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Her principal research interests are the role of dietary fiber in human nutrition and in the human gastrointestinal tract and nutrient bioavailability order 50mg silagra with amex erectile dysfunction hiv medications. He previously was the dean of the Graduate School of Biomedical Sciences and a professor in the Departments of Biochemistry and Medicine at The University of Texas Health Sciences Center at San Antonio order 100 mg silagra fast delivery erectile dysfunction what age does it start. He is the former director of the Center for Food Safety and Applied Nutrition at the Food and Drug Administration. Prior to that, he was a professor of nutri- tional biochemistry at the Massachusetts Institute of Technology. He has in excess of 150 scientific publications in the fields of toxicology and risk assessment. Munro formerly held senior posi- tions at Health and Welfare Canada as director of the Bureau of Chemical Safety and director general of the Food Directorate, Health Protection Branch. He was responsible for research and standard setting activities related to microbial and chemical hazards in food and the nutritional quality of the Canadian food supply. He has contributed significantly to the development of risk assessment procedures in the field of public health, both nationally and internationally, through membership on various committees dealing with the regulatory aspects of risk assessment and risk management of public health hazards. He is a graduate of McGill University in biochemistry and nutrition and holds a Ph. Murphy’s research interests include dietary assess- ment methodology, development of food composition databases, and nutritional epidemiology. She served as a member of the National Nutri- tion Monitoring Advisory Council and the 2000 Dietary Guidelines Advi- sory Committee, and is currently on editorial boards for the Journal of Food Composition and Analysis and Nutrition Today. Murphy is a member of numerous professional organizations including the American Dietetic Association, the American Society for Nutritional Sciences, the American Public Health Association, the American Society for Clinical Nutrition, and the Society for Nutrition Education. She has over 50 publications on dietary assessment methodology and has lectured nationally and inter- nationally on this subject. Nuttall is a member of the American Diabetes Association, the Endocrine Society, and the Ameri- can Society of Biological Chemists and is a fellow of the American College of Physicians and the American College of Nutrition. His research interests include diabetes mellitus, control of glycogen metabolism, and glycogen synthase and phosphorylase systems. Previously, he was chair and a professor of the Depart- ment of Biostatistics and Epidemiology at the School of Public Health and Health Sciences at the University of Massachusetts at Amherst. Pastides is a consultant to the World Health Organization’s Program in Environ- mental Health and is a fellow of the American College of Epidemiology. He was a Fulbright Senior Research Fellow and visiting professor at the University of Athens Medical School in Greece from 1987 to 1988. Pastides has been a principal investigator or coinvestigator on over 30 externally-funded research grants, results of which have been published in numerous peer-reviewed journals. He is the recipient of several prestigious awards such as the Borden Award in Nutrition of the Canadian Society for Nutritional Sciences, the Sandoz Award of the Clinical Research Society of Toronto, the Agnes Higgins Award of the March of Dimes, the Osborne Mendel Award of the American Society for Nutrition Sciences, and the Nutrition Award of the American Academy of Pediatrics. Pencharz has served on the grant review boards for the Medical Research Council, the National Institutes of Health, the U. His research expertise is protein, amino acid, and energy metabolism in neonates and young adults, especially in patients suffering from cystic fibrosis. Luke’s– Roosevelt Hospital Center, and a professor of medicine at the College of Physicians and Surgeons, Columbia University. His research interests are in the hormonal control of carbohydrate metabolism, diabetes mellitus, obesity, and food intake regulation. Pi-Sunyer is a past president of the American Diabetes Association, the American Society for Clinical Nutri- tion, and the North American Association for the Study of Obesity. Pi-Sunyer is editor-in- chief of Obesity Research and associate editor of the International Journal of Obesity. Rand’s general expertise is in statistical modeling and application of statistics to biomedical problems. He was the recipient of several honors and awards and has served on many journal editorial boards. Reeds served as a permanent member of the Nutrition Study Section, National Institutes of Health and the International Review Panel, United Kingdom Agricultural and Food Research Council. Reeds’ research expertise was protein metabolism and amino acid requirements, specifically the regula- tion of growth and protein deposition by diet and other environmental variables such as stress and infection. Rimm is project director of a National Heart, Lung, and Blood Institute- and National Cancer Institute-funded prospective study of diet and chronic disease among men, as well as the principal investigator of a National Institute on Alcoholism and Alcohol Abuse study. Memberships include the Executive Committee of the Epidemiology and Prevention Council of the American Heart Asso- ciation and the Society for Epidemiologic Research. He has authored over 150 papers with a main research focus on the associations between diet and other lifestyle characteristics and the risk of obesity, diabetes, and cardiovascular disease. Department of Agriculture Human Nutrition Research Center on Aging at Tufts University. She is also a professor of nutrition in the School of Nutrition Science and Policy at Tufts and a professor of psychiatry and a scientific staff member in the Department of Pediatrics at Tufts University Medical School. Her research focus is infant and adult obesity, infant nutrient requirements, breastfeeding, and nutri- tion and aging. She chairs national meetings on dietary prevention of obesity and sits on international committees for evaluation of nutritional requirements. He has more than 100 scientific publications on food safety and risk assessment and has lectured nationally and internationally on these subjects. Rodricks is the author of Calculated Risks, a nontechnical introduction to toxicology and risk assessment. Her laboratory is actively involved in research on dietary fiber, phytoestrogens from flax and soy, and whole grains. Slavin has published more than 100 reviewed research articles and has given hundreds of nutrition semi- nars for professional and lay audiences. She is a science communicator for the Institute of Food Technologists and a member of numerous scientific societies, including the America Dietetic Association, the American Soci- ety for Nutritional Sciences, and the American Association for Cancer Research. She is a frequent source for the media on topics ranging from functional foods to sports nutrition. Her research interests are human nutrition, dietary fiber, nutrient bioavailability, sports nutrition, carbo- hydrate metabolism, and the role of diet in cancer prevention. He has served on the editorial board of the Journal of Nutrition, as program manager of the U. His research interests are dietary fiber and cholesterol and bile acid metabolism. Her special- ties within these areas are in social and economic determinates of health and nutrition, population-level indicators of risk, evaluation of public poli- cies in response to food insecurity, and the statistical analysis of dietary intake data at the individual and population levels. Tarasuk has served on several committees and advisory groups including the Nutrition Expert Advisory Group of the Canadian Community Health Survey, the External Advisory Panel for Food Directorate Review of Policies on the Addition of Vitamins and Minerals to Foods, the Expert Scientific Workshop to Evalu- ate the Integrated National Food and Nutrition Survey, the Advisory Baseline Study Group for the Canada Prenatal Nutrition Program, and the Nutrition Expert Group for the National Population Health Survey. Previously, he was Vice President for Corporate Research at Baxter-International and associate dean of the School of Medicine at West Virginia University. He has held professorships in the departments of pharmacology and toxicology in sev- eral medical schools including Iowa, Virginia, and West Virginia.

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The prognosis is dependent Hepatic failure on the underlying cause and co-morbid features silagra 50 mg generic erectile dysfunction at the age of 18. Hypoxia Hypoxia and/or hypotension Vitamin deficiency Vitamin B12 Thiamine (Wernicke–Korsakoff) Coma Intracrania Definition Trauma Head injury Coma is a state of unrousable unconsciousness cheap silagra 100mg fast delivery how does the erectile dysfunction pump work. Vascular Transient ischaemic attack, stroke, any intracranial bleed or space- occupying lesion Aetiology Epilepsy May be post-ictal (after a seizure) or The causes are mainly those of acute confusional state nonconvulsive status (see Table above), although there are other causes as well. No response 1 Best verbal response Management Orientated 5 Following resuscitation treatment of the underlying Disorientated 4 Inappropriate words 3 cause is the main priority. In at-risk patients such as alco- Best motor response holics and in pregnancy, intravenous thiamine should Obeys verbal commands 6 be given prior to any intravenous glucose as there Localizes painful stimuli 5 Withdrawal to pain 4 is a small risk of precipitating irreversible Wernicke– Flexion to pain 3 Korsakoff’s syndrome. No response 1 r Empirical use of naloxone (reverses opiates), flumaze- nil (reverses benzodiazepines) should be considered. Head Injury Definition Head injury is one of the most common causes of death Clinical features and disability in young men, mainly due to road traffic It is important to establish the level of consciousness. Incidence 1 The first priority is resuscitation – stabilise airway, Common;basedonhospitalattendancesandadmissions breathing and circulation and check the glucose level the incidence is ∼250 per 100,000 population. Hypoxia, hypoglycaemia or hypotension are reversible causes of coma and will exacerbate any Age other cause. Chapter 7: Disorders of conciousness and memory 313 r Penetrating trauma: Penetration of the skull by an ex- swelling of the brain. Pathophysiology The pathology of head injury can be divided into two groups: Complications r Primary brain damage: Short term: Vascular, e. Subarachnoid and intracerebral ticularly on the side of the trauma (coup lesion) and haemorrhage may also occur. Long term: ii Diffuse axonal injury due to shearing forces caus- r Posttraumatic epilepsy. Patients r Chronic traumatic encephalopathy (the punch drunk who survive such injury may have severe brain syndrome seen in professional boxers). Ifneckinjuryissuspected,thepatientshould cal treatment, whereas primary brain damage occurs be immobilised until a spinal cord injury or unstable at the time of injury and therefore can only be in- cervical spine has been excluded. Followingtrauma,thebrainismuch Coma Scale, and full neurological and general exami- more susceptible to hypoxia and hypotension due to nation. The decision to admit for observation is based disruption of autoregulation and impaired vascular on the history and assessment at presentation. Osmotic diuretics such as mannitol Clinical features may also be used to reduce brain oedema. In more severe injuries, there is persistent post- mission to intensive care for intracerebral pressure traumatic amnesia. Patients All patients require close monitoring to check for devel- may have other injuries depending on the nature of the opment of complications that require urgent treatment. Over a period of several hours there is oozing of r the patient is difficult to assess, e. Apathy and/or depression are common, there may be Prognosis disturbances of sleep, confusion of day & night, with Recovery may take weeks to months. Other neurological signs with a persisting disability or impairment is 100 such as hemiparesis, seizures tend to occur very late in per 100,000. Generally, in the early stages, the patient is aware of a loss of their memory and may become very frus- Dementia trated and anxious. They lose the ability to function in daily life grad- Definition ually, and in later stages they become more apathetic, Asyndromeofacquiredcognitiveimpairment,withpro- with little spontaneous effort and therefore require full gressive global loss of cognitive function in the context personal care such as feeding, washing, dressing and of normal arousal. Acollateral history from a relative or close carer who Incidence has known the patient for a long time is essential. The 1% of those aged 65–74 years, 10% of those over 75 and carer is often the one most emotionally affected by the 25% of those over 85 years. Aetiology There are numerous causes of dementia, including Investigations r Alzheimer’s disease (most common >60%). These are to exclude any treatable causes of chronic con- r multi-infarct dementia caused by multiple small in- fusion. Management The specific management strategies are covered under Clinical features specific causes but general treatment includes the fol- See also under specific causes of dementia. Patients may lowing: have impairment of the following cognitive functions: r Multidisciplinary assessment. Chapter 7: Disorders of conciousness and memory 315 r Antidepressantsmayimprovefunctionallevelinthose r Neurochemical analysis reveals that patients with with low mood. The features are those of dementia, but with an insidious onset and progressive decline in memory and at least one of: Alzheimer’s disease r Dysphasia: Loss in language skills, especially with Definition names and understanding speech. Most common neurodegenerative disorder and cause of r Agnosia: Loss of ability to recognise objects, people, dementia. The onset can be in middle age, but the incidence rises r Disturbance in executive functioning (higher mental with age. Aetiology/pathophysiology r Risk factors include family history, Down’s syndrome Macroscopy and previous head injury. The brain is small, with shrinkage of the gyri and widen- r Molecular analysis of the amyloid found in the brains ing of the sulci. It is r Senile plaques in the cerebral cortex – spherical de- thought that these plaques then cause inflammation posits with a central core of amyloid composed of and hence neurotoxicity and apoptosis. Amyloid is also seen deposited in cere- r Mutations on Chr 21 in Down’s syndrome cause over- bral arteries causing amyloid angiopathy. The tan- dominant disorder with mutations on Chr 14 or 21 – gles are composed of a microtubule binding protein these cause increased activity of the secretases. These are also seen in Lewy many of the normal methods of sterilisation including body dementia. There are other (β secretase) has been cloned, leading to hopes of other prion diseases such as targeted therapies. Rapidly progressive dementia caused by a prion (pro- It is currently thought that a normal glycoprotein teinaceous infectious agent), described in 1982 by neu- in the brain (the function of which is unknown) rologist Stanley Prusiner undergoes conformational change to become prion pro- tein (PrP). This abnormally conformed protein is resis- tant to digestion by proteases and tends to form poly- Incidence mers. In familial cases, it appears More common in certain parts of the world due to fa- that the abnormal protein arises spontaneously due to a milial cases, e. It is in- volved in glycolytic pathways, mediating carbohydrate Microscopy metabolism. Deficiency leads to ischaemic damage to Neuronalloss,increaseinglialcells,lackofinflammation the brainstem. Other signs include ptosis, abnormal pupillary re- There are raised levels of a normal intraneuronal protein actions and altered consciousness. There is no reliable method of confirming diagnosis Occasionally, patients present with Korsakoff’s, with except by brain biopsy or postmortem. Patients may have a peripheral neuropathy due to other Prognosis nutritional deficiencies. Investigations Diagnosis is usually clinical, and on response to thi- Wernicke–Korsakoff syndrome amine.

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Estimation of whether biting insect populations have increased can be important buy silagra with american express erectile dysfunction doctors fort worth, as they may serve as disease vectors discount silagra online visa best erectile dysfunction doctors nyc. Water quality may be important as poor water quality may contribute to disease and mortality (e. Primary contamination by toxic substances can also lead to morbidity and mortality (e. Information on the condition and behaviour of animals prior to the outbreak should be recorded if possible, as should any changes in their abundance and distribution. Specific features of problem areas Other specific features not mentioned above should be noted and provided to the diagnostician. Supplementary investigations If further investigations are carried out these reports should be summarised and kept as a supplement to the original findings. These reports should be copied to the diagnostic laboratory where the specimens were sent. Chapter 1, Field manual of wildlife diseases: general field procedures and diseases of birds. Deciding whether a disease should be managed or not, rests largely on the extent to which it endangers human and animal health and welfare, economic systems, conservation aspirations, and the likelihood that intervention will achieve disease management objectives. The appropriate approach will depend on the characteristics of the problem and, when dealing with an infectious disease, on the correct identification of reservoirs, hosts and vectors of infection. Prevention and control of a disease is usually more easily achieved than complete eradication [►Section 3. Appropriate disease management options will depend on whether one is dealing with endemic or epidemic disease, and whether the intention is to prevent or control disease spread. Management measures may target the pathogen, host, vector, environmental factors or human activities. Ultimately, an integrated approach involving several complimentary measures is likely to be most successful in managing diseases in wetlands. Disinfection and sanitation procedures target pathogens and can be very effective at controlling spread of infection but must be used with caution in wetland situations to avoid negative impacts on biodiversity. Animal carcases represent a significant potential source of infection and require rapid and appropriate collection and disposal. Disposal options are varied and again need to be used with caution in wetland situations to reduce risks of pollution of water courses or further spread of infection. Targeting vectors in integrated disease control strategies can be effective and usually take the form of environmental management, biological controls and/or chemical controls, or actions to reduce the contact between susceptible hosts and vectors. To reduce negative impacts on biodiversity caution must be used when using these measures within wetlands. Vaccination programmes, often supplemented by other disease control measures, can help control and even eliminate diseases affecting livestock. Vaccination of wildlife is feasible but it is often complex - other management strategies may be of greater value. Habitat modification in wetlands can eliminate or reduce the risk of disease, by reducing the prevalence of disease-causing agents, vectors and/or hosts and their contact with one another, through the manipulation of wetland hydrology, vegetation and topography and alterations in host distribution and density. Movement restrictions of animals and people, usually imposed by government authorities, can be an effective tool in preventing and controlling disease transmission through avoiding contact between infected and susceptible animals. Complete eradication of a disease requires a thorough understanding of its epidemiology, sufficient political and stakeholder support and thorough resourcing and is thus rarely achieved! Elimination of disease from an area is a more likely outcome although this depends on measures to prevent re-emergence being taken. Sanitation measures involve preventing animal contact with physical, microbiological, biological or chemical agents of disease, which are often found in wastes, and maintaining clean, hygienic conditions. Inadequate sanitation is a major cause of disease worldwide and simple measures for improving sanitation are known to have significant beneficial impacts on public and animal health. Disinfection prevents the mechanical transmission of disease agents from one location to another by animals and inanimate objects, by eliminating many or all pathogenic microorganisms (except bacterial spores) on inanimate objects so that they will no longer serve as a source of infection. Disinfection following fieldwork prevents transfer of infection on fomites such as boots and clothing. Measures taken to prevent a disease outbreak For public health and biosecurity reasons, people working in wetlands should maintain high standards of sanitation and hygiene, and avoid direct contact with human and animal faeces, solid wastes, domestic, industrial and agricultural wastes [►Section 3. Effective sanitation and hygiene can be achieved through engineering solutions (e. Livestock housing should be regularly cleaned and disinfected and waste and clean water should be separated and safely stored. Waste materials from captive animals should be properly processed and disposed of. Cleaning is a necessary first step that allows the subsequent disinfecting agent to come into direct contact with pathogens on the surfaces of an object. Some viruses, bacteria and other infectious agents can persist in the environment for protracted periods. Disinfection is only practical for circumstances in which the pathogen or disease transmission occurs in a very limited area. The appropriateness of disinfectants will be informed by information on the presence of non-target species and other potential environmental impacts, particularly any adverse effects on wetland ecosystem function. Disinfection for wildlife disease situations is often difficult and likely to be most effective where wild animals are concentrated, such as at artificial feeding or watering sites. Measures taken during a disease outbreak During a disease outbreak, it may be necessary (if practical) to disinfect the local environment to prevent recurrence. Procedures are generally similar, however, the nature and infectivity of the pathogen will affect the protocols employed. For example, chytrid fungus and foot and mouth disease virus will require very different procedures for decontamination. As a consequence, disinfection of a disease outbreak site should always be conducted under the guidance of disease control specialists. From the above, the following should be done, as appropriate: during disinfection activities, easily cleaned protective clothes such as waterproof coveralls and rubber boots and gloves should be worn, and all clothes should be thoroughly washed after use and before leaving the outbreak area. If possible, personnel should wash their hair before leaving the area, and always before going to other wetland areas. Personnel handling potentially infectious agents should not work with similar species or those susceptible to disease for at least seven days after participating in disease control activities. Disinfection processes require a suitable disinfectant, containers for the solution once it has been diluted to the appropriate strength and a suitable method for its application. Vehicles and boats with pumps and tanks can be used to store and dispense disinfectant. All vehicles should be cleaned and disinfected on entering and leaving an outbreak area.

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