By I. Emet. Emmanuel College.

Residents are expected to: • Demonstrate respect generic 200mg celebrex otc arthritis in fingers diagnosis, compassion cheap celebrex 200mg otc arthritis in horses back legs, and integrity; a responsiveness to the needs of patients and society that supersedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development. Residents are expected to: • Understand how their patient care and other professional practices affect other health care professionals, the health care organization, and the larger society, as well as how these elements of the system affect their own practice. With guidance and direct supervision, participate in breaking bad news to patients. With guidance and direct supervision, participate in discussing basic issues regarding advance directives with patients and their families. With guidance and direct supervision participate in discussing basic end-of-life issues with patients and their families. Participate in family and interdisciplinary team conferences discussing end-of-life care and incorporating the patient’s wishes in that discussion. The role of the primary care physician in the coordination of care during key transitions (e. With guidance and direct supervision, participate in discussing basic issues regarding advance directives with patients and their families. With guidance and direct supervision participate in discussing basic end-of-life issues with patients and their families. Always treat cognitively impaired patients and patients at the end of their lives with utmost respect and dignity. Symptoms sometimes seen during end-of-life care and the basic principles of their management (e. Communication Skills • With guidance and direct supervision, participate in breaking bad news to patients. Management Skills • Appropriately assessing and treating pain when necessary with nonnarctoic and narcotic analgesics. The basics of the potential role of genetic information in diagnostic decision making. Describe the basic principles of using genetic information in clinical decision making. The basics of the potential role of genetic information in therapeutic decision making. The potential roles and limitations of genetic testing in disease prevention and early detection. Communication Skills • Counsel with regard to (a) possible causes, (b) appropriate further evaluation to establish the diagnosis of an underlying disease, and (c) the impact on the family (genetic counseling). The genetics and role of alpha-1 antitrypsin deficiency in some patients with emphysema. The basic principles of the role of genetics in dyslipidemia, particularly familial combined hyperlipidemia. The etiology of obesity, including excessive caloric intake, insufficient energy expenditure leading to low resting metabolic rate, genetic predisposition, environmental factors affecting weight gain, psychologic stressors, and lower socioeconomic status. Laboratory interpretation: Students should be able to recommend when to order diagnostic and laboratory tests and be able to interpret them, both prior to and after initiating treatment based o the differential diagnosis including consideration of test cost and performance characteristics as well as patient preferences. Communication skills: Students should be able to: • Communicate the diagnosis, treatment plan, and subsequent follow-up to the patient and his or her family.

The way the system functions is critical to achieving high quality patient care purchase celebrex 200mg arthritis in dogs home remedies, ensuring patient safety buy celebrex 200 mg cheap symptoms of arthritis in horses feet, reducing sources of errors in medicine, and promoting an environment that respects disclosure without blame. Furthermore, we have begun to focus on the patient as the center of the health care delivery system and to assess quality from the perspectives of the patient and the physician. With the patient as the center of the health care delivery system, the physician becomes a collaborative partner with other health professionals who share a common goal of providing safe, accessible, high quality, evidence-based care. The principles of clinical quality improvement, including the notion of variation in practice as a quality issue and the concept of medical care as a process which can be studied and improved. Principles of medical record organization in both inpatient and ambulatory settings. The importance of complete medical documentation in the context of measuring quality of care, avoiding redundancy, preventing medical errors, and improving patient safety. The need for a multidimensional approach to the assessment of quality, including the patient’s perspective of quality. The relationship of quality and cost in health care from the standpoint of the individual, health care systems, and society. Potential benefits and pitfalls of critical pathways/practice guidelines intended to improve the quality of care. Using patient education materials to facilitate patients’ participation in their own care. Using the medical records system efficiently to produce medical notes that communicate information clearly. Working collaboratively with other health professionals in the delivery of quality care. Assessing the patients’ needs from the standpoint of the individual, family, and community. Reporting patient safety concerns and medical errors to the appropriate individuals. Using resources, appropriate information systems, and the tenants of evidence-based medicine to assess systems-based practice issues. Recognize the importance of systems, particularly inter-professional collaboration, in delivering high quality patient care. Strive to improve the timeliness diagnostic and therapeutic decision making in order to improve quality of care, increase patient satisfaction, and reduce health care costs. Appreciate that medical error prevention and patient safety are the responsibility of all health care providers and systems and accept the appropriate degree of responsibility at the medical student level. Respect other health care professionals as colleagues on a patient-centered health delivery team and as mutual contributors to high quality patient care. Common environmental diseases that are likely to be encountered by an internist and the principal etiologic agents associated with them. Pathogenesis of specific occupational diseases and the types of risks that may be encountered in the home or at the work site: • Musculoskeletal/ergonomic or “repetitive stress” disorders (e. Information sources for determining the risk of specific environmental and occupational health hazards. Obtaining an appropriate occupational history on all patients and identifying those patients whose health may have been adversely affected by their living conditions or work environment. Considering the possibility that the patient’s illness may be related to their home or work environment. Providing patients with sound advice on the prevention of occupational and environmental-related diseases. Accurately diagnosing and developing a cost-effective basic management plan for common occupational health problems (e.

Nuclear Prevention: Try to relocate to avoid living near a nuclear target such as a big city or military base order 100mg celebrex overnight delivery arthritis pain wakes me up. If you have a formal shelter and long term supplies then there is probably a role for monitoring equipment cheap celebrex 200mg with amex arthritis in knee replacement. If you are using an expedient shelter it would seem to be logical that you stay in your shelter for as long as practical and if forced to leave only do so for brief periods. If you are forced to leave is there any value in knowing how much radiation you have received? Simple sheltering from the initial blast significantly reduces this initial exposure. Added to this is exposure from fallout (residual radiation) over the short to medium term. Issues such as the weather and ground or air explosion will have a big impact on dose of radiation delivered. When considering clinical radiation effects they are broken down into: - Immediate symptoms (0. The brain is very sensitive to high doses and this leads to confusion, seizures, and coma. Patients presenting with cerebral and vascular signs and symptoms will die over a 1 to 2-week time frame. In an austere situation without access to dosimeters the timing of onset of initial symptoms, and the length of the symptom-free period enable you to estimate very roughly the likely exposure, and mortality, and provide a guide for triaging medical resources. Deaths approach 50% at the top end of the range 450-800rads: Initial symptoms 30-60 minutes post exposure lasting 12-48 hours. A significant number of deaths and injuries arise from other effects of the explosion. If you are planning for a nuclear disaster then you will need to address the issue of burn management and stock your supplies accordingly Blast: Injuries occur for 2 reasons. Firstly damage from the pressure wave itself – ear, lung, and gut injuries are most common, and secondly from collision with objects carried by the blast wave (wood, glass, nails), or the patient themselves colliding with solid objects when thrown by the wave. Potassium Iodide: Radioactive isotopes of iodine can be taken up by the thyroid gland following a nuclear blast. By - 119 - Survival and Austere Medicine: An Introduction taking potassium iodide or potassium iodate supplement (approximately 76% iodine); the uptake by the thyroid gland can be blocked to a degree. The dose is 130 mg once a day starting before exposure and continuing for 10 days. Potassium iodate has been shown to be more palatable to children as it tastes much less bitter in comparison to iodide. This determination is based on a careful review of published literature articles containing reports, data, and experiences of people who were exposed to high levels of thallium or cesium-137, and who were treated effectively with Prussian blue. Russian scientists following Chernobyl have suggested that the ingestion of excessive calcium in combination with vitamin D may decrease absorption of radioactive strontium. The excess calcium may be taken up in place of some of the otherwise bioavailable strontium leaving the rest to be cleared from the body without deposition. This is scientifically sound theory although there is no evidence demonstrating a benefit but no reason to think it would be harmful. Biological Prevention Hygiene is the single most important step to prevention illness/death from the use of biological weapons or biological agents in general. This includes clean drinking water, proper waste disposal, and hygienic food preparation, cooking, food storing, and slaughter of animals. Make sure that you have strict guidelines relating to hygiene, and that everybody in your group understands and follows them. Do a risk analysis of what you believe is the biggest biological threat for your group.

A small number (<1%) will suffer from a severe infection (West Nile encephalitis order celebrex 200 mg with visa arthritis in back after surgery, West Nile meningitis cheap celebrex 200 mg online arthritis medial knee, or acute flaccid paralysis). People over 50 years old or with suppressed immune systems are most likely to develop severe illness or die. Economic importance There is potential for significant economic losses to the equine industry, through death and illness in horses. Illness in humans can result in economic losses due to the time lost from normal activities. Effects on wildlife and in zoological collections can have a significant impact on tourism. Epidemic/epizootic West Nile websites virus in the United States; guidelines for surveillance, prevention and control. A bibliography of key resources providing information and guidance on disease management. World Health Organization Avenue Appia 20 1211 Geneva 27 Switzerland ℡ + 41 (0) 22 791 21 11 Fax: +41 (0) 22 791 31 11 www. There are many disease types, including: infectious, toxic, nutritional, traumatic, immunological, developmental, congenital/genetic and cancers. Disease is often viewed as a matter of survival or death when, in fact, effects are often far more subtle, instead affecting productivity, development, behaviour, ability to compete for resources or evade predation, or susceptibility to other diseases factors which can consequentially influence population status. Well functioning wetlands with well managed livestock, with little interface, with well managed wildlife should provide human wetland dwellers with the ideal healthy environment in which to thrive. Disease is an integral part of ecosystems serving an important role in population dynamics. However, there are anthropogenic threats affecting wetlands including climate change, substantial habitat modification, pollution, invasive alien species, pathogen pollution, wildlife and domestic animal trade, agricultural intensification and expansion, increasing industrial and human population pressures including the interface between humans and domestic and wild animals within wetlands, all of which may act as drivers for emergence or re-emergence of diseases. Wetlands are meeting places for people, livestock and wildlife and infectious diseases can be readily transmitted at these interfaces. Stress is often an integral aspect of disease capable of exacerbating existing disease conditions and increasing susceptibility to infection. There are a broad range of stressors including toxins, nutritional stress, disturbance from humans and/or predators, competition, concurrent disease, weather and other environmental perturbations. Stressors can be additive, working together to alter the disease dynamics within an individual host or a population. Impacts of disease on public and livestock health, biodiversity, livelihoods and economies can be significant. The emergence and re-emergence of diseases has become a wildlife conservation issue both in terms of the impact of the diseases themselves and of the actions taken to control them. Some diseases may be significant sources of morbidity and mortality of wetland species and in some cases (e. There are many disease types, including: infectious, toxic, nutritional, traumatic, immunological, developmental, congenital/genetic and cancers. Disease is often viewed as a matter of survival or death when, in fact, effects are often far more subtle, instead affecting productivity, development, behaviour, ability to compete for resources or evade predation, or susceptibility to other diseases factors which can consequentially influence population status. Well functioning wetlands with well managed livestock, with little interface, with well managed wildlife should provide human wetland dwellers with the ideal healthy environment in which to thrive. Disease is an integral part of ecosystems serving an important role in population dynamics.

Long-term intake of dietary fiber and decreased risk of coronary heart disease among women buy 100mg celebrex with mastercard lupus arthritis in feet. Effect of dose and modification of viscous properties of oat gum on plasma glucose and insulin following an oral glucose load quality 200mg celebrex arthritis medication names. Effects of fructo-oligosaccharides on blood glucose and serum lipids in diabetic subjects. Resistant starch is more effective than cholestyramine as a lipid-lowering agent in the rat. Comparative epidemiology of cancers of the colon, rectum, prostate and breast in Shanghai, China versus the United States. Saturated fatty acids are synthesized by the body to provide an adequate level needed for their physiological and structural func- tions; they have no known role in preventing chronic diseases. It is neither possible nor advisable to achieve 0 percent of energy from saturated fatty acids in typical whole-food diets. This is because all fat and oil sources are mixtures of fatty acids, and consuming 0 percent of energy would require extraordinary changes in pat- terns of dietary intake. It is possible to have a diet low in saturated fatty acids by following the dietary guidance provided in Chapter 11. Linoleic acid is the only n-6 polyunsaturated fatty acid that is an essential fatty acid; it serves as a precursor to eicosanoids. A lack of dietary n-6 polyunsaturated fatty acids is characterized by rough and scaly skin, dermatitis, and an elevated eicosatrienoic acid:arachidonic acid (triene:tetraene) ratio. A lack of α-linolenic acid in the diet can result in clinical symptoms of a deficiency (e. Because trans fatty acids are unavoidable in ordinary, nonvegan diets, consuming 0 percent of energy would require significant changes in patterns of dietary intake. As with saturated fatty acids, such adjustments may introduce undesirable effects (e. Nevertheless, it is recommended that trans fatty acid consumption be as low as possible while consuming a nutri- tionally adequate diet. It also aids in the absorption of the fat-soluble vitamins A, D, E, and K and carotenoids. Dietary fat consists primarily (98 percent) of triacylglycerol, which is com- posed of one glycerol molecule esterified with three fatty acid molecules, and smaller amounts of phospholipids and sterols. The fatty acids vary in carbon chain length and degree of unsaturation (number of double bonds in the carbon chain). The fatty acids can be classified into the following categories: • Saturated fatty acids • Cis monounsaturated fatty acids • Cis polyunsaturated fatty acids —n-6 fatty acids —n-3 fatty acids • Trans fatty acids Dietary fat derives from both animal and plant products. In general, animal fats have higher melting points and are solid at room temperature, which is a reflection of their high content of saturated fatty acids. Plant fats (oils) tend to have lower melting points and are liquid at room tem- perature (oils); this is explained by their high content of unsaturated fatty acids. Trans fatty acids have physical properties generally resembling saturated fatty acids and their presence tends to harden fats. In the discussion below, total fat intake refers to the intake of all forms of triacylglycerol, regardless of fatty acid composition, in terms of percentage of total energy intake. Fatty acids may themselves be ligands for, or serve as precursors for, the synthesis of unknown endogenous ligands for nuclear peroxisome proliferator activating receptors (Kliewer et al. These receptors are important regulators of adipogenesis, inflammation, insulin action, and neurological function. Phospholipids Phospholipids are a form of fat that contains one glycerol molecule that is esterified with two fatty acids and either inositol, choline, serine, or ethanolamine. Phospholipids are primarily located in the membranes of cells in the body and the globule membranes in milk.

In the 75 largest counties generic 100mg celebrex mastercard x rays of arthritis in fingers, 49 percent of felony drug defendants are non-Hispanic blacks and 26 percent are non- Hispanic whites (Cohen and Kyckelhahn 2010) buy celebrex 200 mg cheap rheumatoid arthritis definition medical. Incarceration The racial disparity evident in drug arrests increases as cases wend their way through the criminal justice system. Black defendants constitute 44 percent and white defendants 55 percent of persons convicted of drug felonies in state courts. Among defendants convicted of drug felonies, 61 percent of whites and 70 percent of blacks are sentenced to incarceration. Whites sentenced to incarceration for drug felonies received a mean maximum sentence length of 29 months, compared with 34 months for blacks (Durose, Farole, and Rosenmerkel 2009). As Table 3 shows, the number of African Americans admitted to state prison as new court commitments on drug charges has consistently exceeded the number of whites during the past 10 years. Subscriber: Univ of Minnesota - Twin Cities; date: 23 October 2013 Race and Drugs Table 3 State Prison Admissions for Drug Offenses by Race, 2000–2009 White Black Other* 2000 28,784 49,714 723 2001 29,704 49,798 797 2002 33,777 52,275 869 2003 34,958 49,285 876 2004 34,377 42,859 879 2005 40,707 43,251 1,024 2006 40,519 45,217 1,079 2007 35,364 45,174 1,084 2008 32,459 43,259 1,036 2009 31,380 40,790 828 (*) Includes some persons of Hispanic origin; however, there are additional persons of Hispanic origin who are new court commitments who were not categorized as to race and who are not included in these figures. Human Rights Watch calculated that the black rate of new court prison commitments on drug charges in 2003 was 10 times greater than the white rate. Among the 97,239 federal prisoners serving time for drug offenses at the end of 2009, 43. For most serious crimes, arrest and victimization survey data provide useful—although incomplete—information on the demographics of criminal offending (Like-Haislip, in this volume). Arrests primarily reflect geographic deployment of police personnel and law enforcement priorities. The principal source of national data on drug offenders comes from national surveys and self-report studies. National youth surveys have also included questions on drug offending that yield useful information. The available data leave little doubt that racial differences in drug offending do not account for the stark racial disparities in arrests and incarceration. Decades of arrest and incarceration have apparently had little impact on the use of illicit drugs. Subscriber: Univ of Minnesota - Twin Cities; date: 23 October 2013 Race and Drugs possession offenses, and those data suggest that far more whites than blacks illegally possess drugs. Click to view larger Figure 2 Percentage by Race of Illicit Drug Use in Lifetime, Past Year, and Past Month Among Persons Aged 12 and Over Note: Total includes all users regardless of race or ethnicity. But because the white population in the United States is substantially greater than the black, comparable rates of drug use result in far4 greater numbers of white users. As Figure 3 shows, for example, slightly more than six times as many whites (86,537,000) report having used drugs in their lives as blacks (13,629,000). Click to view larger Figure 4 Percentage by Race of Illicit Drug Use Among Persons Aged 12 and Over in the Past Month, by Type of Drug Note: “white” and “black” categories do not include people of Hispanic ethnicity. Click to view larger Figure 5 Illicit Drug Use by Persons Aged 12 and Over in Past Month by Race and Drug Type, Numbers in Thousands Note: “white” and “black” categories do not include people of Hispanic ethnicity. Subscriber: Univ of Minnesota - Twin Cities; date: 23 October 2013 Race and Drugs Figure 4 shows that rates of drug use by type of drug do not substantially differ for whites, blacks, and Hispanics. African Americans rates are somewhat higher than whites’ for the listed drugs except prescription drugs, but because of the different sizes of the black and white populations, the numbers of white users for every drug greatly exceed those for black users, as Figure 5 shows. The most heavily used drug is marijuana; the number of white marijuana users was more than four times the number of black users. Prescription drugs are the second most prevalent type of illicit drug use: among persons reporting using them in the preceding month, 5,145,000 were white and 602,000 were black.

It is also essential that physicians avoid boundary crossings or violations with their children cheap celebrex 200mg line arthritis in lower back right side; only in Parental leave emergencies should they assume a direct clinical role purchase 100mg celebrex with mastercard arthritis knee early symptoms; other- Every provincial housestaff organization has negotiated paren- wise, they should join in a collaborative relationship with their tal leave policies for their members, and many directly address child’s physician and their child. These policies mesh nicely with the principles and goals of the federal paren- Physician parents report that long work hours reduce the qual- tal leave program and allow many trainees up to a year of leave. Where possible, Residents should be supported and, indeed, encouraged to parents should protect structured time to engage with their take advantage of parental leave during their training. Healthy children, be consistently involved with their children’s com- attachment and bonding with a child requires time. Adequate munity, and ensure that a culture of open and welcome com- leave also allows for the entire family to grow together as they munication is fostered. Children will not accept medicine as an move through the phases of expectation, arrival, integration excuse for parental distance or under-involvement, nor should and, fnally, resumption of professional roles. Besides, spending time with children is a healthy way to in physician families is a smart one and directly contributes to remove oneself from the stresses of medical training, return the long-term sustainability of the physician workforce. Career choices Specialty medicine in Canada is experiencing signifcant demo- graphic shifts, including with respect to the gender and age of practitioners. This creates a remarkably busy family environment that re- Case resolution quires careful planning, open communication, fexibility and The resident books a meeting with the program director creativity to manage well. Busy physician parents need to pay and formally requested the maximum parental leave open particularly good attention to their partner’s emotional and to them. The program director expressed his happiness physical needs in order to bring richness and closeness to for the resident and family while indicating that he will the relationship. However, there was one month in counselling should signifcant relationship diffculties arise: particular that posed a challenge in terms of call and early intervention is associated with high rates of success. This was readily managed with the resident’s Inadvertently, this can lead to physician parents having unreal- partner, and everyone was satisfed. Physician parents are well resident considers this year of leave one of their best life served by engaging in community activities with a diversity of experiences. Health Awareness Workshop Reference University programs are encouraged to openly and warmly Manual. Staying human in the medical family: the family members to program orientation sessions and retreats unique role of doctor-parents. Family-friendly programs often have an edge in recruiting and retaining ex- cellent residents who, in turn, contribute to the goals of the department in a spirit of collegiality, community and respect. Thus physical As a rule, they are energetic, hard-working, enthusiastic, intel- activity become a low priority, and a lack of healthy exercise ligent and self-disciplined. They have learned to delay gratifca- erodes one’s energy level and sense of well-being even more. They are idealistic, and most come to medicine because they are inspired to contribute Emotional and physical fatigue lead to behavioural changes. Decreased interest in activities that were once enjoyed during free time leads to social withdrawal and personal isolation. However, the profession of medicine is demanding, and it is Relationships with family and friends are compromised, and diffcult to put limits around its practice. Poor constant exposure to suffering, heavy workloads, long hours, coping strategies that are adopted might include the increased time pressures, physical and mental demands, and a lack of intake of caffeine and alcohol, or the use of illicit drugs. Physicians are acutely Faced with some or all of these effects, one might experience aware of the distress of others but are often less attentive to at the same time a reduced sense of accomplishment and the stress and fatigue that they experience themselves. It is easy to lose sight of one’s accomplishments caring for others often leads to neglect of oneself. This is the sign of We know that physicians, as a group, are well informed with signifcant stress. We also know that when physicians are overwhelmed by the demands Given that the demands of the profession are ever present, of their profession, they are vulnerable to neglecting those what is the solution?