T. Narkam. University of Maryland at Baltimore.
The hydrochloride form has a higher percentage of glucosamine and is considered by most practitioners to be the preferred form buy generic silagra 50mg on line. Also best 50 mg silagra, some patients with diabetes report that glucosamine interferes with their blood glucose levels silagra 100 mg free shipping, so this formula should be used with caution cheap 100 mg silagra amex. It is important to consider the following points: ● This formula is intended to improve blood glucose control and prevent diabetic neuropathies, especially in type two diabetes. It is not intended to replace prescription medication for the treatment of these diseases. While debate about the benefits of the picolinate form over a chelate continues, patients with diabetes would need 800 μg per day, rather than the 25 μg here. If 800 mcg is used, a chelate should be recommended, since results of toxicity studies on high doses of picolinic acid are not con- clusive. The following points are important to remember when this formula is used: ● This formula contains saw palmetto and Epilobium parvifolum, both well- respected herbs in the treatment of prostate conditions. Before using this product, the patient should consider the following: ● This is a balanced formula containing ω-3, ω-6, and ω-9 fatty acids. Headache/Migraine A formula commonly used to alleviate headaches is shown in Table 5-15. Some points to consider in evaluating the effectiveness of the formula are: ● The herbal ingredients in this formula are well supported. Feverfew has a long history of use in the prevention of migraines because of its involve- ment in blocking the release of histamine, which causes vasodilation of blood vessels. Cameron E, Pauling L, Leibovitz B: Ascorbic acid and cancer: a review, Cancer Res 39:663-81, 1979. Austria R, Semenzato A, Bettero A: Stability of vitamin C derivatives in solution and topical formulations, J Pharm Biomed Anal 15:795-801, 1997. Mastroiacovo P, Mazzone T, Addis A, et al: High vitamin A intake and early pregnancy in major malformations: a multicenter prospective controlled study, Theratology 59:7-11, 1999. Borel P, Grolier P, Mekki N, et al: Low and high responders to pharmacological doses of beta-carotene: proportion in the population, mechanisms involved and consequences on beta-carotene metabolism, J Lipid Res 39:2250-60, 1998. Zia H, Amini H, Hekmatyar F, et al: In vivo and in vitro availability of commercial vitamin C tablets, Pahlavi Med J 8:414-8, 1977. Delpre G, et al: Sublingual therapy for cobalamin deficiency as an alternative to oral and parenteral cobalamin supplementation, Lancet 354:740-1, 1999. Eberlein-Konig B, Placzek M, Przybilla B: Protective effect against sunburn of combined systemic ascorbic acid (vitamin C) and d-alpha-tocopherol (vitamin E), J Am Acad Dermatol 38:45-8, 1998. Kalliomaki M, et al: Probiotics in primary prevention of atopic disease: a randomized placebo-controlled trial, Lancet 357:1076-9, 2001. Nasman B, et al: Serum dehydroepiandrosterone sulfate in Alzheimer’s disease and multi-infarct dementia, Biol Psychiatry 30:684-90, 1991. Crook T, et al: Effects of phosphatidylserine in Alzheimer’s disease, Psychopharmacol Bull 28:61-6, 1992. Cenacchi T, et al: Cognitive decline in the elderly: a double-blind, placebo- controlled multicentre study on efficacy of phosphatidylserine administration, Aging Apr; 5(2):123-33, 1993. Fava M, Giannelli A, Rapisarda V, et al: Rapidity of onset of the antidepressant effect of parenteral S-adenosyl-L-methionine, Psychiatry Res 56:295-7, 1995. Vutyavanich T, Kraisarin T, Ruangsri R: Ginger for nausea and vomiting in pregnancy: randomized, double-masked, placebo-controlled trial, Obstet Gynecol 97:577-82, 2001. Mazza G, Cottrell T: Volatile components of roots, stems, leaves, and flowers of Echinacea species, J Agric Food Chem 47:3081-5, 1999. Gallo M, Sarkar M, Au W, et al: Pregnancy outcome following gestational exposure to echinacea: a prospective controlled study, Arch Intern Med 160: 3141-3, 2000. Langsjoen P, Willis R, Folkers K: Treatment of essential hypertension with coenzyme Q10, Mol Aspects Med 15(suppl):S265-72, 1994. Xia L, Bjornstedt M, Nordman T, et al: Reduction of ubiquinone by lipoamide dehydrogenase. Shimizu K, Iino A, Nakajima J, et al: Suppression of glucose absorption by some fractions extracted from Gymnema sylvestre leaves, J Vet Med Sci 59:245-51, 1997. Schoenen J, et al: High-dose riboflavin as a prophylactic treatment of migraine: results of an open pilot study, Cephalalgia 14:328-32, 1994. Peikert A, et al: Prophylaxis of migraine with oral magnesium: results from a prospective, multi-centre, placebo-controlled and double-blind randomized study, Cephalalgia 16:257-63, 1996. This chapter considers issues of nutritional assessment through history- taking, examination, and biochemical investigation. It is important to note at this stage that there are no absolute standards by which we may define mal- nutrition. The onset of nutritional deficiency is usually insidious and often obscured by coexistent illness, medication, and drug use. No one assessment technique, either clinical or biochemical, is a reliable indicator of deficiency except in the most severe cases. The middle equation describing structure and reg- ulation is particularly useful in summing up the rationale behind many of our nutritional interventions. Themperature, pH, and antioxidant status are all variables that affect the process. A host of other endogenous and exogenous substances including toxins, hormones, and phytochemicals may influence any one enzymatic process. In the assessment of nutritional intake, there are two areas for considera- tion: the quantity of nutrients ingested and the adequacy of this intake for the individual. Retrospective methods of data collection, such as 24-hour recall, are depend- ent on memory and one can assume that there is underreporting of energy and nutrient intake by as much as 20%—even when a computer-assisted method is used. Prospective methods such as food diaries may cause the subject to change eating habits or to consciously or unconsciously edit the record. Having obtained an estimate of the dietary intake, one must decide how to process it. The data can be analyzed with a computer or “eyeballed” for a general impression of the number of portions from major food groups and the quality of food eaten. The former method is obviously more accurate but is still compromised by a number of factors including the following: ● The adequacy of the database for local conditions ● The variation in the nutrient content of foods and changing bioavailability Chapter 6 / Assessment of Nutritional Status 139 ● Changing fortification patterns ● The production of “new” foods ● The use of supplements ● Many other confounding variables In practice, I use 24-hour recall and then ask for a five-day diary before the next visit. I then “eyeball” the records for adequacy of portions and supple- ment this evaluation with a more detailed estimate of protein intake, using an abbreviated table of protein values. I emphasize protein because it is fre- quently inadequate in the patients that I encounter most often (i. An estimate of nutrient intake level says nothing, of course, about the bioavailability of a nutrient for a particular individual. Usually, we cannot know about the issues of absorption, transport, cellular utilization, and loss. Ultimately, an answer can only be found through a therapeutic trial of the nutrient concerned. This reflects the ambiguity inherent in a blanket recommendation that is then applied to individuals. It is almost routine for clients to be taking either herbal or nutritional sup- plements. It is essential for one to actually look at the bottles for content fig- ures, because there is a vast array of preparations that go by generic titles such as B complex. While discussing a client’s dietary pattern, it is also useful to ask about hypoglycemic symptoms. I do not attribute a great deal of etiologic signifi- cance to functional hypoglycemia but do regard it as an indicator of the ade- quacy of protein/carbohydrate ratios, as well as a manifestation of excess refined carbohydrate intake, stimulant use, and stress. Functional hypo- glycemia most commonly manifests as tiredness, irritability, and carbohy- drate or caffeine craving in the late morning or afternoon. At this point, it is usually convenient to ask about medication and drug use, especially in view of the frequency and significance of medication- nutrient interactions. Nutrient Deficiency Symptoms Figure 6-2 is a schema representing the progressive development of malnu- trition. In prosperous, urbanized populations, gross deficiency symp- toms and signs will be uncommon. The subtle manifestations of deficiency will appear as changes in subjective feelings of well-being, especially in 140 Part One / Principles of Nutritional Medicine regard to psychologic state and energy levels. The often progressive and insidious nature of nutritional deficiency means there is no clear-cut point at which malnutrition can be defined. There is no gold standard for determin- ing nutritional status because2: ● There is no universally accepted definition of malnutrition.
Findings from ani- mal studies have indicated that a combination of Ginkgo biloba and Zingiber officinale (ginger) has anxiolytic effects comparable to those of diazepam; however best silagra 50 mg, in high doses generic silagra 100mg on-line, anxiogenic properties were also noted purchase silagra 100mg with amex. She had experienced an abrupt onset of dizziness generic 100 mg silagra fast delivery, lightheadedness, and uncomfortable “electric sensations” 230 Part Two / Disease Management in her trunk and limbs. These symptoms were followed by moderately severe anxiety, verging on panic, and a feeling of breathlessness. Over the next few weeks, these sensations followed a fluctuating course with an over- all increase in severity, but neurologic and cardiologic investigation failed to demonstrate any identifiable problem. Left with no clear-cut diagnosis and continuing to have inexplicable symptoms, Merran began having frank panic attacks, and she was referred to me. She had not been treated for psychological problems before, but neither had her life been as stressful as it had been in the previous 18 months with worry over her depressed, unemployed husband and a mildly anorexic daughter preparing for final year school examinations. Merran’s general health was good, and she had passed smoothly through menopause 2 years previously without significant physical or psychologic symptoms. She took no medication or supplements except calcium carbon- ate as an osteoporosis preventive, although results of a recent bone density test had been normal. Her digestion was good, but her dietary history revealed a low protein intake in the context of a very light breakfast and lunch and animal protein at tea time on only three to four occasions per week. At our first interview, her original symptoms were still prominent, together with marked initial and middle insomnia and some mild depressive symptoms, such as loss of confidence and drive and occa- sional tearfulness. On examination, Merran showed herself to be a quiet, likeable, intelligent woman who expressed herself well, was psychologically minded, and appeared tense but not clinically depressed. Her blood pressure was on the low side, 110/70 mm Hg sitting, and she appeared to be a chest breather with occasional sighs. Mg deficiency) Chapter 11 / Anxiety 231 Merran was not keen on taking any medication, even for temporary night sedation, so we decided initially on tryptophan, 500 mg, at night with a low dose (<25 mg) multi-B vitamin, pending further nutritional investigation. At the same time, symptoms of dizziness and chest tightness appeared but rapidly resolved with rebreathing from cupped hands. Tryptophan (500 mg) had not improved sleeping greatly, but more protein at lunchtime had reduced her tendency to experience more prominent symptoms later in the afternoon. When prescribing tryptophan, I always explain the history and symptoms of eosinophilia-myalgia syndrome so that patients can recognize the symp- toms in the (extremely) unlikely event that they experience this problem. Breath re-education was obviously a priority for Merran; she agreed to undertake this with instruction from me (with the help of a biofeedback device) and also in the ongoing context of a yoga class. Orosco M, Rouch C, Dauge V: Behavioral responses to ingestion of different sources of fat. Evidence from studies using acute tryptophan depletion, Adv Exp Med Biol 467:43-55, 1999. Carroll D, Ring C, Suter M, Willemsen G: The effects of an oral multivitamin combination with calcium, magnesium, and zinc on psychological well-being in healthy young male volunteers: a double-blind placebo-controlled trial, Psychopharmacology (Berl) 150:220-5, 2000. Pearlstein T, Steiner M: Non-antidepressant treatment of premenstrual syndrome, J Clin Psychiatry 61(suppl 12):22-7, 2000. Thys-Jacobs S: Micronutrients and the premenstrual syndrome: the case for calcium, J Am Coll Nutr 19:220-7, 2000. Diefendorf D, Healey J, Kalyn W, editors: The healing power of vitamins, minerals and herbs, Surry Hills, Australia, 2000, Readers Digest. Kuhlmann J, Berger W, Podzuweit H, Schmidt U: The influence of valerian treatment on “reaction time, alertness and concentration” in volunteers, Pharmacopsychiatry 32:235-41, 1999. Malsch U, Kieser M: Efficacy of kava-kava in the treatment of non-psychotic anxiety, following pretreatment with benzodiazepines, Psychopharmacology (Berl) 157:277-83, 2001. John’s Wort, Ginseng, Echinacea, Saw Palmetto, and Kava, Ann Intern Med 136:42-53, 2002. Bourin M, Bougerol T, Guitton B, Broutin E: A combination of plant extracts in the treatment of outpatients with adjustment disorder with anxious mood: controlled study versus placebo, Fundam Clin Pharmacol 11:127-32, 1997. This multifac- torial disease results from the interaction of genetic, allergic, environmental, infectious, emotional, and nutritional factors. The underlying pathophysiol- ogy involves bronchial inflammation associated with airway hyperrespon- siveness and increased mucus production. Although few well-controlled studies support the efficacy of complemen- tary therapies in the treatment of asthma or other atopic disorders, such interventions are popular self-care measures among patients. Such omission is of clinical relevance because herbal preparations have been cited as the third most popular complementary treatment modality by British patients with asthma. They may also be triggered by factors as diverse as food and psy- chosocial stress. Regardless of the trigger, the pathophysiologic changes in asthma are characteristic. An imbalance between an exaggerated humoral and suppressed cell- mediated immune system may influence genetic susceptibility to asthma. The T-helper 2 subset produces cytokines, including vari- ous interleukins that stimulate the growth, differentiation, and recruitment of mast cells, basophils, eosinophils, and B cells. IgE, plentiful in mast cells and basophils, mediates bronchospasm, a characteristic of asthma. Over the last 20 years, an increased intake of linoleic acid has coincided with an increased prevalence of asthma, eczema, and allergic rhinitis4 and has also paralleled a decrease in fish consumption. A decreased cellular capacity to cope with oxidative stress is a potential risk factor for an asthma attack. This can be caused by direct inflammatory damage or induction of an autonomic imbalance between muscarinic receptor-mediated contraction and the β-adrenergic–mediated relaxation of pulmonary smooth muscle. Reduction of platelet glutathione peroxidase activity in the most severe cases suggests a diminished capacity to restore part of the antioxidant defenses; however, a case-control study failed to demonstrate any association between antioxi- dant intake and asthma. However, food sensitivities are only likely to contribute to asthmatic symptoms in a few people and only those with nonseasonal asthma. A practical approach to managing perennial asthma is to initially remove all foods eaten at least twice a week from the diet. However, in a review Ardern and Ram7 con- cluded that routine tartrazine exclusion may not benefit most patients, except those few individuals with proven sensitivity. Despite conflicting evi- dence as to whether tartrazine causes exacerbations of asthma, some studies have demonstrated a positive association, especially in individuals with cross-sensitivity to aspirin. Overall, IgE-mediated reactions to food are a minor cause of respiratory symptoms, particularly in children. Although the role of food intolerance in asthma is well recognized, it is not the major cause of asthma, and there are no available data to support the use of nutritional supplements in the treatment of chronic asthma. Nonetheless, a diet that favors fish (ω-3 fatty acids) rather than meat (ω-6 fatty acids) may be helpful. Results of a population-based, cross-sectional sur- vey indicated that protein-rich and fat-rich or high-fat foods of animal origin were associated with a higher incidence of asthma in teenagers. In fact, sudden elimination of caffeinated drinks can result in rebound bronchoconstriction. Theophylline, a popular bronchodilating prescription drug, is a metabolite of caffeine. Eight randomized, controlled trials, six of parallel design and two cross-over stud- ies, produced little evidence to recommend that people with asthma supple- ment or modify their dietary intake of fish oil to improve their asthma control. However, clinical stud- ies in patients with asthma have yielded contradictory results. Controlled clinical trials have demonstrated that supplementation with 100 μg of selenium and/or 400 mg of magnesium pro- vides symptomatic relief but may not modify objective parameters. A high magnesium intake is negatively associated with and a low zinc intake is positively associated with bronchial hyperre- activity. Ephedra is one option because its sympathomimetic action favors bronchodilatation. The ginkgolides have the capacity to antagonize bronchoconstriction, bronchial hyperresponsiveness, and the allergic response effects of platelet-activating factor. Tryptophan should be avoided; it is the precursor of serotonin, a bronchoconstrictor in patients with asthma. Chapter 12 / Asthma 239 ● A trial of betaine or glutamic hydrochloride should be considered for patients who have hypochlorhydria as determined by gastric acid testing.
Rather than being evenly irrigation resulted in a reduction of 98 per cent of the distributed throughout the world purchase 50mg silagra with amex, biodiversity is concen- water flow along the lower Helmand river and the com- trated in lowland moist tropical forests cheap silagra 100mg otc,130 silagra 100 mg line, 131 while mon- plete loss of the formerly rich downstream wetlands best silagra 100 mg. In tane tropical and subtropical forests are recognized as addition, drought appears to have intensified over time. Opium poppy cultiva- that range in 12 seasons and above that range in just 2 tion in the Andes is of particular concern, as the altitude seasons. At the same time, population growth has not suitable for such cultivation also corresponds to the espe- abated, leading to intensification of cropping at the cially vulnerable Paramo and sub-Paramo ecosystems. The highlands of the Lao People’s Democratic Republic and Myanmar as they did in Chahar Bolaq, to the extent that no water 127 are part of the Indo-Burma biodiversity hotspot, which is was available downstream. In contrast, the growers estimated to harbour in excess of 13,500 plant species, dependent on tube-well irrigation north of the Boghra 7,000 of which are found nowhere else, but has less than canal are among the least powerful and most marginal 5 per cent of natural land cover remaining. Satellite-based data reveal clusters of persistent ing (or renting) and fuelling pumps, lowering the water coca bush cultivation in protected areas (national parks) table and ultimately degrading the marginal lands. In Colombia, the protected already low capacity of the soil, leading to decreasing areas most affected are encircled by a moving front of opium yields (such as the exceptionally low yield in the agriculture including coca bush cultivation in Sierra de La south in 2015), while the process of degradation may have Macarena, Tinigua and Los Picachos national parks (see been exacerbated by poor water management. Biodiversity and protected areas In Peru, the extent of coca bush cultivation in protected areas is limited. Joppa, “Global patterns of terrestrial vertebrate diversity and conservation”, Proceed- ings of the National Academy of Sciences, vol. Olson and others, “Therrestrial ecoregions of the world: a (Kabul, Afghanistan Research and Evaluation Unit, 2006). Pimm, “Elevational ranges 2010-11 growing season”, Case Study Series (Kabul, Afghanistan of montane birds and deforestation in the western Andes of Colom- Research and Evaluation Unit, 2011). Amazonia Andean ción-Lares revealed that 2 per cent of the land area wasChococommunal participation and the promotion of landOrinoco occupied by coca cultivation, most of which (90 per cent) ownership, community organization, good agricultural was on land without agricultural potential. Slightly less practices, including in post-harvest processes, agroforestry than a quarter of the coca cultivation was in protected and forest management. One successful instance of alternative development extend- In the Plurinational State of Bolivia, the most affected ing to positive environmental effects can be seen in the parks are Isiboro Secure and Carrasco. The first overlaps San Martín Region in Peru, where alternative development with the Alto Beni deforestation front and the second initiatives included the replacement of coca production overlaps with the Chapare-Santa Cruz deforestation front. An additional 687 Impact of drug control interventions on families were involved in 1,415 ha of agroforestry and the environment coffee and cocoa cultivation for fair trade and organic markets. The success of the project rested on the provision Alternative development of non-conditional support to beneficiaries, whether or Target 2. The premise of this strategy is that land owner- which efforts to reduce illicit drug supply contend with ship discourages smallholders from joining or rejoining the socioeconomic conditions of farmers, as well as the the coca economy and allows for the development of long- environment in which the farmers live and earn their term productive projects. Although short-sighted initiatives in the past were not assessed in the project, land ownership also has the potential to slow down the agricultural frontier. In South-East Asia, for example, crop substi- geted for spraying and taking coca bush cultivation to new tution has been criticized for promoting the shifting away municipalities nearby. This explains the shifting of the from swidden agriculture, which allows for fallow periods Andean and Chocoan forest frontiers by coca bush during which the land may regenerate, towards permanent growers. Analyses of does not necessarily translate into unsustainable deforesta- satellite imagery of eastern Bolivia146 implied that that tion. Aggressive campaigns to counter drug traf- agriculture between the 1970s and 1990s took place in ficking and to eradicate coca bush in the 1990s were iden- parallel with a decline in the overall use of land and the tified as the main causes of the decline in forest clearing regrowth of forest on the steepest slopes, even as the popu- from the late 1980s to the 1990s. This highlights the The impact of illicit crop eradication on the environment difficulties in separating deforestation associated with or may have different outcomes and different ramifications caused by coca bush cultivation from land-use change depending on the context. If eradication induces a dis- caused by other activities along the forest frontier. In Afghanistan, for example, the targeted “food zone” that coca production had taken place in 8 of the top 10 initiative in central Helmand, including eradication, may municipalities gaining forest vegetation in 2001 and the have played a role in the relocation of opium poppy grow- total amount of coca produced had dropped markedly by ers north of the Boghra canal and the associated expansion 2010 (to 30 per cent of the initial amount), probably as a of the agricultural frontier north of the canal, which almost result of eradication efforts. In Colombia, since 1994, most coca In the Andean countries, the easiest way for farmers to bush eradication has been conducted by aerial spraying evade law enforcement is to establish their coca bush cul- with the herbicide glyphosate. One study provided 145 Alexander Rincón-Ruiz, Unai Pascual and Suzette Flantua, “Exam- ining spatially varying relationships between coca crops and associ- quantitative evidence to substantiate an overall shift in ated factors in Colombia, using geographically weight regression”, coca bush cultivation towards municipalities with a higher Applied Geography, vol. Killeen and others, “Total historical land-use change in eastern Bolivia: who, where, when, and how much? Country on the Country on the Country with Violence main Afghan main cocaine illicit crop opiate routes? Significantly reduce all forms of violence and related death rates everywhere production and drug trafficking are more clearly associ- ated with lethal violence, while illicit drug use is more Although the drug problem may threaten peace and secu- related to property crime and domestic violence. Moreover, as drug prob- Globally, there is no clear correlation between homicide lems and violence can reinforce each other, it is challeng- rates and prevalence of drug use, but there is an associa- ing to assess to what extent drug problems impact on tion between relatively higher homicide rates and the drug violence and vice versa. Indicators of drug-related violence transit status of a country, albeit with variations within may exist for certain locations and time periods, but data each group of countries. This is compounded by the multiple in cocaine-producing countries than in other countries. Violence can be both lethal and non- flows appear to be associated with relatively lower homi- lethal; it can sometimes be highly visible, and it can some- cide rates,153 suggesting that while drug transit and pro- times be hidden by its perpetrators and thus difficult to duction can be associated with higher homicide rates, that identify. There are differences across regions, Different stages of the drug problem result in different countries and drug types. One way used to conceptualize Impact of drug use on violence these differences is to distinguish between psychopharma- cological violence (violence stemming from direct drug The relationship between drug use and violent crime is use or withdrawal from drug use), economic violence (vio- still under-researched and not properly understood, even lence stemming from users’ attempts to secure resources though it is clear that some connection exists between the to buy drugs) and systemic violence (violence stemming two phenomena. There is also enormous variation in the from struggles for control between or within criminal populations and in the sample sizes used in existing stud- groups over the illicit production and distribution of ies. Meta-analyses of research studies suggest that certain drugs tend to drive the general association between drug use and crime and that the asso- 150 A. State power, criminal com- ciation tends to be stronger for property crime and drug petition, and drug violence”, Journal of Conflict Resolution, vol. Goldstein, “The drugs/violence nexus: a tripartite concep- tual framework”, Journal of Drug Issues, vol. Goldstein, “The relationship between drugs and violence in the on the main Afghan opiate routes? Since the peak in crime in 1991, homicide rates have organizations; to retaliate against state law enforcement or declined steadily. In this sense, drug-related violence often affects the “crack” markets, although the association between the criminals and state officials, but it is not limited to them rise in “crack” use and violent criminality was not automatic. Violence the peak in the use of “crack” occurred in 1984, yet the peak resulting from market disputes between and within drug in homicides occurred in 1988, while an earlier uptick occurred trafficking organizations, and from confrontation with in 1980. The increase in homicides appeared to be clearly state forces, can be lethal because it is more likely to related to the violent disputes generated by control over the involve firearms. It is also likely to have medium- and “crack” markets, while the connection to “crack” use itself was tenuous despite widespread perceptions to the contrary. Figure 20 illustrates the diverging trends (New York, Cambridge University Press, 2006). This divergence has not A review of studies conducted in Australia, the United been systematically explained, although several factors Kingdom and the United States found a greater likelihood related to those countries’ political and societal landscapes of property crimes being committed among people who and to the organization of illicit drug markets may account use drugs than among those who do not. In Colombia, powerful drug trafficking groups and focused on people who use drugs (mostly amphetamines the combination of internal armed conflict and the illicit and opiates) who had sought treatment or reported drug drug trade have contributed to high levels of violence. A stronger relationship was found between addition, as seen in the example of the Plurinational State drug use and shoplifting, general theft and drug dealing of Bolivia, societal pressure, particularly from coca bush than between drug use and other crimes. Gen- prevalent in cocaine-producing countries, the different erally, the evidence for psychopharmacological violence homicide levels demonstrate that socioeconomic and polit- was weaker. The relatively few existing studies have found drug use to Violence associated with illicit drug markets also varies be a risk factor for different types of family-related violence, across regions. For example, although countries in both such as minor and severe intimate-partner violence and Latin America and South-East Asia play key roles in the child maltreatment. Some studies have also found a con- illicit production of cocaine and opium, the former has sistent link between witnessing or being a victim of vio- been associated with significantly higher levels of violence lence early in life and engaging in drug use and crime later than the latter. Drug use is among the risk factors for both perpe- trating and being a victim of family-related violence. Gamarra, “Fighting drugs in Bolivia: United States and found to be a stronger predictor of committing an offence Bolivian perceptions at odds”, in Coca, Cocaine and the Bolivian Reality, M. In Afghanistan, an analysis of the impact of opium production on terrorist attacks 20 and casualties between 1994 and 2008 estimated that a 25 per cent increase in the number of hectares of cultivated 0 opium poppy was associated with an average of 0.
Household outbreaks Any household outbreaks that are investigated should be reported regardless of mode of transmission cheap silagra 50mg amex. This is in contrast to the previous policy whereby reporting of household outbreaks likely to have resulted from secondary transmission was discouraged 23 discount silagra 100mg. General points to note when using this form Judgement is required in filling out this form generic silagra 100 mg with mastercard. This form records the evidence used for the key outbreak conclusions purchase silagra 100mg with mastercard, notably evidence for (i) recognising the outbreak, (ii) mode of transmission and vehicle/source, and (iii) implicating a contributing factor. This code should also be used to identify all the individual cases involved in the outbreak on the relevant disease case report forms. Reporting Authority Name of public Name of the person responsible for investigating the outbreak. This will remove the outbreak from all standard reporting in EpiSurv Name of outbreak Optional field allowing an outbreak name to be included. Condition and Implicated Contaminant Implicated Provide the name and subtype (if applicable) of the implicated causative agent contaminant (pathogen/toxin/chemical) if known. The same applies if the Other known condition/implicated pathogen option is selected – the Condition (disease) must be specified. Note that where implicated contaminant might be unknown, it may still be possible to complete the Condition (disease) field. List of common contaminants and their suggested corresponding conditions is available in the appendix. Most of these definitions will include a reference to time and place requirements as well as laboratory and/or clinical features. Laboratory confirmed - Specify the case definition for a laboratory-confirmed case. This will usually be based on isolating a microorganism from a case or other specific laboratory evidence of infection or exposure. Clinically confirmed - Specify the case definition for a confirmed case where clinical criteria alone have been used to define a confirmed case or a clinically compatible illness and contact with a confirmed case. This will usually be based on a set of clinical features which were considered to be insufficiently specific to justify the case being considered confirmed. Select exposed the Actual option if number is definite, and select the Approx option if the number is not known exactly. This figure provides a denominator that may later be used to calculate an attack rate (the numerator being the number of cases, as recorded below). Number of cases Specify the number of laboratory confirmed, clinically confirmed, probable and total cases, based on the case definitions provided above (note: the total no. Outbreak dates Specify the date of onset of illness in the first case and the last case of the outbreak. If the outbreak has not finished, select the Outbreak ongoing checkbox, and update at the conclusion of the investigation. Age of cases Indicate the number of cases for which age information was available. Specify the median value (middle) and range of values (minimum and maximum) for these cases’ ages in years. Note this should be for total cases (lab-confirmed, clinically confirmed and probable). Incubation period This is the time interval between initial contact with an infectious or toxic agent and the appearance of the first sign or symptom of the disease. Specify the median value (middle) and range of values (minimum and maximum) for incubation period, if it can be estimated, and select either the days or hours option to indicate the time unit. Duration of illness Specify the median value (middle) and range of values (minimum and maximum) for the duration of illness, if it can be estimated, and select either the days or hours option to indicate the time unit. Circumstances of Exposure/Transmission How was the Select the option that best describes how the outbreak was first recognised. This includes outbreaks from contact with a specific contaminated environment such as a swimming pool, farm, institution or workplace. This will part of a well- often be the case for common event and person-to-person outbreaks. It may also defined exposed apply to some outbreaks linked to specific places such as a workplace. Provide the date of exposure and the date of the last exposure if the exposure occurred over several days. If there is only one exposure occurred exposure setting, complete the first setting where exposure occurred and leave the second setting blank. To complete an exposure setting, first select the appropriate headline option: Food premises Institution Workplace/Community/Other Once the headline option has been selected, indicate the setting where the exposure occurred. Complete the Setting name field by selecting the appropriate option from the drop- down list, or add a new setting if applicable. The following lists are available in EpiSurv: Food Premises, Long term care facility, Hospital, Prison, School, Childcare Centre, and Workplace. If there is only one contaminated preparation setting, complete the first setting where food/beverage was prepared food/beverage was and leave the second setting blank. Complete the Setting name by selecting the appropriate option from the drop-down list, or add a new setting if applicable. The following lists are available in EpiSurv: Food Premises, Long term care facility, Hospital, Prison, School, and Childcare Centre. If the transmission causative agent (organism/toxin/chemical) is known then the mode(s) of transmission will often be obvious. If the mode of transmission is not listed, select Other mode of transmission and provide details. If the mode of transmission is not known, select the Mode of transmission unknown option For each mode of transmission selected, indicate whether it was a primary or secondary mode, and select the option that best describes the level of evidence available. Primary mode relates to the mode responsible for the initiation of the outbreak and secondary modes are other modes that develop during the course of the outbreak. For each source entered, select the option that best describes the level of evidence available. If you have specified a food source, select from the drop-down list of Food Category that best describes the identified source. Factors Contributing to Outbreak For each mode of transmission selected, select all corresponding contributing factors that apply in the relevant category. For each contributing factor selected, indicate whether the contributing factor is Confirmed, or Suspected by selecting the appropriate option. Foodborne If the outbreak is foodborne, indicate all the risk factors that are likely to have outbreak contributed to the outbreak. If a risk factor is not listed, select the Other factor checkbox and provide details. Waterborne If the outbreak is waterborne, indicate all the risk factors that are likely to have outbreak contributed to the outbreak. Person to person If the outbreak is person to person, indicate all the risk factors that are likely to outbreak have contributed to the outbreak. Environmental If the outbreak is environmental, indicate all the risk factors that are likely to have outbreak contributed to the outbreak. Other outbreaks If none of the above is appropriate, select the Other Risk Factor, and specify as precisely as possible. Management of the Outbreak How was the Indicate whether there was any specific action taken to control the outbreak. If yes, outbreak indicate which control measures were undertaken and provide details. Was insufficient Indicate whether insufficient information to complete the form was provided. Condition and implicated contaminant Some common contaminants (pathogen/toxin/chemical) and their suggested corresponding conditions (diseases) are listed below. Note that the following conditions are also available in the conditions (diseases) drop-down list where pathogen might be unknown/ unavailable: conjunctivitis, dengue fever, gastroenteritis - unknown cause, influenza-like illness, respiratory illness, toxic shellfish poisoning, etc Please contact EpiSurv Support to add to the list(s). A list that matches your entry will appear as soon as you type in at least three characters into the field.