J. Musan. Northern Illinois University.

A problem in interpretation may arise because different leukocyte classes accumulate different levels of ascorbate; for example buy cheap nolvadex 20 mg on line, granulocytes contain less ascorbate than mononuclear leukocytes order nolvadex once a day. Thus trauma or inflammation discount nolvadex 20 mg with amex, which increase granulocyte levels order nolvadex with paypal, may decrease total leukocyte ascorbate levels. Measurement of leukocyte vitamin C should therefore be accompanied by a differential count. In early vitamin D deficiency, there is a normal Chapter 6 / Assessment of Nutritional Status 161 fasting calcium level, low to low/normal phosphorous level, low 25-hydroxy- cholecalciferol level, increased parathyroid hormone level and increased alkaline phosphatase level, and raised 1,25 dihydroxycholecalciferol level. With chronic deficiency, this pattern remains the same, except that there is a fall in 1,25 dihydroxycholecalciferol. Because there is a close relationship between serum vitamin E and lipid levels, measurements are best expressed in terms of vitamin E/lipid ratios. Platelet vitamin E is probably a more sensitive indicator of dietary tocopherol intake, but this assay requires more blood and a more elaborate laboratory procedure. A number of functional tests that rely on vitamin E’s protective action against oxidation exist. However, measures of oxidative susceptibility are not necessarily indices of vitamin E status alone. Total serum calcium is maintained within close limits despite a negative calcium balance, and abnormalities are usually found only when there is marked disease such as hypoparathyroidism. Ionized calcium may be a more sensitive indicator of calcium balance but is difficult to measure and is affected by venous stasis and pH. Twenty-four hour measurement of urinary calcium levels can be used to monitor calcium supplementation, but isolated readings are affected by too many variables including renal function. Alkaline dietary loads and metabolisable organic anions such as citrate, for example, reduce calcium excretion, whereas the opposite is true for acid loads and sodium. The state of bone storage may be monitored through bone density esti- mation and indirectly through urinary telopeptides. Muscle or bone levels are the best guide to magnesium status, because serum levels can be maintained at the expense of the limited stores. A 1-hour version of the test is now available, and this may make its regular application more practicable. Initially, body iron stores fall and this is reflected in decreasing serum ferritin levels. There can be confounding effects from lymphoma, liver disease, infec- tion, thalassemia, age, and sex. In the second stage, the lack of sufficient iron supply is reflected in a low serum iron level, decreased transferrin saturation, and increased erythrocyte protoporphyrin levels. Confounding effects for serum iron include alcoholism; infection; malignancy; deficiencies of B6, B12, folate, and vitamin C; and viral hepatitis. For total iron-binding capacity, the 162 Part One / Principles of Nutritional Medicine confounding effects include infection, protein-calorie malnutrition, alcoholic cirrhosis, malignancy, pregnancy, and viral hepatitis. Confounding effects include infection, B12 and folate deficiency, chronic dis- eases, hemoglobinopathies, sex, and altitude. However, as with B12, it is important to remember that values of ferritin, for example, in the low-normal range may be associated with some measure of impaired energy or cognitive performance. There is no completely satisfactory test for zinc status, and the prolif- eration of static and functional tests over the years is adequate testimony to this fact. A low serum zinc level is a late marker of zinc deficiency, and in fact, all tests of tissue or tissue fluid level (including red and white blood cells, hair, nails, saliva, sweat, and urine) have marked limitations. Zinc-loading tests are not routinely performed, and functional tests of zinc-related enzymes or proteins (e. We may still conclude that the best way to test for zinc deficiency is through a therapeutic trial. The assessment of copper levels in the blood is complicated by the fact that more than 90% of circulating copper is bound to ceruloplasmin, which is an acute-phase reactant whose level will be influenced by inflammation and a number of pathologic conditions. Pregnancy, hormone replacement therapy, and the contraceptive pill all tend to raise copper levels, which, even under normal circumstances, tend to be higher in women. Red blood cell superoxide dismutase is a potentially useful but not widely available test. Lymphocyte manganese superoxide dismutase can be affected by a number of disease states and inflammation. There is no reliable method of chromium estimation, and as with other micronutrients, the best test is often a therapeutic trial. Thus glu- cose, insulin, and lipid values should be monitored before and after supple- mentation. Plasma selenium gives a fairly good guide to short-term sele- nium status and whole-blood or erythrocyte selenium to longer-term status. The urinary iodine test is enjoying a revival of interest because of the growing realization that there is a return of widespread iodine deficiency in the community. With respect to the first problem, split hair samples were sent to six laboratories in the United States, and the results were compared. For many of the trace nutrients, however, one can find evidence to support good correlations with other parameters of nutrient status. There is a good correlation between hair and plasma selenium levels in healthy children. Accumulation of minerals in hair involves very different processes from those that are reflected, for example, in erythrocyte mineral levels. Hair min- erals accumulate over time, and their concentrations are influenced by endocrine and dietary factors. Hair zinc levels increased in experimental ani- mals when the protein/carbohydrate ratio increased. Practitioners who use metabolic typing systems 164 Part One / Principles of Nutritional Medicine must conduct their own research projects to investigate these possibilities further. External contamination of hair with elements, such as copper, is a prob- lem that cannot be completely eliminated by laboratory processing. It is particularly useful in alerting one to the possibilities of toxic metal accu- mulation and in identifying trace nutrient deficiencies (e. I have been impressed with the consistency of the profiles, the correlation of low nutrient levels with other, corroborative tests, and the response of hair levels to mineral supplementation. Thyroid Function Of all the endocrine systems, the thyroid merits special attention because of the significant incidence of thyroid problems and also the far-reaching effects of even minimal thyroid dysfunction. Hypothyroidism is not an all- or-nothing phenomenon, and it is becoming increasingly clear that thyroid failure encompasses a spectrum of dysfunction from overt myxoedema to subtle problems of cellular responsiveness manifesting in ill-defined clinical ways. To do justice to this variety of clinical presentation, testing methods must be appropriately sensitive. Further supporting evidence can be obtained from the temperature recording method described previously. The urinary level of triiodothyronine may prove a good indicator of sub- tle thyroid dysfunction,50 and the urinary iodine level should not be forgot- ten as part of the overall thyroid testing. Results of other tests, such as measurements of total cholesterol and crea- tine phosophokinase, may be abnormal, but they lack specificity. Fried R: The psychology and physiology of breathing, New York, 1993, Plenum Press. Brostoff J, Gamlin L: The complete guide to food allergy and intolerance, London, 1989, Bloomsbury Publishing. Tintera J: The hypoadrenocortical state and its management, N Y State J Med 35(13), 1955. Shibata K, Matsuo H: The relationship between protein intake and the ratio of N methyl -2-pyridone and N methylnicotinamide, Agric Biol Chem 52:2747-52, 1988. Therada A, Nakada M, Nakada K, et al: Selenium administration to a ten year old boy receiving long term parenteral nutrition—change in selenium concentration in blood and hair, J Trace Elem Med Biol 10:1-5, 1996. Gershoff S, McGandy R, Nondastuda A, et al: Trace minerals in human and rat hair, Am J Nutr 30:868-72, 1977. Laboratory investigations are used to predict disease and to confirm a working diagnosis in persons with suspected disease.

The trophozoites purchase nolvadex online now, which are virtually the only forms pres- ent in diarrheic stools nolvadex 10mg cheap, are of little importance as transmitters of the infection because they are not very resistant to desiccation or the action of gastric juices buy nolvadex 20 mg lowest price. The cysts purchase nolvadex in india, which are found in abundance in pasty or formed feces, are the principal ele- ments of transmission, since they survive in the soil for eight days at temperatures between 28°C and 34°C and for 40 days at 2°C to 6°C. For this reason, the chronic patient and the healthy carrier are more effective sources of infection than the acute patient. In the last two decades it has also been documented that sexual practices which include anal-oral or anal-genital-oral contact are an important risk factor for infection. Except in the case of monkeys, it is believed that animals acquire the infection from human reservoirs. Human- to-human transmission is also suspected: of three patients diagnosed in Venezuela, two had not had any contact with animals (Chacin-Bonilla, 1983). Diagnosis: Clinical manifestations alone are not sufficient to differentiate dysen- tery caused by amebiasis from other causes of dysentery. Laboratory diagnosis is based on three fecal examinations, each taken half a day apart, and serologic tests in special cases. Direct examination of diarrheic feces almost always reveals tropho- zoites, whereas cysts and occasional trophozoites are found in formed and pasty feces. Samples of diarrheic fecal matter should be examined as soon as possible after collection unless steps are taken to preserve the trophozoites, for which pur- pose trichromic or iron hematoxylin stain is recommended (García and Bruckner, 1997). Samples from formed or pasty feces may be examined using stool concen- tration methods and direct microscopic observation of cysts. The clinical manifestations of extraintestinal amebiasis are not sufficient for a definitive diagnosis. Thests such as the enzyme-linked immunosorbent assay make it possible to identify 90% of all cases, although this technique only detects 10% of intestinal cases (Restrepo et al. Thests designed to identify foreign bodies, such as radioisotopic imaging, ultrasound, and computerized tomography, may help to locate the lesion, but they are not diagnostic of the disease. Control: Basically, amebiasis is controlled by avoiding contamination of the environment with human feces and educating the general public—children in par- ticular, in order to reach the people in the household who handle food—and com- mercial food handlers about proper hygiene to prevent transmission of the infection. The following measures are essential in order to avoid contamination: proper dis- posal of human excreta, protection of water sources from fecal contamination, treatment of chronic patients and healthy carriers who are spreading cysts, and supervision of food preparation in public places where raw food is eaten. Health education should stress the danger of drinking water or eating raw vegetables that might be contami- nated, as well as the importance of washing one’s hands after defecating and before preparing food. Education programs should be targeted toward high-risk groups such as homosexuals and swineherds in order to prevent infections caused by E. In endemic areas, water and food should be either boiled or treated with nine drops of 2% tincture of iodine per liter of water for 30 minutes. Travelers vis- iting endemic areas should consume only bottled water (including ice made from bottled water) and cooked food. Quatorze cas d’Entamoeba polecki chez des refugies du Sud-Est asiatique: remarques sur l’aspect morphologique du parasite. Entamoeba polecki and other intestinal protozoa in Papua New Guinea Highland children. Entamoeba polecki: Morphology, immunology, antigen study and clinic of the first infections in Czechoslovakia. Entamoeba histolytica and Entamoeba dispar are distinct species: Clinical, epidemiological and serological evidence. Presencia de microorganismos patógenos en hortalizas de consumo crudo en Costa Rica. Etiology: Of the 73 species of Babesia that have been described as parasites of mammals, only slightly more than a dozen are important for domestic animals and only five occasionally infect man: 1) B. Since the diagnosis of Babesia is still based mainly on the morphology of the parasites, it is possible that man may be infected by other species which have not yet been identified with certainty. When an infected tick bites a mammal, pyriform parasites (sporo- zoites measuring 1. The majority of the parasites grow inside the red blood cells as pyriform trophozoites or merozoites, the rest as gametocytes. The trophozoites or merozoites often divide asexually into two organisms, forming a “V. When they achieve full growth and measure between 1 µm and 5 µm in length, the parasites break free of the erythrocytes, often destroying them in the process, and invade new ones. This cycle is repeated until either the infection is brought under control or the host dies. The gametocytes, on the other hand, develop inside the host’s erythrocytes until they become an oval or round parasite, at which point they stop growing. These gametocytes are the precursors of the parasite’s sex- ual stage, which continue to multiply inside the tick. Even after the infection is controlled, the parasite usually maintains a low-level presence in the host erythrocytes for a very long time. The lat- ter in turn become kinetes, which migrate to the hemocele and from there invade numerous organs of the tick, where they divide asexually and invade even more organs. Some of the kinetes invade oocytes; once inside the egg, they can be passed on to the next generation of ticks via transovarial transmission. Other kinetes invade the salivary glands, where they are transformed into sporozoites after the gland has undergone certain developmental changes that take place while the arthropod ingests its blood meal. Because of the time required for this process to occur, sporo- zoites are not inoculated until a few days after the infected tick begins to feed (Mehlhorn and Schein, 1985). Geographic Distribution: Animal babesias occurs almost everywhere in the world where ticks exist, including both the tropical zones and many temperate areas as well. The first case was confirmed in the former Yugoslavia in 1957 and attributed to B. In addition, some 22 cases have been identified in Europe and there has been 1 case in Taiwan. The total number of cases described in the world is estimated to be fewer than 200. However, there is evidence that the infection is much more frequent than the disease. Occurrence in Animals: Animal babesiosis is widespread throughout the world, with the highest prevalence in the tropics. It is one of the most important diseases of cattle in Africa, the Middle East and other parts of Asia, Australia, Central America, and the northern half of South America. The disease poses a risk for 50% to 70% of the cattle in the world and causes heavy economic losses, and has been compared to malaria in man. In Germany, it was found in 38% of 255 field voles (Microtus agrestis) (Krampitz, 1979). They are characterized by severe illness, often with pyrexia, chills, anemia, muscular pain, prostration, hemoglobinuria, and jaun- dice. The spleen plays a very important role in resistance to the parasite, and splenectomy is undoubtedly a predisposing factor. Some patients may have mild splenomegaly and hepatomegaly, and mild to severe hemolytic anemia is common as well. Recovery is slow, with malaise and fatigue persisting for several months (Ruebush, 1984). The incubation period between the tick bite and the appearance of symptoms can range from 7 to 28 days. Because of epidemiologic similarities with infections caused by Borrelia burgdorferi and Ehrlichia spp. The Disease in Animals: In the affected domestic species the symptomatology of babesiosis is similar, characterized by the triad of fever, anemia, and jaundice. The sensitivity of nervous tissue to anoxia often results in symptoms of agitation and convulsions. Babesiosis in cattle can range from mild to fatal, and those animals that recover usually harbor a subclinical infection and act as healthy carriers. Calves and young equines 6 to 9 months of age are relatively resistant to the infection and disease. In endemic areas, most animals acquire an asymptomatic infection when they are young that confers premunition (i. By contrast, animals arriving from parasite-free areas usually develop a severe form of the disease.

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The rate of influenza immunization to people aged 65 years and older was increased from 45% to 70% by a primary health care-based multiprofessional approach. The efficacy of the Theory of Planned Behavior in predicting a best practice to prevent salmonellosis. Effectiveness of a mass media campaign to recruit young adults for testing of Chlamydia trachomatis by use of home obtained and mailed samples. Prevention of viral hepatitis C: assessment of a comic strip-based information campaign targeting adolescents. Maltezou H, Maragos A, Halharapi T, Karagiannis I, Karageorgou K, Remoudaki H, et al. Factors influencing influenza vaccination rates among healthcare workers in Greek hospitals. Evaluation of a population-based prevention programme against influenza among Swiss elderly people. A literature review on effective risk communication for the prevention and control of communicable diseases in Europe 188. 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Further research is necessary to better a drug shortage include adverse events and medication errors buy nolvadex 10 mg line. In some cases discount nolvadex online master card, alternate medications may not create barriers to safe and effective medication therapy on a daily exist and may lead to poor patient outcomes purchase 20 mg nolvadex amex. Even when alternate medications are procured purchase 10mg nolvadex with amex, there are patient harm, shortages may also have an effect on the drug unintended consequences, including adverse events and medica- budget of the institution. Furthermore, clinicians may need to tion errors associated with the alternative therapy. To our 7 A medication error was defined as “any error occurring in knowledge, the effects of drug shortages on patient complaints the medication use process. The purpose tabulated as well as the types of medication errors (wrong drug of our survey was to quantify the effect of drug shortages on dispensed/administered, wrong dose dispensed/administered, patient outcomes, clinical pharmacy operations, patient com- wrong administration route, wrong frequency, wrong indica- plaints, and institutional cost. Respondents were also asked about informational gaps from previous surveys as well as to gather the number of category G-I events at their institutions caused contemporary data regarding these patient care issues. The MedAssets Pharmacy Coalition is composed of individuals from several health care Patient Outcomes areas, including acute care, nonacute care, management, and Information was solicited regarding drug shortages and delays industry. An e-mail was then sent to pharmacy directors in the of care or cancellations of care and the total numbers of each MedAssets Pharmacy Group Purchasing Organization mem- of these events. Delayed care was defined as any treatment that could not be provided when it was required. Cancelled care was defined The survey launched on October 2, 2012, and concluded on as any treatment that was abandoned or terminated because October 23, 2012, with 3 e-mails sent to encourage participa- of a drug being unavailable. No personal or institutional identifying information was death, treatment failure, readmission due to treatment failure, collected, and respondents had the option of not respond- increased length of hospitalization, increased patient monitor- ing to questions. This study was approved as exempt by the ing, patient transferral to an institution with a supply of the Northwestern University and Midwestern University institu- needed medication, delay of therapy, suboptimal treatment, tional review boards. The survey focused on 6 different domains: demographics, adverse events, medication errors, patient outcomes, patient Patient Complaints complaints, and institutional cost. Survey respondents were Respondents were asked if their institutions had received any asked to think about the question in the context of the last 2 patient complaints caused by drug shortages and the number years prior to the survey. Demographics Demographic questions included type of institution, location of Institutional Cost institution, number of patients served, and the drug category of Respondents were asked if they were estimating their costs medications that were unavailable. Adverse events were categorized according to the National Participant Comments Cancer Institute Guidelines for Investigators: Adverse Event Respondents were invited to summarize the effect of drug Reporting Requirements. Comments as a case in which the adverse event may be related to the were categorized into 5 different domains: medication error, drug shortage, and “probably related” was defined as a case adverse event, patient outcome, patient complaints, and insti- in which the adverse event is likely related to the shortage. Each comment could be categorized into more than requiring intervention were also listed. Medication Errors Results Of 183 respondents, 53% (n = 97) reported 1 to 10 medication The survey was sent to 1,516 directors of pharmacy in the errors, and 2. Serious errors were reported responded with 193 respondents (response rate 13%) agree- by 5 respondents (2. The majority of the respondents were permanent harm); 9 respondents (5%), with 1 to 5 category from acute care institutions that serve less than 100 patients, H (required intervention to sustain life); and 2 respondents and the location of the respondents was divided evenly among (1. The most common types of medication errors reported common categories of medications that respondents reported were omission (n = 86, 55. Patient Outcomes Adverse Events There were 134 respondents reporting delayed care, while 64 Of 174 respondents, 42% (n = 73) reported no possible or respondents reported cancelled care. Institutional Cost Of 187 respondents, 51 (27%) reported that they are estimating aN = 236 individual reports, 155 respondents. From b“Other” category included possible incorrect dosage, inappropriate monitoring, these respondents, 50 gave numbers on their estimated costs, delay in treatment because of lack of knowledge, incorrect substitution, not a pre- servative-free product, delay in administration, delay in therapy, drug-drug with 37 (73%) calculating costs from drug shortages of greater interaction (n = 1 for each report). Of Participant Comments the 64 respondents reporting cancelled care, 60 reported the A total of 123 respondents provided comments regarding the number of delayed care events, with 53 respondents (88. These cancellations 74% were related to institutional cost (including the cost of included procedures (39. The most common out- managing shortages), 24% to patient outcomes, 11% to medica- comes reported by respondents were alternative medication tion errors, and 8% to adverse events. Medication errors complaint because of drug shortages, with 66 respondents were most frequently associated with omission, wrong dose reporting the number of complaints received. Report of 1 dispensed/administered, and wrong drug dispensed/admin- to 5 patient complaints came from 43 respondents (65%), istered. Procedures, surgeries, and chemotherapy treatments and 12 respondents (18%) reported greater than 10 patient were cancelled because of drug shortages by approximately two complaints. These medications included metoclopramide (n = 1), This survey demonstrates that institutions are experiencing methotrexate (n = 1), and bumetanide (n = 1). Our survey additionally revealed that patient complaints There were also reports from 32% noting an adverse outcome are being received because of drug shortages and that there “frequently or always” from drug shortages. In addition, the have been readmissions for treatment failure caused by drug survey reported that the majority of hospitals had experienced shortages. Health care institutions should consider the poten- increased drug costs, most commonly because of the need to tial effects of shortages on Hospital Consumer Assessment of purchase more costly alternative medication from alternate Healthcare Providers and Systems scores, specifically patient sources,2 consistent with findings from our survey. The results from our survey were driven by respondents from Drug shortages have been increasing since the early 2000s, acute care institutions; however, based on other survey results, and several surveys have been conducted regarding the effects 2,3 clearly all sizes and types of hospitals are affected by short- of these shortages. During documentation of events was the desired goal, and the abso- this time frame, 4% of respondents (n = 15) reported a serious adverse drug reaction. Reporting rates 1 to 5 disabling events caused by a shortage; 34 respondents may have been low as respondents may not have disclosed reported 1 to 5 events requiring intervention from a shortage; medication errors or adverse events that occurred at their orga- and 2 respondents reported 1 to 5 patient deaths caused by a nizations. Thus, the number of occurrences of these events is likely under-reported, as has been noted in previous studies. A drug shortage survey conducted Despite these limitations, the results of this survey provide in 2010 by the Institute for Safe Medication Practices of 1,800 valuable ongoing information regarding harms because of drug health care professionals revealed that more than half of the shortages. Medication errors and adverse events continue to the fact that many of these issues were reported with high-alert occur because of drug shortages, and an increasing number of medications, including propofol, heparin, morphine, and che- health care resources are being dedicated to shortage manage- motherapeutic agents. National survey of the impact of drug shortages in acute Senior Infectious Diseases Pharmacist and Clinical Practice Manager, care hospitals. The impact of drug shortages on children with cancer—the example of mechlorethamine. Antimicrobial drug shortages: a crisis amidst the epidemic and the need for antimicrobial stewardship efforts to lessen the effects. Need for standardization in assessing impact of antibiotic shortages on patient outcomes. Through our personal experiences leading our respective health care organizations, we have tackled these complex issues, and we present in this paper the lessons we have learned along the way. Notably, we acknowledge that improving access and scheduling requires systems-level transformation and that such transformation can uncover previously unrecognized resources and improve all aspects of care delivery. This problem of scheduling and access is further complicated by the lack of clear, evidence-based standards for appropriate wait times for both routine primary and specialty care. Best practices from localized markets currently exist as the only comparisons available. What is clear is that the timing and setting of care should be considered in the context of patient condition and health status. Cost of Waiting The impact of long patient wait times on health outcomes is not well studied, and the sparse study of the issue precludes making any broad conclusions, except for those individuals with acute conditions, where difficulties with access and lengthy wait times are associated with negative outcomes. Prolonged wait times represent a burden on patients and their families, as reflected by diminished quality of medical care and the adverse experience of obtaining and receiving care. Although not reflecting health outcomes directly, patients with nonurgent needs who experience prolonged wait times have been shown to have a higher rate of noncompliance and appointment no-shows (Kehle et al. Prolonged wait times and access deficiencies also have a negative impact on providers and staff. Although often unacknowledged, the inefficiencies that exist throughout health care have been found to contribute to the high level of provider dissatisfaction and burn out in primary care (Sinsky et al. Using fewer and longer in-person visits and designated patient outreach, Group Health teams were able to integrate e-mail messages, telephone visits, and proactive care activities into their everyday work flow with a significant decrease in provider burnout (Reid et al. Spreading best practices in scheduling and access may help to reduce professional and team frustration, and to rekindle the satisfaction and joy in care delivery. In addition, eliminating prolonged waits can alleviate unnecessary costs (Gilboy et al. The positive return on investment that might be anticipated from a redesign of scheduling processes could be substantial for the patient and the health care system. Scheduling improvements alone can maximize provider supply with a resulting decrease in wait times for appointments. The science of optimizing access and wait times is still evolving, with little comprehensive measurement of wait times for appointments, and with targets that are often pragmatic—reflecting practitioner, staff, room availability, and cost—as opposed to evidence based.