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By R. Keldron. State University of New York at Buffalo. 2019.

Nutritional Supplementation Trials of nutritional supplementation include single vitamin supplements and multiple micronutrient approaches order 20mg vytorin otc. The study was a double-blind design across three study centers (Southampton discount vytorin 30 mg otc, Sheffield vytorin 30mg discount, Oxford) [20]. Thus, in a pre-specified analysis, amongst winter births, neonates delivered to mothers allocated vitamin D supplements had more than 0. For women in the intervention group the snack was made from green leafy vegetables, fruit, and milk, whereas women in the control group received a snack made up of low-micronutrient vegetables such as potato and onion. Women took the snacks daily from 90 days or more before pregnancy until delivery, in addition to the usual diet. The intervention had a marked effect on the prevalence of gestational diabetes—halving rates in women in the intervention group compared with women in the control group. There was a reduction in the prevalence of low birth weight among mothers who were not underweight and who were supplemented for three months before conception (treatment 34% vs. A recent systematic review found no convincing evidence of long-term benefits on growth, blood pressure or cognitive function, of maternal multiple micronutrient supplements started during pregnancy [47], but no studies of micronutrient supplementation starting preconceptionally, such as the Mumbai trial, have achieved long enough follow-up yet to answer this question. Health Behaviour Change Interventions Behavior change approaches during preconception and pregnancy can improve women’s health behaviors. While nutrient supplementation addresses specific nutrient deficiencies, behavior change approaches can improve overall diet quality. Pregnancy is a period when women are more likely to improve their health behaviors. Thus, it is a time when unhealthy behaviors, such as smoking and poor diet, can be tackled and healthier behaviors promoted [48]. Changing the health behaviors of women preconceptionally is more challenging not least because this group of women might still be adolescents with little understanding of the influence of their own health on that of their babies. Women’s confidence, or self-efficacy, that they can make such changes is an important determinant of whether they will improve their health behaviors. Low levels of self-efficacy are common among women from disadvantaged backgrounds and mean that women are less likely to have healthy diets [49]. Many studies have demonstrated a relationship between higher levels of self-efficacy and better dietary behaviors [50]. Reviews of evidence have shown that interventions with certain features are more likely to improve health behaviors for disadvantaged women. These include: providing information on risks and benefits of health behaviors; goal-setting; and continued support after the initial intervention [51,52]. The evidence indicates that there is a need for empowerment approaches that work by improving the self-efficacy of participants. Evidence from trials during pregnancy also points to the effectiveness of behavior change approaches. These interventions led to improvements in diet although they did not improve the primary outcomes of gestational diabetes and babies born large for gestational age [53,54]. Importantly, both interventions included goal setting as a component suggesting that empowerment approaches are likely to be more successful in bringing about behavior change. The intervention, the Southampton Initiative for Health, aimed to improve the health behavior of women from disadvantaged backgrounds. These Centres were developed to provide services and support for women with children aged under five years with an initial focus on serving areas of disadvantage. Sure Start staff members come into contact with women and their children attending the Centres. The staff members were trained in skills to support behavior change: Healthy Conversation Skills [55]. As a result of the Healthcare 2017, 5, 14 8 of 12 training, staff changed the way they interacted with women, using open discovery questions, listening more than talking and empowering women to set goals. Evaluation showed that women who came into contact with trained staff had significantly smaller declines in their sense of control and self-efficacy than women in the control group, although an effect on diet was not observed [57]. Self-efficacy and sense of control are psychological factors known to be associated with diet quality among disadvantaged women. These findings suggest that the intervention could improve women’s health behaviors if it were delivered in a setting that allowed frequent contact between women and trained staff. Women access services during pregnancy, providing an opportunity for repeated exposure to the Healthy Conversation Skills intervention and a trial that is assessing the efficacy of the intervention during pregnancy in women who receive antenatal care in Southampton’s maternity hospital is currently underway. Changing the health behaviors of women preconceptionally is more challenging but, arguably more important than pregnancy as a period for prevention of later disease. One of the challenges is how to engage women in interventions preconceptionally and to find ways of sustaining their engagement in a way that is both acceptable and affordable. The behavior change skills (Healthy Conversation Skills) implemented in the Southampton Initiative for Health can be used by health and social care staff in a range of settings and have the potential to address the challenges of engaging women preconceptionally. The skills are easily-acquired and theory-based, and are designed for use in brief consultations, to support diet and lifestyle change. Engaging adolescents is likely to pose additional challenges since they are less likely than women of other ages to be in contact with routine health and social care. Theenagers aged 13–14 years, who attend Hampshire secondary schools, have three weeks of school lessons, supported by teacher professional development, and a visit to an educational facility in the local hospital. The aim of Lifelab is to improve young people’s health literacy and understanding of the long-term influences of their health behaviors on their subsequent health and that of their children [58]. In South Africa, for example, rates of obesity are high among adolescent girls leading to high rates of gestational diabetes and low birth weight. An intervention to reduce obesity among adolescent girls is being developed, that will use community health workers trained in behavior change techniques, to empower adolescent girls to improve their health behaviors [59]. Novel technologies also have potential for engaging adolescents in changing their health behaviors. Such interventions are becoming increasingly common, and there is some evidence of effectiveness [61] though surprisingly little of this evidence concerns adolescence. The challenge that remains is to overcome the problems of low usage, attrition and small effect sizes which have so far characterized such interventions [62]. Interventions across the lifecourse, particularly those focusing on early life factors, may also produce economic benefits. The main gains resulted from improved labor productivity as well as from reduced morbidity and mortality [63]. A lifecourse approach with a focus on early years also has the potential to reduce health inequalities which in turn will produce Healthcare 2017, 5, 14 9 of 12 further economic benefits [10]. Future interventional studies should collect economic data in order to incorporate appropriate analyses of cost-effectiveness. Observational and mechanistic evidence has demonstrated the importance of maternal nutrition, during preconception and pregnancy, as an influence on future offspring health and has also shed light on the mechanisms that link maternal nutrition to fetal and childhood growth and development. The evidence points to the importance of interventions that have the potential to improve maternal nutrition, using a range of nutritional and behavioral strategies targeted at women before and during pregnancy.

In addition to the liver generic vytorin 20mg on line, the schistosome eggs can settle in the intestinal wall vytorin 20mg for sale, lungs cheap vytorin 20 mg with visa, kidneys, blad- der, and other organs, where they cause damage and symptoms in proportion to the parasite burden. Cattle have also been reported to have obstructive phlebitis caused by the presence of adult parasites in the veins. While some areas are making progress through vigorous control campaigns, the infection is spreading to others in the wake of new irrigation projects or carried by individuals. Moreover, the geo- graphic range of the intermediate hosts is greater than that of the human infection. The Aswan Dam in Egypt provides an example of how environmental change can impact on the disease. Although construction of the dam has resulted in important economic benefits for the country, it has also brought about profound ecological changes in the region and created favorable conditions for the survival of the mol- lusks that act as intermediate hosts of S. The dam reduced the flow rate of the Lower Nile and held back the alluvial sediment, thereby favoring penetration of the mollusks by the miracidia and also facilitating human contact with the cercariae that emerge from them. At the same time, there was an increase in human activities, such as fishing and washing clothes and utensils, along the Nile River. The ecology of Lower Egypt (the Nile Delta) also underwent changes favorable to the vectors of this parasitosis. The absence of alluvial sediment promoted the growth and spread of aquatic plants as well as the microflora on which the mollusks feed, with a consequent increase in their popula- tion and greater possibility of transmission of the parasite to the human host (Malek, 1975). The situation in Egypt, which has been repeated in several other countries of Africa, the Americas, and Asia, shows that knowledge of ecological conditions is essential to understanding the variability of the human infection. The growing rate at which dams are being constructed in the developing countries, sometimes with- out prior ecologic and epidemiologic studies to serve as a basis for implementing disease prevention measures, is helping to bring about the spread and intensification of schistosomiasis. These mollusks become infected when their water becomes contaminated with fecal matter from definitive hosts, especially humans, or urine in the case of S. Man acquires the infection by the cutaneous route by entering water that contains mollusks infected with the parasite. Studies in endemic areas have shown that the prevalence of infection in the snails concerned is generally lower than 5% and that the density of free-liv- ing cercariae is extremely low because they are dispersed over a large volume of water. These low rates sug- gest that the intense infections needed to cause disease require relatively prolonged exposure to contaminated water. In some regions, schistosomiasis is also an occupational disease of farm laborers who work in irrigated fields (rice, sugarcane) and fisherman who work in fish culture ponds and rivers. Another highly exposed group is the village women who wash clothing and utensils along the banks of lakes and streams. The infection can also be contracted while bathing, swimming, or playing in the water. Studies in the Americas have shown that rodents alone cannot maintain prolonged environmental contamination, but perhaps baboons (Papio spp. These species play an important epidemiologic role because they contaminate the water, enabling man to become infected. It has been observed that persons infected with abortive animal schistosomes or those that have little pathogenicity for man develop a degree of cross-resistance that protects them against subsequent human schistosome infections. It is even thought that resistance produced by abortive infections of the zoonotic strain S. In light of this heterologous or cross-immunity, some researchers have proposed vaccinating humans with the antigens or parasites of animal species (zooprophylaxis). The influence of factors involving the parasite, host, and environment on the per- sistence of schistosomiasis has been studied using S. Diagnosis: Schistosomiasis is suspected when the characteristic symptoms occur in an epidemiologic environment that facilitates its transmission. The ease with which their presence is confirmed depends on the intensity and duration of the infection; mild and long-standing infections produce few eggs. Whenever schistosomiasis is suspected, samples should be examined over a period of several days, since the passage of eggs is not continuous. The Kato-Katz thick smear technique offers a good balance between simplicity and sensitivity, and it is commonly used in the field (Borel et al. Among the feces concentration techniques, formalin-ether sedimentation is con- sidered one of the most efficient. In chronic cases with scant passage of eggs, the rectal mucosa can be biopsied for high-pressure microscopy. Also, the eclosion test, in which the feces are diluted in unchlorinated water and incubated for about four hours in a centrifuge tube lined with dark paper, can be used. At the end of this time, the upper part of the tube is illuminated in order to concentrate the miracidia, which can be observed with a magnifying glass. In addition to the mere presence of eggs, it is important to determine whether or not the miracidia are alive (which can be seen from the movement of the miracidium or its cilia) because the immune response that leads to fibrosis is triggered by antigens produced by the miracidium. In cases of prepatent, mild, or long-standing infection, the presence of eggs is difficult to demonstrate, and diagnosis therefore usually relies on finding specific antigens or antibodies (Tsang and Wilkins, 1997). However, searching for parasite antigens is not a very efficient approach when the live parasite burden is low. The circumoval precipitation, cercarien-Hullen reaction, miracidial immobilization, and cercarial fluorescent antibody tests are reasonably sensitive and specific, but they are rarely used because they require live parasites. Hence, the reaction of this antigen to IgM antibodies may be a marker of acute disease (Valli et al. A questionnaire administered to students and teachers from schools in urinary schistosomiasis endemic areas revealed a surprisingly large number of S. In many cases, cen- trifugation and examination of the urine sediment is sufficient to find eggs, although filtration in microporous membranes is more sensitive. Examination of the urine sediment for eosinophils reveals more than 80% of all infections. The use of strips dipped in urine to detect blood or proteins also reveals a high number of infections, even though the test is nonspecific. Also, there are now strips impregnated with spe- cific antibodies that reveal the presence of S. Searching for antibodies or antigens in serum was substantially more sensitive than looking for eggs in urine (Al-Sherbiny et al. Chemotherapy of infected individuals is not only curative but also preventive in that it halts the production of eggs that contaminate the environment. In a three-year study carried out in Madagascar, 289 individuals from a village in which S. In most cases, it is not recom- mended to treat the entire community; a more effective approach is to perform par- asitologic examinations and treat only the infected individuals. When the intensity of infection declines in a given population, it may be necessary to resort to serologic diagnosis, which is more sensitive. In communities that have a high prevalence of infection but limited economic resources, treatment can be restricted to the groups with the highest parasite burdens, such as children between 7 and 14 years old. Health education consists essentially in teaching people to avoid contact with con- taminated water and not to contaminate water with their own excreta. However, many of the populations most affected by schistosomiasis are communities with low levels of schooling and such limited resources that they often have no alternative but to use contaminated water or to contaminate the environment with their excreta. The intermediate hosts have been controlled in a number of areas by draining or filling in swampland, removing vegetation from water bodies, and improving irrigation systems.

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Almost all low birthweight deaths in the neonatal period result from preterm birth cheap 30 mg vytorin fast delivery. Rheumatic heart disease buy 20mg vytorin mastercard, hypertensive heart disease order vytorin 20mg without prescription, inflammatory heart diseases, and other cardiovascular diseases. Other neoplasms, endocrine disorders, sense organ diseases, genitourinary diseases, skin diseases, musculoskeletal diseases, and oral conditions. Communicable, maternal, 29,413 89,486 66,607 156,092 156,109 169,531 325,623 perinatal, and nutritional conditions A. Infectious and parasitic 2,817 37,373 49,777 87,150 88,105 129,584 216,734 diseases 1. Note: A blank cell indicates that fewer than 1,000 deaths are attributable to the specific cause. Hepatitis, tropical-cluster diseases, leprosy, dengue, Japanese encephalitis, trachoma, intestinal nematode infections, and other infectious diseases. Low birthweight deaths are those resulting from intrauterine growth retardation or preterm birth. Almost all low birthweight deaths in the neonatal period result from preterm birth. Rheumatic heart disease, hypertensive heart disease, inflammatory heart diseases, and other cardiovascular diseases. Other neoplasms, endocrine disorders, sense organ diseases, genitourinary diseases, skin diseases, musculoskeletal diseases, and oral conditions. Incorporating Deaths Near the Time of Birth Into Estimates of the Global Burden of Disease | 457 Table 6B. Communicable, maternal, perinatal, and 201,606 201,606 222,553 424,158 nutritional conditions A. Note: A blank cell indicates that fewer than 1,000 deaths are attributable to the specific cause. Hepatitis, tropical-cluster diseases, leprosy, dengue, Japanese encephalitis, trachoma, intestinal nematode infections, and other infectious diseases. Low birthweight deaths are those resulting from intrauterine growth retardation or preterm birth. Almost all low birthweight deaths in the neonatal period result from preterm birth. Epilepsy, alcohol use disorders, Alzheimer’s and other dementias, Parkinson’s disease, multiple sclerosis, drug use disorders, post-traumatic stress disorder, obsessive-compulsive disorder, panic disorder, insomnia (primary), migraine, mental retardation attributable to lead exposure, and other neuropsychiatric disorders. Rheumatic heart disease, hypertensive heart disease, inflammatory heart diseases, and other cardiovascular diseases. Other neoplasms, endocrine disorders, sense organ diseases, genitourinary diseases, skin diseases, musculoskeletal diseases, and oral conditions. Communicable, maternal, perinatal, and 1,551 1,551 6,384 7,935 nutritional conditions A. Note: A blank cell indicates that fewer than 1,000 deaths are attributable to the specific cause. Hepatitis, tropical-cluster diseases, leprosy, dengue, Japanese encephalitis, trachoma, intestinal nematode infections, and other infectious diseases. Low birthweight deaths are those resulting from intrauterine growth retardation or preterm birth. Almost all low birthweight deaths in the neonatal period result from preterm birth. Epilepsy, alcohol use disorders, Alzheimer’s and other dementias, Parkinson’s disease, multiple sclerosis, drug use disorders, post-traumatic stress disorder, obsessive-compulsive disorder, panic disorder, insomnia (primary), migraine, mental retardation attributable to lead exposure, and other neuropsychiatric disorders. Rheumatic heart disease, hypertensive heart disease, inflammatory heart diseases, and other cardiovascular diseases. Other neoplasms, endocrine disorders, sense organ diseases, genitourinary diseases, skin diseases, musculoskeletal diseases, and oral conditions. Communicable, maternal, perinatal, and 202,202 202,202 228,937 431,139 nutritional conditions A. Note: A blank cell indicates that fewer than 1,000 deaths are attributable to the specific cause. Hepatitis, tropical-cluster diseases, leprosy, dengue, Japanese encephalitis, trachoma, intestinal nematode infections, and other infectious diseases. Low birthweight deaths are those resulting from intrauterine growth retardation or preterm birth. Almost all low birthweight deaths in the neonatal period result from preterm birth. Epilepsy, alcohol use disorders, Alzheimer’s and other dementias, Parkinson’s disease, multiple sclerosis, drug use disorders, post-traumatic stress disorder, obsessive-compulsive disorder, panic disorder, insomnia (primary), migraine, mental retardation attributable to lead exposure, and other neuropsychiatric disorders. Rheumatic heart disease, hypertensive heart disease, inflammatory heart diseases, and other cardiovascular diseases. Other neoplasms, endocrine disorders, sense organ diseases, genitourinary diseases, skin diseases, musculoskeletal diseases, and oral conditions. Estimates of deaths from specific causes the formats in which the two sets of numbers are presented. To facilitate comparison of the two sets the need for a separate book—Jamison and others (2006)— of findings, annex table 6C. One of the motivations of this chapter is that for their category sepsis or pneumonia. Low birthweight deaths are those resulting from intrauterine growth retardation or preterm neonatal deaths account for fully 37 percent of the world- birth. Almost all low birthwieght deaths in the neonatal period result from preterm birth. Chapter 3 provides an estimate for birth asphyxia and birth trauma deaths for ages zero to wide total of deaths among children under age five. At an earlier stage of this and Regional Burden of Disease Attributable to Selected Major Risk Factors, vol. Lopez, Anthony Rodgers, and work,Nancy Hancock and JiaWang provided valuable inputs Christopher J. Improving Birth Outcomes: Meeting the Challenge in the vided detailed and valuable critical reaction. The term child mortality rate is sometimes used to denote what we Estimates of Intrapartum Stillbirths and Intrapartum-Related Neonatal call the under five mortality rate. New York: further discussed in Fishman and others (2004) and in chapter 4 of this Oxford University Press. Geneva: Global of Disease in 1990: Summary Results, Sensitivity Analysis, and Future Forum for Health Research, Child Health and Nutrition Research Directions. Shahid-Salles, Julian Jamison, and others Global Burden of Disease and Injury Series. Incorporating Deaths Near the Time of Birth Into Estimates of the Global Burden of Disease | 463 Glossary Age-standardized rate An age-standardized rate is a weighted bronchial airflow is usually reversible and between asthma average of the age-specific rates, where the weights are the pro- episodes the flow of air through the airways is usually good. The potential confounding effect of age is wide array of disorders, including diseases of the cardiac mus- removed when comparing age-standardized rates computed cle and of the vascular system supplying the heart, brain, and using the same standard population. The of body structure and function, and domains of activities/par- “optimal” levels of functioning are defined as those levels above ticipation.

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As discussed previously in section “Belief that ‘Doctor Knows Best order generic vytorin from india,’” Kim seems to be willing to tolerate a paternalistic approach from a male doctor purchase generic vytorin pills, and this could be due to her age buy generic vytorin canada. As such, Kim likely considers her primary care doctor to be an authority figure—an “authority in the face of which one does not dare to openly show resistance or refusal” (Fainzang, 2005, p. According to Fainzang (2005), patients who do not wish 189 to demonstrate “open opposition” to their doctors will sometimes lie in order to “avoid conflict, criticism, or blame” (p. Nevertheless, while it is considered unacceptable for patients to withhold information from their doctors, for a doctor to withhold information “comes within the framework of permissible lying” (Fainzang, 2005, p. According to Fainzang (2005), “Numerous doctors claim the privilege of knowledge concerning the patient’s body and tend not to disclose information that might enable the patient to make his own choices concerning his being” (p. In addition, patients’ knowledge tends to be undervalued by doctors (Risberg, 2006); and decisions regarding diagnosis and treatment are based on “objective evidence” of disease (e. Research indicates that patients are more likely to trust doctors who listen to them and show a genuine interest in their well-being (Houle et al. In turn, trust in one’s doctor increases the likelihood that patients will disclose information to their doctors (Copeland et al. Considering that the majority of patients wish to actively participate in their healthcare (Barry & Edgman- Levitan, 2012; Chin, 2002; Flynn et al. Six out of the nine participants who indicated that their ability to communicate with their doctors was influenced by their level of trust in their doctors explained that they had engaged in self-treatment. As with the issue of secret-keeping, the majority of the literature on self-treatment places patients in a subservient position to the doctor and largely focuses on “self-medication” with unauthorized drugs and alcohol (e. Self-medication is defined by Verma, Mohan, and Pandey (2010) as “the use of medication by a patient on his own initiative or on the advice of a pharmacist or a lay person instead of consulting a medical practitioner” (p. Fainzang (2013) argued that patient self-medication is a form of self-advocacy that involves a thoughtful process of “self-examination, self-diagnosis, and self-prescription” (p. Because female patients in particular often need to prove the validity of their complaints (Hoffman & Tarzian, 2001; Munch, 2004) and patients who challenge their doctors tend to be thought of as “difficult” (Frosch et al. In the current study, the term “self-treatment” was chosen instead of “self- medication” due to its negative connotation in the majority of the literature. In the current study, six participants chose to either stop or start taking a medication or supplement without consulting their doctors. For example, Jenna shared that she was struggling with symptoms from thyroid cancer, which remained undiagnosed 191 for approximately four months because her blood work continued to show as “normal. During the fourth month period before her diagnosis, Jenna spoke with a friend “who has thyroid issues [and] got [her] on a multivitamin and 10k units of vitamin D3. As a result, Carla explained, “I started self- treating in July of 2002 and pretty much consider myself to still be self-treating [and] the current doc/insurance just run my labs. Research conducted by Holtgräfe and Zentes (2012) revealed a correlation between patient self-treatment and distrust in the opinion of health professionals. In a study of individuals with gastrointestinal disorders, patients with a graduate-level education were more likely to self-treat than those with a secondary 192 education or below (Kua, Ng, Lhode, Kowalski, & Gwee, 2012). Educational attainment is positively correlated with “health literacy,” or “the degree to which individuals have the capacity to obtain, process, and understand basic health information to make appropriate health decisions (Lubetkin et al. White and colleagues argued that patients who are highly health literate are less likely to trust their doctors’ recommendations without verifying the information and exploring additional options. Regardless of patients’ reasons for self-treatment, there are potential risks to stopping or starting medications and supplements without consulting a doctor. According to Ruiz (2010), potential risks include incorrect self-diagnosis, adverse reactions, and dangerous drug interactions. In Shawna’s experience, her choice to self-treat with iodine supplements may have caused a significant spike in her level of thyroid antibodies— which worsens the symptoms of Hashimoto’s disease. Shawna explained, I thought since the doctors kept saying my thyroid was okay, maybe I just needed something natural as a boost, not really having a lot of information. I also was clicking on ads on the internet and read some doctor that insisted we are all iodine deficient and promoting his pills. Considering that most patients want to be involved in the decision making process (Barry & Edgman-Levitan, 2012; Chin, 2002; Flynn et al. As previously discussed, patients trust doctors who listen to them without interrupting (Hedberg & Lynoe, 2013; Skirbekk et al. The majority of participants’ responses to questions regarding the potential influence of gender on treatment experiences revealed that the doctors’ gender had little influence on doctor-patient communication. However, participant responses indicated that being female influenced doctor-patient communication, particularly regarding the participants’ perceptions of being taken seriously and when the participants expressed emotion. Within Subtheme 3: Role of 194 Gender are the following subthemes: no preference for specific doctor gender, preference for female doctor, being taken seriously, and presence of emotion. When asked if it mattered whether their doctors were male or female, the majority of participants (13 out of 16) indicated no preference for their doctor to be a specific gender. Michelle shared that she has been treated by both male and female doctors and she believes that the “Dr. Although Alicia’s and Jessica’s responses suggested an initial preference for a female doctor, they ultimately expressed no preference for their doctor to be a specific gender. When asked if it mattered whether their doctors were male or female, Alicia responded, “I’m not sure. I wonder if a woman might be more understanding, but I feel that my [male] physician is very understanding. Although a number of studies indicate that patients prefer doctors of the same gender (e. Rather, the competence and communication skills of doctors appear to be more important to patients than the doctors’ gender (Bertakis & Azari, 2012; Bourke, 2002; Mavis, Vasilenko, Schnuth, Marshall, & Jeffs, 2005; Thempest et al. This finding is consistent with the results of the current study, with 13 out of 16 participants referring to 196 the importance of their doctors’ competence and communication skills in lieu of their doctors’ gender. The ability for doctors to communicate effectively with their patients is crucial to meeting their patients’ needs and expectations (Godager, 2012). Numerous studies have revealed that patients prefer doctors who listen attentively, answer their questions, and include them in decision making—practices that are characteristic of patient-centered approaches (Carlsen & Aakvik, 2006; Copeland et al. Research indicates that female doctors tend to use patient-centered approaches more often than male doctors, as evidenced by longer consultations and a greater psychosocial focus in their discussions (Beach, 2000; Bertakis, 2009; Bertakis & Azari, 2012; Firth Cozens, 2008b; Hall & Roter, 2002; Hall et al. Considering the aforementioned findings regarding patient-centered approaches, it was expected that the participants in the current study would express a preference for female doctors. The fact that the participants in the current study reported no preference for a specific doctor gender might be due to the fact that only four out of the 16 participants interviewed (Alicia, Autumn, Kari, and Karen) consistently had doctors who did not make them feel unheard, invalidated, dismissed, not empathized with, or disrespected (discussed previously in “Subtheme 2: Participant Self-Advocacy”). In other words, during the time of their interviews, the majority of the participants might have still been seeking doctors who use a patient-centered approach. If this is the case, the gender of the doctors ultimately chosen by participants remains unknown because at the time of 197 the interviews, participants were not asked whether or not they were seeking or considering seeking new doctors.

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Journal of Infectious by insertion of the bacteriophage L54a genome Diseases 171 discount vytorin 30mg line, 607–613 cheap 30 mg vytorin free shipping. Diversity of stx2 converting bacteriophages (2006) Predominance of clones carrying induced from Shiga-toxin-producing Escherichia Panton–Valentine leukocidin genes among coli strains isolated from cattle purchase vytorin with a visa. Journal of Clinical Microbiology (2004b) Free Shiga toxin bacteriophages 44, 4515–4527. Journal of Clinical Microbiology 46, Phage conversion of Panton–Valentine 3246–3258. Nature (2007) A generalized transducing phage for the Reviews Microbiology 8, 541–551. Shiga-like toxin-converting phages from (2003a) Superantigens and streptococcal toxic Escherichia coli strains that cause hemorrhagic shock syndrome. Infection and Immunity Sequence analysis of Escherichia coli O157:H7 70, 1896–1908. Applied and Zentralblatt für Bakteriologie A 247, 95–100 (in Environmental Microbiology 73, 8032–8040. Journal of General Microbiology 39, innate immune modulators staphylococcal 321–333. Journal of Experimental Medicine Bioscience, Biotechnology and Biochemistry 137, 1338–1353. Hendrickson 5 The Lion and the Mouse: How Bacteriophages Create, Liberate and Decimate Bacterial Pathogens Heather Hendrickson1 1New Zealand Institute for Advanced Study, Massey University ‘…I had my eyes opened by that microscope, to the fact that there is a world of tiny creatures that you can’t see with the naked eye. Like the So interdependent are these organisms that ratchet in the handyman’s tool box, mutation defining which is the proverbial lion of the can be thought of as only permiting change jungle and which the unassuming mouse can in a single direction, that is, away from the be a challenge. On in bacteria means there is no opportunity to evolutionary timescales, however, phages reshuffle combinations of genes that sexually also can convert bacteria from pussy cats into reproducing organisms have, which produce the human predators we call pathogens. A are the accidental architects of the genetic continual accumulation of deleterious combinations that we observe in the bacterial mutations over time is predicted to eventually world. This has profound lineages afer a mere 1700 generations consequences for these organisms and their (Andersson and Hughes, 1996). Thus phages and of fresh insight into the evolutionary processes bacteria are engaged day to day in a undergone by bacteria (Fleischmann et al. In population growth amounts of genomic content in some fraction experiments where bacterial genetic diversity of extant lineages would be novel and notable, would normally emerge as a result of niche there are recent suggestions that an average of specialization and trade-offs, the effect of 81% of bacterial genes might be acquired adding predatory phages is to decrease horizontally (Zhaxybayeva et al. Two major have been proposed as the standard for advantages in using parametric methods are phylogenetic comparison across the three that they are computationally simple and that domains of life because these molecules are multiple genomes for comparison are not present in all branches of life and are required for transferred genes to be identified. Even this overlapping but different sets of genes for paragon of molecular metrics, however, has the same genome. This is due, in part, to been horizontally transferred in some cases the confounding similarity in mutational (Gogarten et al. Homologous genes from process termed amelioration (Lawrence and different organisms can therefore be used to Ochman, 1997). Developmental stages in bacterial align with the inferred organismal tree then a growth, such as sporulation in Bacillus subtilis, transfer event can be inferred (Snel et al. Hendrickson organismal tree to use as the benchmark for recipient genome, and this acquisition takes such comparisons? Multiple methods are place through three processes: transformation, being developed to determine the phylo- conjugation and transduction (Fig. This hypothesis Conjugation Transformation received support recently through direct testing using a set of ubiquitously conserved gene sequences, which suggested a high-level Transduction tree of universal relatedness (Theobald, 2010). How Bacteriophages Create, Liberate and Decimate Bacterial Pathogens 65 it can then be recombined into the recipient selective constraints in order to be maintained genome by repair-like recombination pro- for long periods of time. As such, the that can be as short as 1 kb and can range up following is far from an exhaustive discussion to many hundreds of kb. Upon more detailed but gives a breadth of mechanisms that analysis, many of these gaps can be atributed constrain gene transfer. Integrated phage transmitance of genetic material between genomes can carry genetic elements that donor and recipient cells. This is mediated by contribute both to the pathogenicity of the multiple processes, all of which will have strain and to their own retention (Brüssow et natural host-range limitations to one degree al. If organisms that are the recipient bacterial chromosome or other most closely related are those that are cytoplasmic replicon such as a native plasmid. The mismatch repair in higher organisms contributes directly to system, for example, acts to correct mutations, the species cohesiveness (and, indeed, defines including small insertions and deletions. This will be less likely to to mismatch repair anti-recombination interfere with segregation afer integration. Transfer that involves re- An additional, sequence-based dis- combination into plasmids will also avoid the crimination mechanism has been recognized constraints of integrating into a structured in the clustered, regularly interspaced, short genome. By contrast, the acquired for destruction and have been shown to functions of the inherited genes have the interfere with lateral gene transfer (Marraffini potential to increase the fitness of the and Sontheimer, 2008). Interruptions of important genes or unlikely to be anything more than neutral or regulatory regions, for example, tend to be may be deleterious to the fitness of the detrimental to fitness. Observations of becoming organelles such as mitochondria recently acquired genes may reflect neutral or and chloroplasts (Gray and Doolitle, 1982; even disadvantageous acquisitions in the Moran, 1996; Lang et al. It should be noted, however, that a been maintained up to that point by genetic recent study suggests that rare co-infection drif. Thus, a genome sequence should be events can support genetic exchange in some considered to be a snapshot of a single cases between such obligately intracellular bacterium at some point on its evolutionary bacteria (Kent et al. These ‘core’ extant organisms are subject to both genes, however, have been observed to be speculation and fierce debate. Today, it is generally be appealing, this idea does not appear to be accepted that most bacterial genomes have readily demonstrated (Beauregard-Racine et experienced recent and frequent gene transfer al. Lastly, it would seem that the more and that nearly all genes can be transferred we examine the scope of genes that are (Ochman et al. The conditions in genomic depth we have sampled to a which these organisms live, inside their remarkable degree. These large-scale genomic studies appears to be that organisms are intimately associated with bacterial species are fluid due to fluxes in humans and include both commensals and gene content (Lukjancenko et al. A Capabilities, Pathogenicity, and recent 20-genome sequencing project Beyond examining E. It is the sudden acquisition of genome on average has ~4700 genes and the segments of genetic material that gives total pool of genes shared is 10,000+ (Touchon bacteria access to new niches resulting, for et al. Thus, each genome on average is example, in the spread of antibiotic resistance ~43% core E. This other 57% or 10,000+ have caught our atention in recent years as genes collectively can be referred to as the E. The obvious phages ofen acting as direct mediators of prophage-associated genes in this study were change. Such high levels that serve to either kill or slow the growth of of fluctuating genomic content imply that local bacteria. Bacteria in turn develop the utility of examining single strains as capacities to resist antibiotics. Phages mediate representative of species of bacteria is these processes on both sides by mobilizing probably short-sighted.

Allow the students to take their creations out of the calcium chloride solution and onto a paper plate for observation order generic vytorin on-line. Students should work together to create a poster explaining how scaffolding is the basis for tissue and organ engineering discount 20mg vytorin with visa. Extension The activity may be extended by researching the types of materials used to create scaffolds and the advantages and disadvantages of each type buy vytorin 30 mg free shipping. Students may use the resources found on selected websites, such as the Regenerative Medicine Foundation (http://www. How could the different shapes created in this activity help in organ engineering? But the media often neglects to discuss what stem cells really are, how they are being used in research and treatments, the many different kinds of stem cells and recent advances in stem cell research that may reduce or eliminate the need for controversial embryonic stem cells. Stem cells can be used as unique building blocks in bioengineering and growing tissues and organs. This activity will provide students opportunities to defne stem cells and research their characteristics. Theaching Notes This activity asks students to use the Internet to research what stem cells are and the different types of stem cells. The students will research the characteristics, advantages and disadvantages of different stem cells. To make the most effective use of student research time, suggested resources have been provided. Depending on student access to the Internet, you may choose whether to have students do this research in or out of class. After gathering and synthesizing information, the students will create a commercial to share their fndings with other students. The discussion of stem cells will culminate with a gallery walk that synthesizes the stem cell information. Sharing the rubric at the end of this lesson plan helps students meet expectations. Explain to students they will have the opportunity to defne this term and research how different types of stem cells are used in different therapies. They will use two to three resources to research this basic question and fnd out what is different between adult and embryonic stem cells. In order to move to the next section of this activity, each student will write a paragraph explaining what a stem cell is, which may be used as a formative assessment. After the students have completed their paragraph satisfactorily, students will be placed in a group of two or three students and choose to research pluripotent or multipotent stem cells. The student will be required to explain how the specifc stem cell is used and the advantages and disadvantages. Discussion: Helping Students Build Understanding and Make Connections After students share the commercials they will synthesize the information by completing a gallery walk. Place four (or more) posters on the wall with the following labels: Pluripotent Advantages, Pluripotent Disadvantages, Multipotent Advantages, Multipotent Disadvantages. Students in each group will write down as many facts on the sheet as they can remember in three minutes. After three minutes, the posters will be passed to the next group and the process repeated until all groups have written on each of the posters. Place the posters on the wall and allow students to walk around the room silently and place two checks on each paper for the strongest point. These posters will provide a visual representation of the research that can be posted in the class and referred to throughout this course. They should be shared with students in advance and may be developed with students. Theachers may adjust this rubric to ft their grading system and to emphasize different aspects of the project as appropriate for their curriculum. Extension This activity may be extended by asking students to research how stem cells may be used to combat chronic disease, such as cancer. Because this research area is evolving rapidly, online information is more likely to be up-to-date than information in print. Some options include: National Institutes of Health The National Institutes of Health has a number of resources on stem cells, including: • Current Research http://stemcells. Does not seem Shows a full Shows a good Shows partial Commercial to understand the understanding of understanding of understanding of content stem cell very the stem cell. Student uses Accuracy (of both appropriate Presents accurate Presents accurate Hard to tell if the written notes and sources. Material material 90% to material 75% to student knew the oral presentation) accurate based on 95% of the time. Student is able Student is able Student is able Student is unable to accurately to accurately to accurately to accurately Comprehension articulate the articulate most of articulate part of articulate the topic. Provides a Performs the Provides an complete Provides a simple commercial exceptional Commercial commercial that commercial that in-person for the commercial that quality falls within 30 does not meet the class and/or does meets the time seconds of the time requirements. Before delving deeper into the uses of different types of stem cells, defne the phrase “stem cell. On another sheet of paper make a chart similar to this one but with enough space to record all your fndings. Key Vocabulary • Regenerative medicine • Organ engineering • Scaffold • Bioprinting Time Required • Approximately 90 minutes to research regenerative medicine (may be done outside of class) • Approximately 60 minutes to create regenerative medicine magazine cover (may be done outside of class) • Approximately 90 minutes to present regenerative medicine covers (for class of 30 students) Materials • Computers with Internet access and print materials for research • Rubric Background Information Regenerative medicine holds the possibility of using stem cells to engineer and grow tissues and organs. In the past, if someone had a diseased bladder he or she most likely would develop kidney disease and possibly would die. But in 2001, a young boy was given a new bladder that had been grown for him in the lab. This feld of medicine continues to evolve, thus students must keep up with new advances by reading current research. Depending on student access to the Internet, you may choose to have students do this research in or out of class. After gathering and synthesizing information, the students will create a magazine cover highlighting their favorite advances in regenerative medicine. Safety Students should follow school/district Internet access guidelines to ensure safe browsing. Procedure Begin by watching a video on regenerative medicine, such as Heal, Feed, Sustain: How Biotechnology Can Help Save the World (http://www. Explain that they will be able to answer many of these questions and others after completing this project. Explain that regenerative medicine is a constantly changing feld, thus they will be using online resources to discover current advances. The student will work in groups of two to complete the following Regenerative Medicine: Changing Life handout. In order to move to the next section, the teacher may use the student sheet as a formative assessment. After the students have completed the research, the students will create a magazine cover highlighting a key use of regenerative medicine and details of this use. They should be shared with students in advance and may be developed with students.

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There is solid evidence from both experimental animals and man that the immune response of the T helper 1 lymphocytes (cell-mediated immunity)—especially the production of gamma interferon and tumor necrosis factor alpha—protects against leishmaniasis purchase vytorin with paypal, and the infection may resolve spontaneously or remain asympto- matic best buy vytorin. There is also some evidence that these reactions might contribute to tissue damage in cutaneous leishmaniasis (Ribeiro de Jesus et al cheap vytorin uk. In several organ transplant recipients, the disease recurred after treat- ment, resulting in the death of some patients (Berenguer et al. The Disease in Animals: Visceral leishmaniasis in domestic dogs also occurs in geographic foci. Frequently, but not always, the prevalence in man and dogs in the same area is similar, although there may be areas of canine infection where no human infection exists. The disease causes cutaneous and systemic lesions, but the former are more evident. The cutaneous lesions are non-pruritic and include areas of alopecia, desquamation, and inflammation. The most frequent systemic mani- festations are intermittent fever, anemia, hypergammaglobulinemia, hypoalbumine- mia, lymphadenopathy, splenomegaly, lethargy, and weight loss. Episodes of diar- rhea, glomerulonephritis, and polyarthritis sometimes also occur. Antimonial treatment is not very effective and recurrences are frequent (Barriga, 1997). Severity of clinical symptoms does not appear to be related to parasite load, as very heavily parasitized dogs may have mild symptomatology. In Brazil, more than 30% of infected dogs had no apparent clinical symptoms (Hipólito et al. Infection in the fox Lycalopex vetulus in northeast Brazil is similar to that of dogs. Some ani- mals may have clinically inapparent infections, while others manifest different forms of the disease, including very serious and even fatal cases. Source of Infection and Mode of Transmission: The epidemiology of the dis- ease varies from region to region and from one area to another. In the Americas, the reservoirs of visceral leishmaniasis are dogs and the wild canids. The infection is spread among canids and from these animals to man by the bite of the phlebotomine fly Lutzomyia longipalpis. The epidemic significance of the man-dog link seems to vary from area to area; while some authors have found no correlation between the prevalence in humans and in dogs (Paranhos-Silva et al. The most important endemic area in the Americas is in northeastern Brazil; the main foci are distributed across a semiarid region that is subject to prolonged droughts. The disease is basically rural, with a few cases occurring in populations or places on the outskirts of cities. The largest concentration of cases occurs in foothill areas or in mountain valleys, where the dis- ease is endemic with periodic epidemic outbreaks. In the flatlands, on the other hand, cases are sporadic and occur primarily in the most humid areas, near rivers. In Brazil, the geographic distribution of the disease coincides with that of the vec- tor. The main, and possibly the only, vector in the endemic area of northeastern Brazil is the phlebotomine L. Dogs are an especially suitable reservoir because they offer the vector direct access to the parasitized macrophages of their cutaneous lesions. In studies con- ducted in Ceará, Brazil, parasites were detected in the skin of 77. In addi- tion, humans have been found to have a lesser number of parasites in their skin than dogs. Amastigotes are scarce in human skin and only rarely serve as a source of infection for the vector. A wild host of visceral leishmaniasis in northeastern Brazil is the fox Lycalopex vetulus, which often comes near houses to hunt chickens. Amastigotes are abun- dant in the fox’s skin, and it is a great source of infection for the vector (Garnham, 1971). In the tropical rain forest region of the lower Amazon, such as the state of Pará, where the number of cases in humans and domestic dogs is low, the reser- voir of the parasite is suspected to be a wild canid. In the Mediterranean basin, dogs are also the principal reservoir, while several species of the genus Phlebotomus serve as vectors. In the Middle East, jackals and dogs are the hosts and the main sources of infection for phlebotomines. In India, by contrast, no dogs or other animals have been found to be infected, and man is the main reservoir (Bhattacharya and Ghosh, 1983). Prevalence of the disease was very high in the country’s large cities, but it was reduced significantly as a result of an antimalaria campaign that eliminated both mosquitoes and phlebotomines. When the campaign was discontinued, Bihar experienced an epidemic resurgence of kala- azar (see Geographic Distribution and Occurrence in Man). In the absence of an ani- mal reservoir, subclinical human infections may play an important role in maintain- ing the disease (Manson and Apted, 1982). Person-to-person transmission takes place by means of Phlebotomus argentipes, an eminently anthropophilic insect which feeds solely on humans. In India, the number of parasites circulating in human blood was found to be sufficient to infect the vector. Transmission occurs inside houses, which constitute microfoci of infection (Manson and Apted, 1982). In Sudan, the infection has been found in wild rodents of the species Arvicanthis niloti- cus and Acomys albigena, domestic rats Rattus rattus, and carnivores Felis philippsi and Genetta sangalensis. It is believed that rodents are the primary hosts for the agent and that carnivores are secondary reservoirs. Humans develop parasitemia and, under epidemic conditions, can be a source of infection for the vectors. Numerous investigators believe that visceral leishmaniasis was originally an infection that circulated enzootically among wild animals (canids and perhaps rodents), and that later, domestic dogs were included in its cycle; eventually, the dis- ease became an infection transmitted between humans without the intervention of an animal reservoir, as is the case of kala-azar in India. An argument in favor of this hypothesis is dogs’ low degree of adaptation to the parasite and their susceptibility to the clinical disease, which suggests that they are a rather new host in the natural history of the disease. In the Americas, it has been suggested that the fox Cerdocyon thous, which becomes infected without becoming ill, could have been the original reservoir. However, more research is needed, especially concerning rate of infection, to confirm that this animal is the original reservoir (Lainson, 1983). Diagnosis: Confirmation of visceral leishmaniasis is made by identifying the par- asite. In the form of visceral leishmaniasis that occurs in the Americas, the parasite can rarely be seen in films of peripheral blood; however, this technique can yield positive results for kala-azar in India. The most sensitive procedure (98% positivity) is splenic aspiration, but this technique entails high risk, especially in patients with anemia and clotting problems. In the early stages of the disease, when parasites are scarce, culture in Novy-McNeal-Nicolle or another appropriate medium or intraperitoneal inoculation in hamsters can be used.

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