By R. Nafalem. Austin College. 2018.

Techniques to assist prioritizing include values clarif- week to see if they can “work smarter buy generic cialis extra dosage 200mg on-line. Techniques in this domain include set- ting personal and professional goals (short- order cialis extra dosage 100mg with mastercard, medium- and Key references long-term) and using a personal organizer (e. Shiftwork, fatigue, and safety in emergency career trajectory are examples of roadmaps to success. Patient Safety in Emergency the most out of these priorities, a well-organized work space Medicine. Finally, it is important to manage available resources, whether assistants, colleagues, mentors, or technologies. Other forms of intimidation and • discuss the elements of intimidation and harassment and harassment reported by resident physicians have included inap- how they affect residents during training, and propriate physical contact, sexual harassment, the assignment • describe an approach to dealing with intimidation and of work as a punishment, loss of privileges and opportunities, harassment within the context of a residency program. Dealing with intimidation and harassment Case For intimidation and harassment to be tackled effectively, it is Your residency program is under accreditation next year. In some cases, it is faculty who may you will institute as a faculty administrator to prepare for be more concerned about the repercussions of reporting for this event? On the fip side, trainees should recognize that, in many cases, the individuals Introduction involved in bullying are not aware of the effect they are hav- Intimidation, harassment and workplace bullying have prob- ing. In many cases, individuals who intimidate and/or harass ably existed as long as the institution of medicine, but have others need education in effective communication as teachers started to be addressed by medical faculties only within the last and administrators, rather than disciplinary action. At a fundamental level, intimidation and harass- cal schools have now adopted directors or deans of equity to ment are defned not only by the behaviour and motivations deal with confict issues between faculty and trainees. Many of the perpetrator, but by the response of the individual who of these individuals directly report to the dean of medicine or is targeted. It should be seen as causing a negative effect on to “high-level” faculty committees with the ability to institute the victim (e. They focus on the content, psychological issues and or harassment is ever appropriate, such acts must be persistent procedures surrounding the issue of confict. Program directors, faculty members and importance of reporting such events, not only so that medical residents must be aware of these resources and deem them trainees can protect themselves, but also to help prevent their to be effective in dealing with such concerns. By taking action against bullying are unable to demonstrate such mechanisms may be put on behaviours, medical students and resident can help to change probation and risk losing their accreditation status. In tying such importance to this issue, the Royal College ensures Where intimidation and harassment leads that programs will endeavour to create a training environment Intimidation and/or harassment can lead to poor job satisfac- that limits intimidation and harassment, adequately deals with tion and psychological distress. It has been associated with issues that arise, and takes steps against the perpetuation of mental health problems and a desire to leave medical train- unacceptable behaviours, for the beneft of future generations ing. Where intimidation and harassment occur Physicians in training experience intimidation and/or harass- ment in all areas of medical training—that is, in the clinical, research, administrative and political realms. More than half of respondents to a recent Canadian survey reported that they had experienced intimidation and/or harassment while in residency training. Training status and gender were felt to be the two main bases for the intimidation and/or harassment. The happy docs teaching faculty are aware of policy and procedures for study: a Canadian Association of Internes and Residents well- dealing with intimidation and harassment (e. A meeting could be organized with the tion within and outside of residency training in Canada. This may be done with a teaching session using case examples or role playing from the director of equity. Residents should also be encouraged not to conceal, but rather report concerns around intimidation and harass- ment so that the accreditation team can make appropriate recommendations that will ultimately be addressed by the individual programs. Challenges to collegiality are dis- Collegiality involves certain rights and is tempered by specifc cussed with respect to disruptive physician behaviours, confict obligations. In academic contexts, it pertains to a commitment management, and gender-based and generational tensions. Collegiality allows physicians to educate one an- on the health care team are discussed. Physicians have an obligation to put restrictions Resident leaders, medical educators and program directors on their collegiality: in particular, they must give the welfare of should all endeavour to foster collegiality in professional rela- their patients priority over their collegial relationships. One method of doing so is to encourage the mentor- ing of residents by faculty members, and of medical students Although collegiality is highly prized by individual practitioners by residents, whether in person, by email or through websites. One cannot become an effective Scholar and Medical academic half-days), between supervisors and residents, and Expert without sharing information with peers. As a body, residents be an effective Health Advocate without the cooperation of can decide on a topic concerning physician health that could one’s supervisors and peers—which will itself be shaped by be mediated by increased collegial relations (e. One learns stress related to time pressures in training) and invite a faculty effective approaches through the wisdom and example of member who feels comfortable sharing personal experience to other practitioners. To fulfll the general observation, more formal methods include a 360 de- obligations of their Professional Role with respect to patient gree evaluation process by which residents are evaluated by all care, ethical behaviour and self-regulation, physicians cannot members of the health care team, including their peers. In addition to supporting these domains feedback is often perceived as less critical and constructive of competency, collegiality by defnition engenders the kind of in criticism, when discussing topics of communication with mutual respect and support that helps to prevent the intimida- colleagues. This kind of evaluation process can ensure that the tion and harassment of colleagues. Moreover, where healthy resident is evaluated fairly by all members of the team and collegiality exists, physicians will not only support one another removes pressure off of the physician preceptor who may during good times, but will also protect one another’s health by have challenges providing critical feedback. For the residents recognizing when colleagues are in trouble and helping them involved, it builds skills in giving feedback on professional to get the support they need. Ottawa: departments that do not foster collegiality suffer from poor The Royal College of Physicians and Surgeons of Canada.

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Once a diseased colony has been found purchase cialis extra dosage 50 mg without prescription, it will not move and can be counted and monitored (and potentially treated discount cialis extra dosage 40mg online, if viable methods are developed). Corals also have the potential to re-grow over dead skeleton by re-sheeting and in this way they function more like plants. By reducing the amount of anthropogenic stressors on reefs, it is also possible to try to optimise conditions favourable for reef health and coral growth. Ensure that divers collecting samples or visiting sites always visit healthy sites before those considered to be diseased. There is evidence to suggest corals that survive a bleaching episode may later succumb to opportunistic infections, as their resistance is lowered by the stress of bleaching. In such cases, imposing a quarantine on a reef acutely impacted by either bleaching or disease may be worthwhile. The reef can be closed to human activity by prohibiting diving, snorkelling and fishing for a period of time. Managers should make every effort to disseminate to the public locally-relevant information on coral diseases and their potential impacts. Managers may also focus their attention on target groups who interact regularly with the reef: fishers, recreational divers, and diving tourism operators and their clients In the longer term a number of actions can help to prevent disease and its spread between corals: Restrict translocation of corals to prevent movement of disease. Provide guidance for proper handling and containment regimes during coral disease experiments. Monitor proposed coral management and research activities, as well as rehabilitation or remediation activities, to minimise or avoid ethical and legal problems with the potential spread of disease. Promote the use of universal precaution measures when dealing with diseases in the field. Encourage ethical behaviour and improved sanitary practices among divers and other users of the marine environment. Harnessing enthusiasm among divers will provide managers with additional observers underwater, and the only efforts that are necessary are some initial training and regular communication. Livestock & humans None Wildlife Experiments have shown that black band disease can be eliminated and the rate of appearance of new infections can be reduced through re-introduction of herbivorous urchins Diadema antillarum into habitats where they were formally abundant. In addition to the loss of coral tissue, disease can cause significant changes in reproduction rates, growth rates, community structure, species diversity and abundance of reef-associated organisms. Effect on livestock & None humans Economic importance The revenue earned from fishing, tourism, recreation, education and research associated with coral reefs is of major importance to many local and national economies and can be severely affected by diseases of the coral in these areas. Crayfish plague is a disease caused by an oomycete (water mould) that affectsCrayfish plague is a disease caused by an oomycete (water mould) that affectsCrayfish plague is a disease caused by an oomycete (water mould) that affects wild and farmed freshwater crayfish. Species affected All species of freshwater crayfish are currently consideredAll species are currently considered susceptible to crayfish plague. The outcome of infection varies depending on species: All stages of EuropeanAll stages of European crayfish species are consideredconsidered highly susceptible. Laboratory challenges haveLaboratory challenges have shown that Australianthat Australian crayfish species are also highly susceptible. North American crayfishNorth American crayfish do not usually present with clinical diseasedo not usually present with clinical disease when infected withwhen infected with A. Crayfish th plague spread to Europe in the 19plague spread to Europe in the 19 century and is now consideredconsidered widespreadwidespread throughout this continent. Crayfish plague is therefore found in the same freshwatersame freshwater, aquatic environments as its host. Zoospores are also spread via flowing water, infected crayfish and less commonly by migratory and/or translocated fish. How does the disease Introductions of North American crayfish (directly into the wild or into fish spread between groups farms, from which escapes occurred) are believed to have initially spread of animals? The disease is spread to naïve crayfish populations by: the expansion of invasive, plague-carrying crayfish (e. Initial field signs of crayfish plague include: presence of a number of crayfish during daytime (they are normally nocturnal) crayfish in open water with unsteady, uncoordinated movements crayfish falling over and unable to right themselves weakened rapid tail escape response numerous dead or weak crayfish in water bodies and water courses at the time of initial outbreak. Note that there is no other disease, or pollution effect, that can cause total mortality of crayfish but leave all other animals in the same water unharmed. They depend on environmental conditions, number of zoospores and the density of susceptible crayfish in the area. Clinical signs can include: fungal growth on the soft parts of the shell brown or black spots on the carapace white necrotic musculature in the tail black lines on the soft shell underneath the tail blackening of most of the shell in chronically infected individuals death (within weeks in susceptible species). Recommended action if Contact and seek assistance from appropriate animal health professionals. Note that isolation is only successful before or within 12 hours of the death of infected crayfish. Usually, the only effective way of preventing further spread and maintenance of crayfish plague is to control the spread of North American carrier crayfish. Emphasis should be placed on measures preventing future introductions of non-native or infected crayfish to unaffected water- bodies. North American crayfish have been used in various European countries to replace the lost stocks of native crayfish. This is not recommended as restocking with North American crayfish can further the spread of A. Given the high reproductive rates and the tendency of several North American crayfish species to colonise new habitats, restocking with North American crayfish species would also largely prevent the re-establishment of native crayfish species. Aquaculture As above, actions should be directed at preventing the introduction of crayfish plague, as subsequent control can be very difficult. Movement of water or any equipment from affected to unaffected watersheds should be avoided or undertaken with disinfection precautions. Sodium hypochlorite and iodophores should be used to disinfect equipment and equipment should dried thoroughly (>24 hours). If a new crayfish farm for a highly susceptible species is being planned, investigate whether North American crayfish species are: in the vicinity of the planned site; or present upstream (if North American crayfish are present, it is high likely that susceptible farmed crayfish will eventually become infected).

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The workshop participants will also consider the essential elements of the framework by addressing topics that include buy 200 mg cialis extra dosage with mastercard, but are not limited to: x Compiling the huge diversity of extant data from molecular studies of human disease to assess what is known purchase cialis extra dosage 40 mg free shipping, identify gaps, and recommend priorities to fill these gaps. The Committee will also consider recommending a small number of case studies that might be used as an initial test for the framework. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease 80 The ad hoc Committee will use the workshop results in its deliberations as it develops recommendations for a framework in a consensus report. The report may form a basis for government and other research funding organizations regarding molecular studies of human disease. The report will not, however, include recommendations related to funding, government organization, or policy issues. Project Context and Issues: The ability to sequence genomes and transcriptomes rapidly and cheaply is producing major advances in molecular genetics. These advances, in turn, provide new tools for defining diseases by their biological mechanisms. The recognition and classification of human diseases are fundamental for the practice of medicine, with accurate diagnoses essential for successful treatment. Although diagnostics have begun to embrace the identification and measurement of molecular disease mechanisms, the classification of disease is still largely based on phenotypic factors, or “symptoms and signs. Remarkable advances in molecular biology have brought biomedical research to an “inflection point,” putting the life sciences at the cusp of delivering dramatic improvements in understanding disease to reap the health benefits that formed the rationale for the Human Genome Project. In 2010, we are now poised to use genomics, proteomics, metabolomics, systems analyses, and other derivatives of molecular biology to: x understand disease based on biochemical mechanisms rather than clinical appearances or phenotypes; x transform disease diagnosis; x develop improved screening for, and management of, risk factors for disease; x discover new drugs and reduce side effects by predicting individual responses based on genetic factors; and x transform the practice of clinical medicine. Some in the life sciences community are calling for the launch of a wide-ranging new program to use molecular and systems approaches to build a new “taxonomy” of human diseases. The feasibility of such a program, including the readiness of the technology, willingness of the scientific community to pursue it, and compelling nature of the gaps it would fill, remains to be explored. Embarking on such a program would require that existing data linking molecular, environmental, and experiential factors to disease states be surveyed and compiled, and that gaps in these data be identified and priorities set and acted upon to fill these gaps. In addition, effective and acceptable mechanisms and policies for selection, collection, storage, and management of data, as well as perception, construction, and manipulation network relationships within the data, are clearly needed. Criteria must also be established for providing or denying access to and interpretation of data. Roles of and interfaces among the involved communities (public and private funders, data contributors, clinicians, patients, industry, and others) would need to be explored and defined. And the many ethical considerations surrounding such a program would need to be addressed. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease ͺͳ Each of these areas is technically complex. Undertaking such a program would clearly require the participation and collaboration of many government and private entities over a considerable period of time. To ensure that progress is being made, goals and milestones against which program success can be measured would need to be developed. The Committee would leverage the expertise of additional scientists, clinicians, and others by holding a large (approximately 100 participants) workshop to obtain ideas from the broader scientific and medical communities. The Committee will also consider recommending a small number of case studies that might be used as an initial test for the framework. Desmond-Hellmann previously served as president of product development at Genentech, a position she held from March 2004 through April 30, 2009. In this role, she was responsible for Genentech’s pre-clinical and clinical development, process research and development, business development and product portfolio management. She also served as a member of Genentech’s executive Committee, beginning in 1996. She joined Genentech in 1995 as a clinical scientist, and she was named chief medical officer in 1996. In 1999, she was named executive vice president of development and product operations. During her time at Genentech, several of the company’s patient therapeutics (Lucentis, Avastin, Herceptin, Tarceva, Rituxan and Xolair) were approved by the U. She holds a bachelor of science degree in pre-medicine and a medical degree from the University of Nevada, Reno, and a master’s degree in public health from the University of California, Berkeley. Prior to joining Genentech, Desmond-Hellmann was associate director of clinical cancer research at Bristol-Myers Squibb Pharmaceutical Research Institute. While at Bristol-Myers Squibb, she was the project team leader for the cancer-fighting drug Taxol. She also spent two years in private practice as a medical oncologist before returning to clinical research. In January 2009, Desmond-Hellmann joined the Federal Reserve Bank of San Francisco’s Economic Advisory Council for a three-year term. In July 2008, she was appointed to the California Academy of Sciences board of trustees. Desmond-Hellmann was named to the Biotech Hall of Fame in 2007 and as the Healthcare Businesswomen’s Association Woman of the Year for 2006. She was listed among Fortune magazine’s “top 50 most powerful women in business” in 2001 and from 2003 to 2008. In 2005 and 2006, the Wall Street Journal listed Desmond-Hellmann as one of its “women to watch. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease 84 served a three-year term as a member of the American Association for Cancer Research board of directors, and from 2001 to 2009, she served on the executive Committee of the board of directors of the Biotechnology Industry Organization. Sawyers’ laboratory is currently focused on characterizing signal transduction pathway abnormalities in prostate cancer, with an eye toward translational implications.

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The average rate of brain glucose utilization in the postabsorptive state of adults based on several studies is approximately 33 µmol/100 g of brain/min (5 cheap cialis extra dosage 60 mg online. Based on these data discount cialis extra dosage 60 mg overnight delivery, the brain’s requirement for carbohydrate is in the range of approximately 117 to 142 g/d (Gottstein and Held, 1979; Reinmuth et al. Regardless of age and the associated change in brain mass, the glucose utilization rate/100 g of brain tissue remains rather constant, at least up to age 73 years (Reinmuth et al. In 351 men (aged 21 to 39 years), the average brain weight at autopsy was reported to be 1. There was excellent correlation between body weight and height and brain weight in adults of all ages. Therefore, the overall dietary carbohydrate requirement in the presence of an energy-adequate diet would be approximately 87 (117 – 30) to 112 (142 – 30) g/d. This amount of carbohydrate is similar to that reported to be required for the prevention of ketosis (50 to 100 g) (Bell et al. The carbohydrate requirement is modestly greater than the potential glucose that can be derived from an amount of ingested protein required for nitrogen balance in people ingesting a carbohydrate-free diet (Azar and Bloom, 1963). This amount of carbohydrate will not provide sufficient fuel for those cells that are dependent on anaerobic glycolysis for their energy supply (e. That is, the cyclic interconversion of glucose with lactate or alanine occurs without a net loss of carbon. The amount of dietary protein required approaches the theoretical maximal rate of gluconeogenesis from amino acids in the liver (135 g of glucose/24 h) (Brosnan, 1999). This amount should be sufficient to fuel central nervous system cells without having to rely on a partial replacement of glucose by ketoacids. Although the latter are used by the brain in a concentration-dependent fashion (Sokoloff, 1973), their utilization only becomes quantitatively significant when the supply of glucose is considerably reduced and their circulating concentra- tion has increased several-fold over that present after an overnight fast. Never- theless, it should be recognized that the brain can still receive enough glucose from the metabolism of the glycerol component of fat and from the gluconeogenic amino acids in protein when a very low carbohydrate diet is consumed. It is well known that the overall rate of energy metabolism decreases with aging (Roberts, 2000a). In adults 70 years of age or older, the glucose oxidation rate was only about 10 percent less than in young adults between 19 and 29 years of age (Robert et al. This decrease is similar to that reported from autopsy data in Japan (mean 1,422 to 1,336 g) (Yamaura et al. Whether glucose oxidation changes out of proportion to brain mass remains a controversial issue (Gottstein and Held, 1979; Leenders et al. In any case, the decrease in brain glucose oxidation rate is not likely to be substantially less. There is no evidence to indicate that a certain amount of carbohydrate should be provided as starch or sugars. However, most individuals do not choose to eat a diet in which sugars exceed approximately 30 percent of energy (Nuttall and Gannon, 1981). This increased fuel requirement is due to the establish- ment of the placental–fetal unit and an increased energy supply for growth and development of the fetus. It is also necessary for the maternal adapta- tion to the pregnant state and for moving about the increased mass of the pregnant woman. This increased need for metabolic fuel often includes an increased maternal storage of fat early in pregnancy, as well as suffi- cient energy to sustain the growth of the fetus during the last trimester of pregnancy (Knopp et al. In spite of the recognized need for increased energy-yielding substrates imposed by pregnancy, the magnitude of need, as well as how much of the increased requirement needs to be met from exogenous sources, remains incompletely understood and is highly variable (Tables 5-23 through 5-27). There is general agreement that the additional food energy requirement is relatively small. Several doubly labeled water studies indicate a progres- sive increase in total energy expenditure over the 36 weeks of pregnancy (Forsum et al. The mean difference in energy expenditure between week 0 and 36 in the studies was approximately 460 kcal/d and is proportional to body weight. The fetus does not utilize significant amounts of free fatty acids (Rudolf and Sherwin, 1983). As part of the adaptation to pregnancy, there is a decrease in maternal blood glucose concentration, a development of insulin resistance, and a tendency to develop ketosis (Burt and Davidson, 1974; Cousins et al. A higher mean respiratory quotient for both the basal metabolic rate and total 24-hour energy expenditure has also been reported in pregnant women when compared to the postpartum period. The increased glucose utilization rate persists after fasting, indicating an increased endogenous production rate as well (Assel et al. Thus, irrespective of whether there is an increase in total energy expenditure, these data indicate an increase in glucose utilization. Earlier, it was reported that the glucose turnover in the overnight fasted state based on maternal weight gain remains unchanged from that in the nonpregnant state (Cowett et al. The fetus reportedly uses approximately 8 ml O2/kg/min or 56 kcal/ kg/d (Sparks et al. The transfer of glucose from the mother to the fetus has been estimated to be 17 to 26 g/d in late gestation (Hay, 1994). If this is the case, then glucose can only account for approximately 51 percent of the total oxidizable substrate transferred to the fetus at this stage of gestation. The mean newborn infant brain weight is reported to be approximately 380 g (Dekaban and Sadowsky, 1978).

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