimba: edlive. The following are links to demos/videos showing how Wimba Classroom works: Wimba basics: www. Email When you join the University you will get a University of Edinburgh email account and address which will be used for a variety of essential communications. You must access and manage this account regularly as important information from the University will be sent to this address. If you already have a web-based email account and think you are unlikely to check your University email account, it is your responsibility to set up a forward on your University email. Change of details It is vital that you inform Registry Services of any change to details. You are given the opportunity to check and amend your details annually via your Registration Forms, but details can be changed at any time using the online form found here: www. Transkills training Transkills run a range of personal and professional development training courses for students across the University. Course organisers Eleri Williams (Lecturer in Internal Medicine) has responsibility for the day-to- day running of the course, and should be the first point of contact for all students. Associate tutors Associate tutors with specialist expertise will be invited to contribute/run modules in their specialty areas. The programme director is also there to facilitate your orientation and smooth progression through the degree, from initial induction to subsequent course choice, and the transition into the dissertation stage and to the successful completion of the degree. It is your responsibility to inform the programme director immediately of any problems that are interfering with your coursework or progress through the programme, including any religious or medical requirements that might affect your participation in any aspect of the programme. The style of assessment has been chosen to best complement the taught material and learning outcomes. Times New Roman 12pt, Arial 10pt)  With a structure, style and authorial voice consistent with the related literature – i. The thesis will demonstrate the student’s ability to complete a piece of objective research, which may be in the form of an extended clinical audit, a laboratory based project, a systematic review, or similar in any area of internal medicine. The student will be allocated an individual tutor/ supervisor based at the University of Edinburgh, and we would aim to find people with appropriate specialist interest in the areas required. Candidates will however be encouraged to work closely with senior staff in their home institutions, with mutually beneficial fostering of suitable academic links between the University of Edinburgh and medical institutes worldwide. The submission of the thesis (as per University regulations) on an agreed topic must normally be within 36 months of initial registration. Requests for an extension to the period of study must go through the Programme Director as a formal request to the College Postgraduate Studies Committee. Forms for this purpose, and for ‘interruption of studies’ due to special circumstances, are available from the course organizer. The final thesis will be in two forms: a printed document that will be marked and lodged in the university library, and an electronic version which will be set in the course archive for reference by future students. Students must ensure that their submitted dissertation meets the following criteria:  15,000 words or less (excluding references)  A4 portrait format with appropriate margins  Easily-readable font and font size (e. Progression and distinction Candidates gain the given number of credits required for a degree award incrementally in each academic year. Credits required are as set out in the Scottish Qualifications Framework and incorporated into the University’s Curriculum Framework. Progression on the programme is dependent on satisfactory performance at each level of the award. Students may choose to graduate after one year with a postgraduate certificate (60 credit points), or after the second year (120 credit points) entitling them to a postgraduate diploma. Year 1: During the first year, the student is required to complete (to the satisfaction of the Board of Examiners) all compulsory modules (with the option of replacing the Science of Medicine course with two elective modules from year 2). On satisfactory completion of year 1, they can leave the programme with a Certificate in Internal Medicine, or progress to the second year. All students who obtain a mark of greater than or equal to 40% are entitled to progress into the diploma year. Individuals failing to attain this grade will be deemed to have failed the programme. Students who fail their second year will leave the programme at this point with the award of a postgraduate certificate having attained sufficient credits for this award during their first year. Year 3: Students who achieve 50% or more in the master’s dissertation will be entitled to graduate with a master’s degree. Individuals who fail to achieve 50% will leave the course with the award of a postgraduate diploma. Students who achieve a mark of at least 70% on all courses on the programme will be awarded a master’s with distinction. This programme will adopt progression criteria in accordance with the University’s regulation should they change (we understand that these are being reviewed currently and are awaiting formalisation). The 20-credit Science of Medicine course will have double the weighting to the other 10-credit modules. Taking this into account, the assignment marks in each year will aggregated by averaging. Sufficiently high marks must be achieved at the first sitting in the first year (certificate) to allow progression to the second year (diploma) (see above). The diploma will be marked by two Internal Examiners with quality assurance and check-marking by the External Examiner. The provisional marks and marker comments will be discussed by the Board of Examiners and a decision taken as to the mark awarded and feedback to be given to the candidate.

Copho is likely to have been active in the second quarter of the twelfth century pyridostigmine 60 mg discount, while Mattheus Ferrarius flourished in the middle decades of the century order cheap pyridostigmine. The Roman poet Ovid wrote a facetious poem on cosmetics in the first cen- tury purchase cheap pyridostigmine on-line; see P. Ovidi Nasonis, Amores, Medicamina faciei femineae, Ars amatoris, Remedia  Notes to Pages – amoris, ed. A first-century Greek text, On Cosmetics, is attributed to Cleopatra; all that remains is a fragment on weights and measures. There is no evidence that the full text of this pseudo-Cleopatran Cosmetics was ever available in Latin, though a ref- erence to it may be behind the attribution of the strictly gynecological (and equally pseudonymous) Gynecology of Cleopatra (Gynaecia Cleopatrae) and Pessaries of Cleopatra (De pessis Cleopatrae). Patricia Skinner, Health and Medicine in Early Medieval Southern Italy, The Medieval Mediterranean,  (Leiden: Brill, ), follows Morpurgo in expressing skepticism about Salerno’s uniqueness. My work with the Trotula texts, even though it shows (in the case of the Treatments for Women) English influence, offers nothing to suggest a Parisian connection. And there is more than ample evidence—codicological, documentary, and textual—to confirm the vibrant local intellectual activity in southern Italy (and Salerno in particular) in the early twelfth century. Salernitan physicians figure in tales by, for example, Marie de France, Chrétien de Troyes, and Hartman von Aue. Goitein, A Mediterranean Society: The Jewish Communities of the ArabWorld as Portrayed in the Documents of the Cairo Geniza,  vols. Moshe Gil, ‘‘Sicily, –, in Light of the Geniza Documents and Parallel Sources,’’ in Italia Judaica: Gli ebrei in Sicilia sino all’espulsione del . Atti del V convegno internazionale Palermo, – giugno , Pubblicazioni degli Archivi di Stato, Saggi  (Palermo: Ministero per i Beni Culturali e Ambientali, ), pp. On the total integration of Sicily into the much larger world of Muslim and Jewish Notes to Pages –  Mediterranean culture, see also Abraham Udovitch, ‘‘New Materials for the History of Islamic Sicily,’’ in Giornata di Studio: Del Nuovo sulla Sicilia musulmana (Roma,  maggio ) (Rome: Accademia Nazionale dei Lincei, ), pp. Giorgio (–) (Salerno: Archivio di Stato, ); the document regarding the infirmary dates from  (pp. Amarotta, Salerno romana e medievale: Dinamica di un insedia- mento, Società Salernitana di Storia Patria, Collana di Studi Storici Salernitani,  (Sa- lerno: Pietro Laveglia, ). Among those granted permis- sion to use the baths at Santa Sofia were the nuns of the neighboring house of S. The monastery of Santa Sofia became a female house in the thirteenth century; see Galante, Nuove pergamene,p. Citarella, ‘‘Amalfi and Salerno in the Ninth Century,’’ in Istituzioni civili e organizzazione ecclesiastica nello Stato medievale amalfitano: Atti del Congresso inter- nazionale di studi Amalfitani, Amalfi, – luglio  (Amalfi: Centro di Cultura e Storia Amalfitana, ), pp. For the twelfth century, see Donald Matthew, The Norman Kingdom of Sicily (Cambridge: Cambridge University Press, ). Drell, ‘‘Family Struc- ture in the Principality of Salerno During the Norman Period, –,’’ Anglo- Norman Studies: Proceedings of the Battle Conference  (): –; and ‘‘Marriage, Kinship, and Power: Family Structure in the Principality of Salerno under Norman Rule, –’’ (Ph. For their part, however, men could not alienate their female relatives’ property without the woman’s permission. Katherine Fischer Drew (Philadelphia: University of Pennsylvania Press, ), esp. Evidence concerning the general legal and social history of women in southern Italy in the central Middle Ages has only recently begun to be collected. See in particular the essays of Patricia Skinner, ‘‘Women, Wills and Wealth in Medieval Southern Italy,’’ Early Medieval Europe  (): –; ‘‘The Pos- sessions of Lombard Women in Italy,’’ Medieval Life  (spring ): –; ‘‘Disputes and Disparity: Women at Court in Medieval Southern Italy,’’ Reading Medieval Studies  (): –; ‘‘Women, Literacy and Invisibility in Southern Italy, –,’’ in Women, the Book and the Godly: Selected Proceedings of the St Hilda’s Conference, , ed. Drell notes some shifts in the role of mundoalds (men who held a woman’s mundium) over the course of the twelfth century (pp. Copho, for example, distinguishes special remedies for noble people at least six times. See Copho, Practica, in Rudolf Creutz, ‘‘Der Magister Copho und seine Stellung im Hochsalerno: Aus M. The essays collected by Judith Bennett and Amy Froide in Singlewomen in the European Past, – (Philadelphia: Universityof Pennsylvania Press, ) have laid out many new avenues for research. Muhammad ibn Ahmad ibn Jubayr, The Travels of Ibn Jubayr, being the chronicle of a mediaeval Spanish Moor concerning his journey to the Egypt of Saladin, [etc. It is not clear whether the reference to noble- women in ¶, which was added later in the development of the Trotula ensemble, comes out of a Salernitan context. David Nirenberg, Communities of Violence: Persecution of Minorities in the Middle Ages (Princeton: Princeton University Press, ), pp. For example, the polymath Adelard of Bath and several English or Anglo- Norman physicians are known to have studied in Salerno; some Salernitan physicians also emigrated to England. Moreover, some of the earliest extant manuscripts of Con- stantinian and Salernitan writings come from England. Burnett, The Introduction of Arabic Learning into England, Panizzi Lectures,  (London: British Library, ), pp. On the specific significance of this English connection to Treatments of Women, see below. The definitive studyof the institutional historyof the school remains Paul Oskar Kristeller, ‘‘The School of Salerno: Its Development and Its Contribution to the His- tory of Learning,’’ Bulletin of the History of Medicine  (): –; reprinted in Ital- ian translation with further revisions as Studi sulla Scuola medica Salernitana (Naples: Istituto Italiano per gli Studi Filosofici, ). See also Vivian Nutton, ‘‘Velia and the School of Salerno,’’ Medical History  (): –; and ‘‘Continuity or Rediscovery: The City Physician in Classical Antiquity and Mediaeval Italy,’’ in The Town and State Physician in Europe from the Middle Ages to the Enlightenment, ed. My thanks to Francis Newton for informing me of his findings on the early date of Alfanus’s translation of Nemesius (personal communication, June ). His reli- gion of birth is of less import for this story than his native language. On Constantine and his oeuvre, see Bloch, Monte Cassino, : –, –, and : –; and most recently the essays in Constantine the African and ‘Alī ibn al- ‘Abbās al-Magˇūsī: The ‘‘Pantegni’’ and Related Texts, ed. On the intellectual culture of Monte Cassino, see Newton, Scriptorium and Library. Green, ‘‘Constantinus Africanus and the Con- flict Between Religion and Science,’’ in The Human Embryo: Aristotle and the Arabic  Notes to Pages – and European Traditions, ed. Wack, Lovesickness in the Middle Ages: The ‘‘Viaticum’’ and Its Commen- taries (Philadelphia: University of Pennsylvania Press, ); Gerrit Bos, ‘‘Ibn al-Jazzār on Women’s Diseases and Their Treatment,’’ Medical History  (): –; and idem, Ibn al-Jazzār on Sexual Diseases and Their Treatment, Sir Henry Wellcome Asian Series (London: Kegan Paul, ). Jordan, ‘‘Medicine as Science in the Early Commentaries on ‘Johan- nitius,’ ’’ Traditio  (): –; idem, ‘‘The Construction of a Philosophical Medi- cine: Exegesis and Argument in Salernitan Teaching on the Soul,’’ Osiris,dser. By the third quarter of the twelfth century, Galen’s Ars medendi was added to the collection as well. Brian Lawn, The Salernitan Questions: An Introduction to the History of Medieval and Renaissance Problem Literature (Oxford: Clarendon Press, ); The Prose Salerni- tan Questions (London: British Academy/Oxford University Press, ). See George Washington Corner, Anatomical Texts of the Earlier Middle Ages (Washington, D. Tips on practitioner-patient relations did not always conform to the spirit of the Hippocratic Oath. In discussing sanious flux from the womb, Master Salernus bru- tally observes, ‘‘Sometimes it happens that after their cure patients remain ungrateful toward the physician. Therefore, let them be given cut alum with any kind of cooked food so that they are afflicted once again. For if alum is taken, a lesion will necessarily be generated in some part of the body and they will fall sick again’’ (Catholica Magistri Salerni,inMagistri Salernitani nondum editi, ed.

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