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The harm from products that are legally available generic 5mg aygestin with visa menstrual cycle 9 days early, including tobacco discount 5mg aygestin with mastercard women's health clinic eau claire wi, alcohol and pharmaceuticals order aygestin master card pregnancy 7th month, can be reduced by regulating supply. This can include who is allowed to sell these products, when and where they are available and who they can be sold to. Regulating supply also includes ensuring that substances such as pharmaceuticals, precursors, and volatiles are available for legitimate uses, but not diverted for illicit uses. National Drug Strategy 2016-2025 18 Reduce illicit drug availability and accessibility Preventing or disrupting illicit supply of drugs and precursors reduces availability, leading to a reduction of use and consequential harms. Illicit supply of drugs includes drugs that are prohibited, such as cannabis, heroin, cocaine and methamphetamine, and those diverted from legitimate use, such as pharmaceuticals. It also includes illicit supply of substances that are legitimately available, such as alcohol, tobacco, solvents and those precursors used in illicit drug manufacture. Preventing illicit supply includes dismantling or disruption of distribution networks and manufacturing and cultivation facilities or locations. Strategies that affect supply include: • Regulating retail sale • Age restrictions • Border control • Regulating or disrupting production and distribution. The relative effectiveness of each strategy varies for alcohol, tobacco and other drugs, due to differences in legality and regulation, prevalence of demand and usage behaviours. A comprehensive supply reduction approach should use a mix of these strategies and be tailored to meet the varied needs of communities. Examples of evidence informed supply reduction approaches are described in the table below. This list is not exhaustive, but rather highlights or provides a guide to the key approaches to be considered. An effective supply reduction strategy must reflect evidence as it becomes available and address, emerging issues, drug types and local circumstances. Evidence informed approach Strategies Tobacco Regulating retail sale • Retail licensing schemes, supported by strong enforcement and retailer education. They address adverse health, social and economic consequences of the use of alcohol, tobacco and other drugs on individuals, families and communities. Harm reduction strategies encourage safer behaviours, reduce preventable risk factors and can contribute to a reduction in health and social inequalities among specific population groups. An effective harm reduction approach includes strategies such as drink and drug driving prohibitions, safer design of drinking venues, drug diversion programs, needle and syringe programs, smoke-free areas, safe transport options and sobering up facilities. It includes maintaining public safety and responding to critical incidents, including family and other interpersonal violence in which alcohol or other drugs are implicated. By reducing death, disease (including blood borne viruses), injury, violence and crime, the benefits of harm reduction extend beyond the individual to families, workplaces and wider community. Harm reduction also includes protecting the health and safety of children and other family members in environments affected by drug use. There is significant evidence that the substance misuse of 42 individuals can impact on the lives of their friends and family. For example, research consistently shows a strong association between domestic violence and substance misuse, particularly risky 43 drinking. However, the impact depends on a range of factors, including the type and frequency of 44 substance used and the social environment. Marginalisation and disadvantage are associated with increased harms from drug use and priority populations face greater risks. A complex interplay of factors, including physical health, mental health, generational influences, social determinants and discrimination influence an individual or community’s vulnerability to harmful drug use. Harm reduction can also be achieved by addressing historical, cultural, social, economic and other determinants of health. Many of these deaths were due to multiple drugs being taken, including prescription opioids. The most commonly injected drugs among respondents to the Australian Needle and Syringe Program Surveys between 2009 and 42 Bromfield, L, Lamont, A, Parker, R, & Horsfall, B 2010, in preparation.

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Patient recruit- In Canada cheap aygestin 5 mg overnight delivery women's health recipe finder, the Canadian Institutes for Health Research ment – consents and ethics generic 5mg aygestin with mastercard women's health center in lebanon pa; 4 purchase aygestin 5 mg otc menopause effexor xr. Increasing the impact of research jects in various diseases areas were funded through and development investment. Develop- comprehensive cataloguing of high quality biobank speci- ment of prospective surveillance and monitoring systems mens and biomarkers, and their use in all large-scale studies for personal health data will also contribute to the accu- on patient and population cohorts (‘top-down approach’) mulation of data on individuals across their life course. Thus it is not only omics or imaging technologies misinformation on diseases, their symptoms and potential that will generate vast amounts of data. Aspects include: (1) how health records data from diferent types of registries and to store and provide access to huge amounts of human emerging fows of unstructured data coming from, for ex- health-related sensitive data under a secure and common ample, connected objects or social media. Even though of huge datasets taking into account the fact that storage the launch of translational projects as a main driver for pro- may be either centralised or decentralised; (3) how to in- ducts and services development is key, market successes terrogate such data; and (4) how to link such data to ex- 18 perimental data. Furthermore it needs to be determined • Create a framework for data usage and connect it to who fnances such activities and who will reap the bene- a digital environment to facilitate and improve medi- fts. New solutions, such as cloud computing and secure cal data sharing while ensuring transparency and data user authentication, have been developed to cope with protection. Yet most of these still have to • Support an appropriate infrastructure to collect and demonstrate their applicability, especially in the health store the huge amount of information generated. Some public–priva- • Involve big data organisations in research, motivate te partnership projects of the Innovative Medicines Initiati- and stimulate them to invest in research. For these databases the citizen’s and patient’s lifecycle should be considered not only when an episode of severe Targeted achievements until 2020 and beyond – Re- or acute disease occurs. This recommendation also inclu- commendation des a laboratory quality control nationwide and if possible Europe-wide. Support translational research infrastructures plied and propagated so as to become standard practice in and enforce data harmonisation fostered by health. Develop and encourage the fast uptake of tech- • Give access to data from silos by encouraging and faci- nologies for data capture, storage, manage- litating data sharing. Support analytical methods and modelling way that data are stored, secured and shared, respec- approaches to develop new disease models, e. This requires the following another patient who has the same fngerprint (‘electronic actions: twin’), whose electronic medical record of natural history of disease and treatment outcome will help medical de- • Harmonise the format in which big data are collected cision-making through modelling and prediction. The introduction of genomic (sequence) and molecular • Decide which data will be needed (e. Ministries of health, research ributes to the accuracy of the diagnosis/treatment and justice; institutions for public health and health scheme, e. Create a European ‘big data’ framework and ad- public research bodies including systems biology/me- apt legislation. To leverage this huge potential beneft for patients and citizens, healthcare professionals need to strengthen a. In parallel they need suitable deci- sion-support tools with an easy-to-use interface to make The establishment of the pan-European Research In- their use in clinical routine possible. Electronic health records are and interoperability of big data generated by the re- being introduced into public and private healthcare in most search infrastructures and communities. The availability of very large tifcation is dependent on the results of such research. Furthermore Member States works currently work on collections of very large disea- 21 se-specifc sample and data collections. This is a national network of centres of excellence linking clinical and In France the National Research Strategy (April 2015), research data to address a range of research questions. This programme is part of a national action frame- between Member States, and interoperability of he- work launched in 2014, making 100 million € availab- alth-related registries and health records is a major le for fve years. This context can include micro-orga- lent basic science with clinical and public health research nisms and their characteristics. Given that some of the and through product development and communication mechanisms of expression, interaction and signifcance in both directions. This will require the concerted action are not well understood, it is crucial to continue to seek of a number of sectors, disciplines and agencies. In recent not only to improve the knowledge base, but to develop years, there have been a number of scientifc and tech- meaningful interventions that will positively impact nological breakthroughs underpinning the usefulness of upon an individual’s health. These have been achieved environment on the evolution of disease could have sig- through a number of largely ‘bottom-up’, investigator-dri- nifcant clinical impact. Research into the underlying genetics of di- seases must continue as this will identify new targets for 16.

This remarkable specificity is made possible by computerized interpretation of the diffraction patterns of a laser beam passing through the thread and bouncing off individual cells discount aygestin 5mg with visa pregnancy options. The scat- tered light reaches electronic plates positioned around the stream buy aygestin 5 mg free shipping breast cancer 6 weeks radiation, which record the pattern of light as digital information buy discount aygestin line women's health clinic lynchburg va. Using a computer-controlled magnetic pulse, the operator can pluck specific cells from the stream for further analysis. Flow cy- tometry is powerful enough to detect, for example, fetal cells in a 20 Digital Medicine sample of the mother’s blood and extract them without the need for invasive and sometimes dangerous amniocentesis. It can also count and categorize cancer cells by their shape or the constellation of receptors on their surface. If this becomes possible, flow cytometry will be the tool hospitals use to find stem cells in the blood. These cells will be cultured and redirected to therapeutic levels for treating diseases like Parkinson’s, diabetes, or spinal cord injury. Because they are cultured from an individual’s own cells, the recipient will not require a lifetime of immune suppressants to enable them to do their work. In all cases, the signals are detected by digital arrays and converted to digital information structured and stored by computers. These technologies, revolutionary when they were developed, made noninvasive evaluation of tissues and internal organs possi- ble, tilting diagnosis decisively away from exploratory surgery (and tilting power and clinical influence toward radiology). These images can reveal the extent of damage to the heart or brain from a heart attack or stroke and help determine if a tumor has been destroyed by radiation or chemotherapy. In addition, the capability of diag- nosing the type of lesion has increased by 40 percent. With molec- ular imaging, these technologies will actually be able to identify real-time cellular changes or gene expression patterns that prefigure disease. In the 30 years since they were invented, there has been a logarithmic growth in the computing power of a microchip. This growth in computing power was predicted by Gordon Moore, one of the founders of Intel, in 1967. In one of the most extraordinary (self-fulfilling) predictions in the history of technology, Moore said that the power of a microchip would double every 18 months with cost remaining constant (Figure 2. More powerful computing engines mean more rapid acquisition of images and more options for manipulating and reconstructing these images. Today, these modalities stand on the brink of eliminating the need for invasive procedures, such as colonoscopy and coronary angiography, and are capable of produc- ing remarkable three-dimensional images of functioning internal organs. Changes in Radiology Two key changes in radiology—teleradiology and machine inter- pretation of radiological images—have been made possible by the successful standardization of formats for digital radiological im- ages. With the advent of broad- band Internet connections, radiological images can not only be transmitted instantaneously inside hospitals or clinics, but they can also be sent virtually anywhere in the world where someone is avail- able to interpret them. Teleradiology has created service opportunities for isolated rural hospitals and practitioners who cannot afford full-time sub- specialized radiology coverage. Advances in image recognition software will enable radiology equipment to interpret as well as create radiological images. Recent studies have established that machine-read mammograms detect more lesions and stage them more accurately than do human radi- ologists. Human judgment will be focused on the “tough calls,” the machine-identified exceptions that require overreading. Remote Monitoring In Philadelphia recently, a newly formed technology firm, Car- dioNet, created the first regional wireless network to monitor ambu- latory cardiac patients. This device is contained in a wireless sending unit the size of a personal digital assistant, which transmits the signals to a base station where human operators are assisted by continuous computer monitoring of their heart rhythms. If the patient appears to be experiencing cardiac distress, a voice channel will enable the operator to communicate directly with the patient, verify his or her condition orally, and direct him or her to take action. The system automatically alerts the patient’s physician to the problem and can even trigger an ambulance call to bring the patient to the hospital if required. Taking this process to the next step, Medtronic, the technology leader in cardiac pacemakers, has developed an implantable device that monitors, stores, and transmits information about the patient’s cardiac rhythm directly to the patient’s physician. These devices can be programmed (and reprogrammed remotely) to vary pacing depending on the patient’s unique needs and can also administer an electric shock to restart the patient’s heart if it moves into atrial fibrillation. Progress in miniature sensing technologies is creating a new gen- eration of devices that can be worn or embedded in people’s homes to monitor their health noninvasively and automatically alert fam- ily or caregivers if problems arise. The “smart shirt,” for example, enables monitoring of multiple vital signs (heart rhythms and res- piration) and transmittal of aberrant results to family or the care team.

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Tools One of the most important tools to avoid systematic errors or deviations during these steps is to use audits or second opinions order discount aygestin on line women's health group columbia tn. Too many accidents have occurred due to only a single physicist having performed these very important calculations during commissioning generic 5mg aygestin amex menopause young age. Establishing local networks with three to four hospitals where the physics groups can support each other’s dosimetry processes can be very beneficial safe 5 mg aygestin womens health eugene oregon. It is also important that the national professional societies or the regulator support and manage clinical review and audit programmes. New tools have been explored within radiation oncology that have been adopted from industry, i. The problem was, however, that the staff at the treatment units continued to perform manual correction of the monitor units for the shorter distance, resulting in too low doses being given to about 1000 patients. Similarities exist between this accident and the single overdosage in Glasgow of a young girl in 2006. Both happened after the introduction of a new computer based system and not all of the consequences were evaluated prior to clinical use. In both cases, for a subgroup of patients, the old methods/ procedures were used, not considering the changes that the new system had for consecutive subprocesses. Usually, the major tracks are identified but some very low frequency tracks can be missed, such as in the Glasgow problem. Thus, the introduction of new systems requires in-depth risk analysis and it may be that radiation oncology professionals need support from other areas. Nowadays, these systems are often like big black boxes and there are also systems that include several black boxes within a single system. One cannot emphasize enough the need for training and education of the staff prior to clinical use of these systems. Benchmarking and audits may also be beneficial to improve the safety of these systems. For each step, known incidents and potential problems that can occur have been presented, together with available tools or barriers that have the potential to identify these problems, and hopefully to be able to prohibit them before they influence the treatment of the patient. The barriers that should exist in a radiotherapy process can always be discussed and it is a balance of risk and resources (human resources and/or economics). A way to evaluate the effectiveness of such barriers, as well as to identify other areas where potential incidents can evolve, is to have an incident reporting system either locally (this is mandatory in many countries) and more globally, e. More specific conclusions following this review of the process are: — Working with awareness and alertness: Unusual and complex treatments should always trigger an extra warning and each staff member should be aware and alert in such situations. One should also think in terms of ‘time-out’ and take a step back to a second review of the situation before continuing with treatment. For most critical steps, such as commissioning and calibration of equipment, these steps should always be reviewed, either internally or, preferably, via an external audit. Indications of improved outcome in clinical trials have been seen when a well managed quality system is in place and this is the primary goal for the individual patient — being cured safely. Clinical practice has improved most dramatically over the past decade as a result of better tools/computers for the identification of clinical cancer target volumes and with more precision delivery of the radiation, with the consequent sparing of normal tissues. Unfortunately, however, radiotherapy accidents, resulting in serious physical, functional and even emotional injury to cancer patients, do occur. It is, therefore, appropriate that this symposium review some of these accidents, as an attempt to better understand how to incorporate better preventive measures and to develop better medical management of the outcomes. Prevention of such accidents is, of course, always the most important way to minimize the complex medical and social issues resulting from such accidents, which always affect the patient, their families and friends, as well as the morale of the caregiver staff. As such accidents are never planned, it is important, when they do occur, to capture and record as much information as possible. Our worldwide registry data consist of many types of radiation accident, including industrial, nuclear power plant and medical sources, as is shown in Fig. However, it is noteworthy that the most common cause of death listed in this registry in the United States of America is due to the misuse or misadministration of medical sources, as is noted in the ‘circled’ group in Fig. Specifically, the physicochemical 90 attachment process of the Y to the microspheres was apparently faulty; and soon 90 after the intra-arterial injection, the Y became disassociated from the 20–50 μm 90 particles and the free Y atoms then targeted the bone marrow [1] rather than the tumour tissue. Eight of the patients in this series died, which perhaps is not unexpected, since they all had metastatic cancer. In addition, in the 1970s and 1980s, we at the University of Wisconsin Clinical Cancer Center were developing and using new intra-arterial chemotherapy protocols for the clinical treatment of hepatic metastasis and unresectable pancreatic cancer [3, 4]. We were 90 also planning to use concurrent Y microsphere therapy with the chemotherapy.

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When these conditions obtain discount aygestin 5mg visa menopause vitamins, the womb ‘‘hits the liver and they go together and strike against the abdomen—for the womb rushes and goes upward towards the moisture order aygestin 5 mg visa menstrual underpants. When the womb hits the liver purchase aygestin 5 mg free shipping menopause herbal remedies, it produces sudden suffocation as it occupies the breathing passage around the belly. For example, when the womb strikes the liver or abdomen, ‘‘the woman turns up the whites of her eyes and becomes chilled; some women are livid. If the womb lingers near the liver and the abdomen, the woman dies of the suffocation. Multiple means of treat- ment were employed, including the recommendation that, when the womb moves to the hypochondria (the upper abdomen or perhaps the diaphragm), young widows or virgins be urged to marry (and preferably become preg- nant). This was premised, apparently,on the belief that thewombwas capable of sensing odors. Fetid odors (such as pitch, burnt hair, or castoreum) were applied to the nos- trils to repel the womb from the higher places to which it had strayed, while sweet-smelling substances were applied to the genitalia to coax the uterus back into its proper position. Not all the symptoms were listed every time uterine movement was men- tioned by the Hippocratic writers, nor did all cases of pnix involve uterine movement. Whenanattack occurs, sufferers from the disease collapse, show aphonia, labored breathing, a seizure of the senses, clenching of the teeth, stridor, convulsive contraction of the extremities (but sometimes only weakness), upper abdominal distention, retraction of the uterus, swelling of the thorax, bulging of the network of ves- sels of the face. The whole body is cool, covered with perspiration, the pulse stops or is very small. Critical to his views, and to all contemporary criticisms of the ‘‘wandering womb’’ (in- cluding Galen’s, as we shall see in a moment) were the anatomical discover- ies made at Alexandria in the third century . The womb ‘‘does not issue forth like a wild animal from the lair’’ but is instead ‘‘drawn together because of the stricture caused by the inflammation’’ of these uterine ligaments. Soranus also adamantly rejected the Hippocratic odoriferous therapy, or at least the part of it that employed foul- smelling substances. Yet for all his modifi- cations, Soranus never questioned the disease category itself. On the contrary, his thorough engagement with it was to help render it canonical in almost all later gynecological texts up through the Renaissance. Galen, active only a generation after Soranus, was more accommodating of traditional Hippocratic perspectives. Himself a highly experienced anato- mist,103 Galen no more than Soranus could accept the possibility that the womb actually wandered to various parts of the body since the diaphragm, if nothing else, absolutely prohibited movement to the thorax. He did not, however, question the by now traditional litany of symptoms, let alone the existence of the disease category. He, like Soranus, thought the womb could appear to be drawn up slightly because of inflammation of the ligaments. Yet to explain apnoia hysterike (difficulty of breathing caused by the uterus), Galen offered something of a compromise that would explain how the uterus, with- out moving to the upper parts, could still affect them. He posited a sympa- thetic poisonous reaction caused by either the menses or the woman’s own semen being retained in her uterus. Notable here is Galen’s shift in ideas about how semen and sexuality played into this dis- ease: for Galen, it was not her lack of semen provided by a man that made the widow susceptible, but the buildup of her own seed. Despite these dis- agreements,Galen maintained elements of the traditional odoriferous therapy, though he complemented this with bloodletting, massage, and a host of other treatments. Both Soranus and Galen represented the very highest theoretical tradi- tions of Greek medicine, catering as they did to the elite, Hellenized urban classes of Rome. Their views never eradicated what were apparently deeply rooted popular beliefs that the womb did indeed wander. Even Muscio, in the fifth or sixth century when hewas rendering Soranus into Latin, slipped in the more than suggestive phrase ‘‘when the womb moves upwards toward the chest’’ when referring to uterine suffocation; as he repeated this several times, it seems that he, too, thought the womb capable of more than ‘‘distension caused by the ligaments. One is written into a blank space of a late-ninth-century medical volume by a tenth-century Introduction  hand. Having invoked the aid of the Holy Trinity, the nine orders of the an- gels, the patriarchs, prophets, apostles, martyrs, confessors, virgins, and ‘‘all the saints of God,’’ the priest is to command the womb to cease tormenting the afflicted woman: I conjure you, womb, by our lord Jesus Christ, who walked on the water with dry feet, who cured the infirm, shunned the demons, resuscitated the dead, by whose blood we are redeemed, by whose wounds we are cured, by whose bruise[s] we are healed, by him I conjure you not to harm this maidservant of God, [her name is then to be filled in], nor to hold on to her head, neck, throat, chest, ears, teeth, eyes, nostrils, shoulders, arms, hands, heart, stomach, liver, spleen, kidneys, back, sides, joints, navel, viscera, bladder, thighs, shins, ankles, feet,or toes, but to quietly remain in the placewhich God delegated to you, so that this handmaiden of God, [her name], might be cured. The chief vehicle for Galen’s views in the twelfth century was, of course, Ibn al-Jazzār’s Viaticum. In discussing uterine suffo- cation in book , Ibn al-Jazzār had echoed Galen in asserting that ‘‘the sperm increases, corrupts, and becomes like a poison. Ibn al-Jazzār postulated that the putrefying menses and/or semen in the uterus produced ‘‘a cold vapor’’ that rose to the diaphragm.

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