By G. Curtis. Point Loma Nazarene College.

Some estimated speeds of propagation are 30–60 kilometers per year for fox rabies in Europe starting in 1939 [166] cheap zestoretic 17.5mg on-line, 18–24 miles per year for raccoon rabies in the Eastern United States start- ing in 1977 [49] discount 17.5mg zestoretic, about 140 miles per year for the plague in Europe in 1347–1350 [166], and worldwide in one year for influenza in the 20th century [176]. Epidemiology mod- els with spatial structures have been used to describe spatial heterogeneity [12, 96, 110] and the spatial spread of infectious diseases [38, 54, 59, 90, 166, 193]. Diffusion epidemiology mod- els are formulated from nonspatial models by adding diffusion terms corresponding to the random movements each day of susceptibles and infectives. Dispersal-kernel models are formulated by using integral equations with kernels describing daily con- tacts of infectives with their neighbors. For both types of spatial epidemiology models in infinite domains, one often determines the thresholds (sometimes in terms of R0) above which a traveling wave exists, finds the minimum speed of propagation and the asymptotic speed of propagation (which is usually shown to be equal to the minimum speed), and determines the stability of the traveling wave to perturbations [161, 172]. For spatial models in finite domains, stationary states and their stability have been investigated [38]. Mathematical epidemiology has now evolved into a separate area of population dynamics that is parallel to mathematical ecology. Epidemiology models are now used to combine complex data from various sources in order to study equally complex outcomes. In this paper we have focused on the role of the basic reproduction number R0, which is defined as the average number of people infected when a typical infective enters an entirely susceptible population. We have illustrated the significance of R0 by obtaining explicit expressions for R0 and proving threshold results which imply that a disease can invade a completely susceptible population if and only if R0 > 1. For the basic endemic models without age structure, the expressions for the basic reproduction number R0 are intuitively obvious as the product of the contact rate, the average infectious period, and the fraction surviving the latent period (provided there is an exposed class in the model). But for more complicated models, expressions for R0 must be derived from threshold conditions for the stability of the disease-free equilibrium or the existence of an endemic equilibrium in the feasible region. Many epidemiology models now used to study infectious diseases involve age structures, because fertilities, death rates, and contact rates all depend on the ages of the individuals. Thus the basic reproduction number R0 must be found for these epidemiologic-demographic models. These expressions for R0 are found by examining when there is a positive (endemic) equilibrium in the feasible region, and then it is verified that the disease persists if and only if R0 > 1. To illustrate the application of the theoretical formulas for R0 in models with age groups, two applications have been included in this paper. Based on demographic and epidemiologic estimates for measles in Niger, Africa, the value of the basic repro- duction number found from (6. The interesting aspect of this measles application is that R0 is found for a very rapidly growing population. In contrast, the current fertility and death data in the United States suggests that the population is approaching a stable age distribution with constant total size. Using previously developed models for pertussis (whooping cough) in which the immunity is temporary [105, 106], the basic reproduction numbers are estimated in section 8 to be R0 =5. The interesting aspect of the pertussis calculations is that new types of infectives with lower infectiv- ity occur after the invasion, because infected people who previously had pertussis have lower infectivity when reinfected. Although the contact number σ is equal to R0 when pertussis first invades the population, the new broader collection of typical infectives implies that σRafter the invasion, but for the pertussis models, R0 >σ>Rafter the invasion. Thus the pertussis models have led to an entirely new way of thinking about the differences between the contact number σ and the basic reproduction number R0. The author thanks David Greenhalgh, Hal Smith, Horst Thieme, Nick Trefethen, and Pauline van den Driessche for their helpful suggestions and comments, and thanks Brian Treadway for manuscript preparation assistance. May, The population dynamics of microparasites and their in- vertebrate hosts, Philos. Andreasen, The effect of age-dependent host mortality on the dynamics of an endemic disease, Math. Levin, The dynamics of cocirculating influenza strains conferring partial cross-immunity, J. Bartlett, Stochastic Population Models in Ecology and Epidemiology, Methuen, London, 1960. Bernoulli, Essai d’une nouvelle analyse de la mortalit´e caus´ee par la petite v´erole et des avantages de l’inoculation pour la pr´evenir,inM´emoires de Math´ematiques et de Physique, Acad´emie Royale des Sciences, Paris, 1760, pp. Cooke, Vertically Transmitted Diseases, Biomathematics 23, Springer-Verlag, Berlin, 1993. Liu, Epidemiological models with age structure, proportionate mixing, and cross-immunity, J. Milner, Existence and uniqueness of endemic states for age-structured S-I-R epidemic model, Math. Cliff, Incorporating spatial components into models of epidemic spread, in Epidemic Models: Their Structure and Relation to Data, D. Haggett, Atlas of Disease Distributions: Analytic Approaches to Epi- demiological Data, Blackwell, London, 1988. Metz, On the definition and the compu- tation of the basic reproduction ratio R0 in models for infectious diseases in heterogeneous populations, J. Heesterbeek, Mathematical Epidemiology of Infectious Diseases, Wiley, New York, 2000. Dietz, The incidence of infectious diseases under the influence of seasonal fluctuations,in Mathematical Models in Medicine, J. Dietz, The evaluation of rubella vaccination strategies, in The Mathematical Theory of the Dynamics of Populations, Vol. Schenzle, Mathematical models for infectious disease statistics, in A Cele- bration of Statistics, A.

Knowledge of When asked in an approved written the candidate will list (or select the The candidate will list (or select the immediate measures examination to list the reasons for answer that lists) the reasons for not answer that lists) the reason or to take in cases of not changing the position of a changing the position of a patient buy discount zestoretic 17.5 mg on line. Given a resuscitation mannequin generic zestoretic 17.5 mg, the candidate will demonstrate the The candidate will in 1 minute or when asked to demonstrate the opening of the airway and checking less correctly use the resuscitation opening of the airway and checking for breathing. Given a resuscitation mannequin, the candidate will demonstrate the The candidate will use the and asked to demonstrate the procedure for determining if a resuscitation mannequin to procedure for determining if a patient has a pulse. Given a resuscitation mannequin, the candidate will demonstrate The candidate will use the and asked to demonstrate proper proper hand placements for chest resuscitation mannequin to hand placements for chest compressions. When asked in an approved written the candidate will describe (or select The candidate will describe (or examination to describe the position the answer that describes) the select the answer that describes) the for a patient in shock that does not position for a patient in shock that position for a shock patient that have an injury to the spine or a does not have an injury to the spine does not have an injury to the spine lower extremity, or a lower extremity. Given a rescue mannequin or a the candidate will demonstrate the The candidate will in 10 minutes or volunteer patient, and given a immobilization of a fracture named less, correctly demonstrate the variety of splints and ties, when by the assessor using splints and ties immobilization of the simple limb asked to demonstrate the on either the rescue mannequin or fracture named by the assessor immobilization of a fracture, volunteer patient. To accomplish this, each candidate must: Complete approved education and training and meet all the competencies listed in the table; Pass a written examination for the portion of the competencies on knowledge and understanding; and Successfully accomplish a practical demonstration of skill for selected competencies. The United States Coast Guard requires each mariner seeking proficiency as a seafarer designated to provide medical first aid on board ship to attend a course approved by the National Maritime Center. Written Assessments The knowledge-based or understanding-based portion of the following competencies may be assessed through a written multiple-choice examination. The candidate must achieve a minimum passing grade of 70% in each kind of knowledge or understanding within the competency: the contents of a standard first-aid kit; the anatomy of the body and function of each body system sufficient to understand and apply the required knowledge and understanding; toxicological ship-board hazards; identification of the hazardous substance and the hazards of exposure; assessment of patients; standard isolation techniques; the treatment of burns and scalds, including the description of burns and the rule of nines; heat and cold emergencies; treatment of electrical and chemical burns, including safety of the scene and removal of electrical power; signs, symptoms and treatment of hyperthermia, hypothermia, and dehydration; information on patients to be communicated to radio medical services; medications; and sterilization and sterile techniques. C-3 Demonstrations of Skill In addition to passing a written examination, the competency entitled “Apply immediate first aid in the event of accident or illness on board” requires a practical demonstration of skill to assess proficiency. These assessment guidelines establish the conditions under which the assessment will occur, the performance or behavior the candidate is to accomplish, and the standards against which to measure the performance. The examiner should use a checklist in conducting assessments of practical demonstrations of skill. Checklists allow a training institution or designated examiner to avoid overlooking critical tasks when evaluating a candidate’s practical demonstration. Training institutions and designated examiners should develop their own checklists for use in conducting the assessments in a complete and structured manner. Fractures, Inagradedpractical thecandidatewill Thecandidateproperlyapplies,within dislocations,and exercise,givena properlyim m obilize 10m inutes,anappropriatefem oral m uscularinjuries* sim ulatednon-critical andapplytractiontoa tractiondevice(Haretraction,Thom as patientandassistance sim ulatedfem oral D ring,orSagersplint),perform ing from asecondrescuer, fracture. Inagradedpractical thecandidatewilluse F oreachfracture,thecandidate exercise,givena rigidsplintsto properlyappliesrigidsplints,within5 sim ulatednon-critical im m obilizealong-bone m inutes,andperform sthefollowing patientandassistance fractureof theforearm criticalelem ents: from asecondrescuer andabentknee a. Note:Bent-kneefracture— padded boardsplintsshouldbesecured transverselytothem edialandlateral aspectsof thelegbothaboveand below (distalto)theknee. Cardiacarrest, Inagradedpractical thecandidatewill Thecandidatecorrectlydem onstrates, drowning,asphyxia, exercise,givenanadult dem onstrateairway- accordingtostandardsof the andobstructionof m anikindesignedfor m anagem ent Am ericanHeartAssociation,the airwaybyaforeign cardio-pulm onary techniquesand following: body resuscitation, m anagem entof a a. Inagradedpractical thecandidatewill Thecandidatecorrectlydem onstrates, exercise,givenanadult dem onstrateairway- accordingtostandardsof the m anikindesignedfor m anagem ent Am ericanHeartAssociation: cardio-pulm onary) techniquesand a. Inagradedpractical thecandidatewill Thecandidatecorrectlydem onstrates, exercise,givenanadult dem onstrateairway- accordingtostandardsof the m anikindesignedfor m anagem ent Am ericanHeartAssociation: cardio-pulm onary techniquesand a. To accomplish this, he or she must: Complete approved education and training and meet all the competencies listed in the table; Pass a written examination for the portion of the competencies on knowledge and understanding; and Successfully accomplish a practical demonstration of skill for selected competencies. The United States Coast Guard requires each mariner seeking proficiency as Person in Charge of Medical Care aboard ship to attend a course approved by the National Maritime Center. Written Assessments The knowledge-based or understanding-based portion of the following competencies may be assessed through a written multiple-choice examination. D-4 hyperglycemia, anaphylaxis, dehydration, gonorrhea, syphilis, genital herpes, systemic infections, malaria, and hepatitis A and B; signs of alcoholism and drug abuse; signs of and treatment for toothache and other dental problems; signs, symptoms, and treatments for gynecological conditions, pregnancy and childbirth; methods to determine cause of death and how to prepare a body for storage at sea; personal hygiene; preventing disease aboard ship; preventing disease through vaccination; preparing a patient for evacuation; and methods of cooperation with health authorities in port. Demonstrations Of Skill In addition to passing a written examination, the competency entitled “Provide medical care to the sick and injured while they remain on board” requires a practical demonstration of skill to assess proficiency. These assessment guidelines establish the conditions under which the assessment will occur, the performance or behavior the candidate is to accomplish, and the standards against which to measure the performance. The examiner can use a checklist in conducting assessments of practical demonstrations of skill. Checklists allow a training institution or designated examiner to avoid overlooking critical tasks when evaluating a candidate’s practical demonstration. Training institutions and designated examiners can develop their own checklists for use in conducting the assessments in a complete and structured manner. Careof thecasualty Inagradedpractical thecandidatewilluse Thecandidatecorrectly: involvinginjuriesto exercise,givena externalbandagesto 1. Inagradedpractical thecandidatewill Thecandidate: exercise,givena dem onstratetheproper 1. Inagradedpractical thecandidatewill Thecandidate: exercise,givena dem onstratetheproper 1. Inagradedpractical thecandidatewill Thecandidateflushestheaffected exercise,givena dem onstratetheproper eyewithcopiousam ountof water patientsim ulatinga m ethodof treatinga (saline,if im m ediatelyavailable)to foreignliquidor foreignliquidorsolid washawaychem icalsorsolid solidsubstancein substanceintheeye. Inagradedpractical thecandidatewillstate Thecandidatecorrectlystatesthata exercise,givena whentousea tourniquetwillonlybeapplied patientsim ulatingan tourniquet. Inagradedpractical thecandidatewill Thecandidatecorrectly evaluation,givena bandageasuckingchest dem onstratesthefollowing: sim ulatedchest wound. Knowledge of When asked to state the location of the candidate will state in writing The candidate will state the location emergency signals station bills and forecastle card, and the location of station bills and of station bills and forecastle card, and specific duties describe the information they forecastle card, and describe the and describe all of the following allocated to crew contain, information they contain. When asked to state the purpose, the candidate will state in writing The candidate will correctly state location, and circumstances the purpose, location, and the purpose, location, and requiring lifejackets, exposure suits, circumstances requiring lifejackets, circumstances requiring lifejackets, hardhats, goggles, respirators, exposure suits, hardhats, goggles, exposure suits, hardhats, goggles, emergency escape breathing device, respirators, emergency escape respirators, emergency escape hearing protection, safety shoes and breathing device, hearing breathing device, hearing lumbar support belt, protection, safety shoes and lumbar protection, safety shoes and lumbar support belt. When asked to list the steps to take the candidate will list in writing the The candidate will list all of the upon seeing or hearing a person fall steps to take upon seeing or hearing following actions to take upon overboard, a person fall overboard. Know actions to When given a particular situation, and the candidate will identify in writing the The candidate will correctly identify the take on discovering asked to identify the proper person to proper person to alert for the situation proper person to alert for all of the alert, given. Know value of When asked to list the reasons for the candidate will list in writing the The candidate will list at least 1 of training and drills. When a shipboard alarm system in the candidate will describe in The candidate will, for each system, named and then, asked to describe writing the locations, purpose and correctly describe the locations, its location, purpose and actions to actions to be taken for each of the purpose and actions to be taken be taken for its alarm, shipboard alarm systems named. Take Know the effects of When asked to describe the short the candidate will in writing the candidate wil correctly describe precautions to operational or and long term effects of pollution describe the short and long-term in writing the short and long-term prevent accidental pollution on water, the shoreline and marine effects of pollution on water, the effects of pollution on each of the pollution of of the marine life, shoreline and marine life. When asked to describe common the candidate will describe in The candidate will correctly safety practices for shipboard writing common safety practices describe all 3 common safety work, for shipboard work. Know precautions to When asked to define an “enclosed the candidate will define in writing The candidate will correctly define be taken prior to space” and describe the dangers an “enclosed space” and describe an “enclosed space” and describe at entering enclosed associated with enclosed spaces, the dangers associated with least 2 of the following dangers spaces.

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Active immunization of all people greater than 9 months of age necessarily exposed to infection because of residence purchase 17.5mg zestoretic fast delivery, occupation or travel zestoretic 17.5mg lowest price. Sylvatic /Jungle yellow fever- immunization to all people in rural communities whose occupation brings them into forests in yellow fever areas and for people who visit those areas. Plague Definition A highly infectious bacterial disease which can kill many people within a short time. Epidemiology Occurrence- Endemic in wild rodents living in forests in the highlands. Reservoir- Wild rodents (especially ground squirrels) are the natural vertebrate reservoir of plague. Period of communicability- Fleas may remain infective for months under suitable conditions of temperature and humidity. Bubonic plague is not usually transmitted directly from person to person unless there is contact with pus from suppurating buboes. Pneumonic plague may be highly communicable under appropriate climatic conditions. Immunity after recovery is relative; it may not protect against a large inoculums. Other symptoms are: Sudden high fever Shock Prostration Coma Death within 3-5 days Pneumonic plague Acute onset Severe prostration Watery sputum quickly followed by blood-stained sputum. Early treatment with antibiotics like streptomycin or tetracycline or sulfa groups. Infectious agent Rickettsia typhi (Rickettsia mooseri) Epidemiology Occurrence- Worldwide, found in areas where people and rats occupy the same buildings and where large numbers of mice live. Infection is maintained in nature by a rat-flea-rat cycle where rats are reservoirs (Commonly rattus and rattus novergicus). Incubation period- from 1 to 2 weeks; commonly 12 days Period of communicability- Not directly transmitted from person to person. Clinical Manifestation Prodromal symptoms of headache, myalgia, arthralgia, nausea, and malaise developing 1 to 3 days before the abrupt onset of chills and fever. Diagnosis Epidemiological ground Weilfelix agglutination test (Serology) 110 Communicable Disease Control Treatment 1. Infectious agent Rickettsia Prowazeki Epidemiology Occurrence- In colder areas where people may live under unhygienic conditions and are louse-infected. Occurs sporadically or in major epidemics, for example during wars or famine, when personal hygiene deteriorates and body lice flourish. Mode of transmission- The body louse and head louse are infected by feeding on the blood of a patient with acute typhus fever. Infected lice excrete rickettsiae in their feces and usually defecate at the time of feeding. People are infected by rubbing feces or crushed lice into the bite or into superficial abrasions (scratch inoculation). Incubation period- From 1 to 2 weeks, commonly 12 days Period of communicability- Patients are infective for lice during febrile illness and possibly for 2-3 days after the temperature returns to normal. Infected lice pass rickettsiae in their feces within 2-6 days after the blood meal; it is infective earlier if crushed. Clinical Manifestation Early symptoms of fever, headache, mayalgia, macular eruption appear on the body. Diagnosis Based on clinical and epidemiologic grounds Serologic test (weil-felix agglutination test) Treatment 1. It occurs in epidemic form when it is spread by lice and in endemic form when spread by ticks. Reservoir- Humans for Borrelia recurrentis; , wild rodents and soft ticks through transovarian transmission. Acquired by crushing an infected louse so that it contaminates the bite wound or an abrasion of the skin. Period of communicability- Louse becomes infective 4-5 days after ingestion of blood from an infected person and remains so for life (20-40 days) 114 Communicable Disease Control Susceptibility and resistance- Susceptibility is general. Duration and degree of immunity after clinical attack are unknown; repeated infection may occur. Clinical Manifestation Sudden onset of illness with chills, fever and prostration, headache, mayalgia and arthralgia There may be nausea and vomiting, jaundice and liver swelling. After 4-5 days the temperature comes down, the patient stays free for 8-12 days and then a relapse follows with the same signs but less intense. Diagnosis Clinical and epidemiological grounds Giemsa or Wright stain (blood film) Dark field microscopy of fresh blood. The disease occurs worldwide and 2 million people are expected to be infected; however, most infected individuals show few or no signs and symptoms, and only a small minority develop significant disease. Other animals, like dog, cat, pig, cattle, water buffalo, horse and wild rodents, are hosts for S. Mode of transmission-Infection is acquired from water containing free-swimming larval forms (cercariae) that have developed in snails. Incubation period-Acute systemic manifestations (katayama fever) may occur in primary infections 2-6 weeks after exposure, immediately before and during initial egg deposition. Invasion stage Cercariae penetrate skin Cercarial dermatitis with itching papules and local edema Cercariae remain in skin for 5 days before they enter the lymphatic system and reach the liver. Established infection This is a stage of egg production and eggs reach to the lumen of bladder and bowel. Late stage This is the stage of fibrosis, which occurs where there are eggs in the tissues. Around the bladder this may result in: - Stricture of urethra leading to urine retention or fistula. Diagnosis Demonstration of ova in urine or feces, Biopsy of urine and feces are repeatedly negative (rectal snip, liver biopsy, bladder biopsy). Treatment 121 Communicable Disease Control Praziquantel and oxamniquine are the drugs of choice but in Africa praziquantel is best because of resistance strain of oxamniquine. Clearing of vegetation in water bodies to deprive snails of food and resting place 5.

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Whilst the subject of circadian rhythms will be dealt with in more detail in the next section discount zestoretic 17.5 mg line, it is nonetheless appropriate to consider circadian phase in the context of sleep buy cheap zestoretic 17.5 mg line. Human beings are physiologically programmed to experience two periods of maximal sleepiness in a normal 24 hour cycle. The period from 0300-0500 is a circadian low point for temperature, performance and alertness and during this time the brain triggers sleep and sleepiness. The other period of increased sleepiness is between 1500 and 1700, and most individuals will have experienced an afternoon wave of sleepiness. These windows can be usefully employed to schedule sleep periods or naps when the brain provides a period of maximum sleepiness and an increased opportunity for sleep. Unless information related to time is received from the environment, the clock tends to run slow with the biological day set at longer than 24 hours. One of the most important environmental time cues which synchronises our internal clock to a 24 hour day is bright light. However, it is likely that other aspects of the social environment also provide time cues although these have yet to be identified clearly and the specific mechanisms by which they affect the internal clock remain unknown. The circadian clock cannot adapt immediately to a new environmental time and, as a result, crossing time zones will result in it being out of phase with the new time at the destination. In addition, circadian rhythms for different functions adjust more or less quickly, depending on their own innate rhythm and their interactions with other physiological functions. Thus, after a trans meridian flight, not only is the circadian clock out of step with the external environmental cues, but different internal physiological functions are out of step one with another. In addition, different people adapt at different rates with, in general, the ability to adapt decreasing with age. Finally, individuals who fall into the category of ‘evening types’ (those who are most alert in the later portion of the day) appear to adapt faster than ‘morning types’ (those who are most alert in the early portion of the day) and also show lower levels of daytime sleepiness following eastward flights. The first is as a result of duty periods occurring at unusual or changing times in the day/night sleep cycle and the second when there is a requirement for time zone crossings. This leads to: (i) conflict between the environmental time (in the case of unusual or changing work schedules) or local time (in the case of changing time zones) and body times, and (ii) circadian disruption when the body is required to adjust continuously between day and night schedules. In addition, a further factor that can create sleep loss is a prolonged period of continuous wakefulness. It is clear that a protracted duty period can create fatigue by extending wakefulness and decreasing sleep and may also involve circadian disruption. However, in continuous operations, boredom may also be a factor and when an individual is acting as a passive monitor, particularly of relatively rare events in highly automated aircraft, there is the possibility that these elements will increase the likelihood for physiological sleepiness to emerge. In many flight operations, the time available for sleep is constrained by a number of factors and, if an individual’s physiological timing for sleep does not coincide with the scheduled sleep opportunity, then a cumulative sleep debt can result. It is clearly important for this to be considered when an individual is planning their sleep and rest schedule before, during and after a trip to ensure that there is adequate opportunity for sleep in order to avoid the inevitable effects of both sleepiness and impaired performance. It is estimated that sleep-related vehicle accidents account for up to 20% of all road traffic accidents and drowsy driving is as important a factor in accidents as drunk driving. If the crew member commutes by car they should be reminded that they may be driving after lengthy periods of time on duty. In addition, they may have crossed several time zones or their circadian rhythm for alertness may be at a low point. Good practice dictates that where possible an individual should sleep when tired and crew may wish to make use of quiet areas in their crew report buildings to nap before embarking on the drive home. In general, there is some evidence that taking a caffeine containing beverage followed by a 20 minute nap will improve alertness for 1-2 hours. However, these are only recommendations and should be tailored to the individual crew member’s needs and activities bearing in mind that the best effects are likely to come from combining strategies rather than relying on any one alone. They focus on the underlying physiology and are aimed at reducing the adverse effects of fatigue, sleep loss and circadian disruption resulting from flight operations. Sleep Scheduling Crew members who are sleep deprived before the start of a duty period will experience more difficulties than those who are well rested. Indeed, if they commence a tour of duty with an existing sleep debt, then generally this will only worsen during the trip schedule. Therefore, in addition to getting the best sleep possible before starting a trip, crew members should obtain at least as much sleep during each 24 hour period away as they would during a normal 24 hour period at home. Understanding the circadian and other factors will help them to maximise the sleep opportunities. If they are struggling to stay awake, then sleepiness should be taken as a clear sign to get some sleep. Conversely, if they wake spontaneously and are unable to return to sleep within 15-30 minutes, then they should get out of bed. In other words, if the brain is giving clear signals that the individual is sleepy, then sleep. However, if the individual wakes up and is alert and unable to sleep, they should get up. Key Points _____________________________________________________________________ At Home Get the best possible sleep before starting a trip On a Trip Try to get as much sleep in every 24 hours away as in a normal 24 period at home Trust your own Physiology If the crew member feels sleepy and circumstances permit, then they should sleep If the crew member wakes spontaneously and cannot get back to sleep in 15-30 minutes, they should get up _______________________________________________________________________________ Napping Napping has been shown scientifically to improve subsequent alertness and performance. However, it is important when taking a nap just before a duty period to minimise the chances of going into the deeper phases of sleep. This will help to avoid the condition known as sleep inertia which produces a disorientated sensation which can persist for 10-15 minutes after waking from deep sleep. Limiting the duration of a nap to 45 minutes or less will minimise the chances of having significant amounts of deep sleep but will nonetheless help to decrease the period of continuous wakefulness. If the crew member is able to nap at times other than immediately before a duty period, then the nap can be longer. In these circumstances, a nap of 2 hours or more will enable them to have at least one full cycle of deep and dreaming sleep. At other times, naps can be longer Remember, some sleep is better than none _______________________________________________________________________________ Good Sleep Habits The following recommendations are important and applicable to everyone. It can be useful to establish a pre-sleep routine to help teach the mind and body that it is time to relax and fall asleep. As part of this, a set of cues can then be developed which will assist the individual to relax in preparation for sleep anywhere and anytime. Paying attention to the sleep environment and trying to ensure that the room is dark (by the use of eye shades if necessary) and quiet (by turning off the telephone and using ear plugs) is also important. The bed should, of course, also be comfortable, although in a hotel this is outside the individual’s control and what is comfortable for one person, may not be ideal for another.

However buy 17.5mg zestoretic fast delivery, we also found that these fears often don’t cause significant distress or inter- ference in people’s lives for the first few years purchase 17.5mg zestoretic mastercard. In our study, these fears did not reach phobic proportions until an average age of 14. Generally, other research confirms that these fears tend to begin in childhood or adolescence, on average (Himle et al. Of course, there are some people who have had their fear for as long as they can recall, and others who develop their fear later in life. For example, we once treated a physician who was terrified of getting an injection himself, though he was comfortable seeing blood, taking blood from his patients, and giving injections to others. We have also seen individuals who are comfortable about blood, injection, and medical phobias 19 seeing their own blood (during menstruation or from a nosebleed), but faint at the sight of anyone else’s blood. Some people are afraid of only certain types of needle uses (for example, a blood test but not an injection). Fearsofblood,needles,surgery,andinjury-relatedsitua- tions often go together (Öst 1992), and it is not unusual to fear a wide range of objects and situations having to do with blood, needles, and medical procedures. For exam- ple, one study found that 53 percent of people with den- tal phobias also had a fear of needles, and about 10 percent also had a fear of blood (Poulton et al. For many people, a fear of blood, needles, or medi- cal procedures causes only mild impairment. For example, the fear may mean having to look away during certain scenes in a movie or avoiding getting an annual flu shot. However, for others the fear can have serious implica- tions for their health, work, and even relationships. Imag- ine not being able to visit a spouse or child who is confined to a hospital bed because of a fear of doctors! Even if your fear doesn’t cause you serious problems now, phobias of medical procedures sometimes catch up with us. A person with a fear of needles who develops diabetes may risk not performing regular blood tests or not com- plying with an insulin regimen. Sooner or later, a fear of going to the dentist can lead to serious dental problems because of the lack of regular visits. Or, avoiding all blood work may lead you to miss early signs of an illness, allowing it to become more serious. As we get older, we are confronted with medical situations more and more 20 overcoming medical phobias often. Phobias tend to persist unless a person seeks treat- ment or life circumstances force the person to confront the feared situations. For example, some women with needle phobias naturally overcome their fears during pregnancy because of all the blood work they require. However, for most people, the fear continues until the person makes a conscious decision to overcome it. In the case of blood, needle, and medical phobias, there are no studies supporting the use of medications as a strategy for overcoming fear over the long term. However, evidence from at least one study indicates that taking an antianxiety medication (for example, lorazepam or diazepam) thirty minutes before dental treat- ment may help reduce anxiety during the dental proce- dure (Thom, Sartory, and Jöhren 2000). For people who have a history of fainting, we rec- ommend against the use of antianxiety medications because they are unlikely to help with the fainting response. In fact, they may actually increase the likeli- hood of fainting by reducing your heart rate or blood pressure even more than is typically the case during vasovagal syncope. Because of the overall lack of about blood, injection, and medical phobias 21 evidence supporting medications for blood, needle, medi- cal, and dental phobias, this book will focus more on psy- chological approaches. People use many different approaches to deal with psychological and emotional challenges. Examples include seeking support from friends, dietary changes, prayer, “talk therapy,” hypnosis, and biofeedback. How- ever, this book will focus only on strategies that have been researched extensively for dealing with phobias. Specifically, we’ll focus on techniques that together are often referred to as cognitive and behavioral strategies (the word “cognitive” simply refers to the process of thinking). These include strategies involving changing anxious behaviors, strategies for managing physical symp- toms (such as heightened arousal or faintness), and strat- egies for changing anxious thinking. In fact, it is widely believed that most people don’t overcome their phobias without some sort of exposure to the situations they fear. Essentially, expo- sure involves gradually confronting the feared objects or situations until you are no longer afraid. Numerous stud- ies have confirmed that exposure is effective for over- coming phobias of blood, needles, dentists, and related situations (Antony and Barlow 2002). Exposure is the keystrategyusedinthisbook,andwe’lldiscussitat length in chapter 5. Specifically, techniques involving imagery, muscle relax- ation, or learning to slow down your breathing may help to reduce your anxiety at the doctor’s or dentist’s office (Jerremalm, Jansson, and Öst 1986; Öst, Sterner, and Fellenius 1989). If you’re interested in learning more about relaxation-based techniques, check out the latest edition of The Relaxation and Stress Reduction Workbook (Davis, Eshelman, and McKay 2000). If your anxiety is associated with fainting, this is probably the strategy that you’ll want to focus on most. The exposure exercises will help reduce your fear and the tension exercises will help prevent fainting along the way (Hellström, Fellenius, and Öst 1996; Öst, Fellenius, and Sterner 1991). In con- trast, studies on the treatment of dental phobias have included a wider range of strategies, including techniques for challenging anxious thinking and replacing negative thoughts with more realistic interpretations and predic- tions. Treatments that include both behavioral and cog- nitive elements appear to be useful, particularly for dental phobias (de Jongh et al. These fears tend to begin in childhood or adolescence, and they occur frequently in both males and females. Though the problem is often associated with typical fear symptoms such as a racing heart and breathlessness, it is unique in that fainting is also a common occurrence, par- ticularly among those with blood and needle phobias. In addition to the experience of fear, the emotion of disgust is also a common feature of these phobias. Negative pre- dictions are thought to contribute to the experience of fear and disgust, and behaviors such as avoidance help to maintain the phobia over time. The most important component of any effective treatment for these phobias is exposure to the feared objects or situations. Learning to tense all the muscles of the body in order to temporarily raise blood pressure and prevent fainting is very useful in cases where the phobia is associated with fainting.

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Benefits of Bhastrika Yoga Pranayama (Bellows Breath): Primary: Boosts your metabolic rate so your body burns fat faster promoting natural weight loss cheap zestoretic 17.5 mg without a prescription. Cautions for Practicing Bhastrika Yoga Pranayama (Bellows Breath): If you feel dizzy or nauseous you should slow down the pace of bhastrika pranayama or stop entirely and return to normal breathing buy generic zestoretic 17.5mg on line. If you suffer from vertigo, you should use caution in practicing this breathing exercise. Also, if you have acid or heat related gastric issues such as ulcers you should use caution. Guided Beginner’s Breath of Bhastrika Yoga Pranayama (Bellows Breath): To practice this breathing exercise sit up in a comfortable position. All the breaths should be deep and powerful and you should try to establish a steady rhythm. The pace should be about 1 second for inhalation and about the same for exhalation. Guided Intermediate Bhastrika Yoga Pranayama (Bellows Breath): Once you feel comfortable with the Beginner’s version of Bellows Breath perform the breathing exercise at a faster pace now, about 1 breath per second. Guided Advanced Bhastrika Yoga Pranayama (Bellows Breath): Build up the pace and power with which you do this breathing exercise to almost 2 breaths per second. Secret of Bhastrika Yoga Pranayama (Bellows Breath): The final goal of Yoga is to awaken Kundalini Shakti (latent human potential energy) and Bhastrika Pranayama is one of the most effective breathing exercises for stimulating and raising this energy in you. Think of Kundalini as smoldering embers deep within you and think of Bhastrika as waves of prana stoking and igniting these embers. Prevention includes the avoidance of triggers such as allergens and medications to reduce the inflammatory response (Rattray, 2000). Also be aware of client’s who are on medications that would need modifications for massage Effectiveness: May be soothing for client who may have high anxiety when it comes to taking a deep breathe and can also make big changes in easing their breathing 61 Alternative Treatments: Acupuncture Insertion of thin needles into skin in specific points on body to try to relieve asthma is suggested in some studies *See experienced licensed acupuncturist or medical doctor if trying this treatment Breathing Exercises Techniques such as Buteyko breathing or yoga breathing are used to reduce hyperventilation and regulate breathing, some studies show these techniques may help reduce symptoms Herbal Remedies Usually involves blends of herbs, taking herbs in combinations might be more effective that only one. Some Concerns: Quality of Dose- some are not standardized and may vary in quality Side Effects- range from mild to severe dependant on dosage and herb taken. Herbs may contain ephedra or similar substances which may increase blood pressure Drug Interactions- certain herbs may interact with other medications negatively Talk to your doctor before trying any of these alternative treatments to see what the best approach is for you. They tighten up and constrict, which can worsen wheezing, coughing, and chest tightness in people with asthma. Led by researchers from the University of Wisconsin, a group of scientists found that certain areas of the brain cause worsening asthma symptoms when a person is under stress. Researchers exposed a group of people with mild asthma to triggers that caused both inflammation and muscle constriction. When symptoms flared, the participants were asked to read words that were either emotionally charged, such as "lonesome"; neutral, such as "curtains"; or asthma-related, such as "wheezing. The results, published in the Proceedings of the National Academy of Science, show a possible link between emotions and asthma. Until researchers find a clear link between anxiety and asthma, keep symptoms in check by managing stress and treating asthma with appropriate medication. Persistent asthma means you have symptoms more than once a week, but not constantly. Treating persistent asthma requires long-term maintenance therapy, such as an inhaled corticosteroid, plus rescue therapy when something triggers symptoms. And when your symptoms are out of control, an anti-inflammatory, such as the oral steroid prednisone, might be necessary. The problem is that prednisone can cause mood swings as a side effect, adding fuel to the anxiety fire. Then, a vicious circle can begin, where anxiety worsens asthma, and asthma worsens anxiety, says Kelkar. The solution is to talk to a health-care provider about your symptoms, triggers, and 63 stress. Also discuss other treatment options that can help get your asthma under control again. Managing Asthma and Anxiety "There are numerous stress-reduction techniques, ranging from meditation, yoga, and Pilates to jogging, listening to music, and hobbies," says Rosch. They can help you make anxiety one less asthma trigger for you to worry about: Keep your mind free of stressful thoughts. Use the power of positive thinking to keep your mind going in the right direction. Let your allergist know that stress is a trigger, so she or he can keep your anxiety in mind when treating your symptoms. If you know you need to get everything done before a deadline, delegate so you can take some time for yourself. Practicing relaxation exercises can help lessen the negative effects of stress and asthma. Try deep breathing, progressive muscle relaxation, and clearing negative thoughts. Also, eat right and avoid junk food, coffee, and soda -- which can make you feel drained after the sugar-high and caffeine effects wear off. This can help your overall health, give you more energy to combat stress, and put you in a better position to manage asthma. Sleep helps you recharge your batteries -- physically, emotionally, and even cognitively -- according to the National Sleep Foundation. Douglas Kinghornb, , Abstract Current research in drug discovery from medicinal plants involves a multifaceted approach combining botanical, phytochemical, biological, and molecular techniques. Several natural product drugs of plant origin have either recently been introduced to the United States market, including arteether, galantamine, nitisinone, and tiotropium, or are currently involved in late-phase clinical trials. Our group has also isolated several compounds, mainly from edible plant species or plants used as dietary supplements, that may act as chemopreventive agents. Although drug discovery from medicinal plants continues to provide an important source of new drug leads, numerous challenges are encountered including the procurement of plant materials, the selection and implementation of appropriate high-throughput screening bioassays, and the scale-up of active compounds. Over 20 new drugs launched on the market between 2000 and 2005, originating from terrestrial plants, terrestrial microorganisms, marine organisms, and terrestrial vertebrates and invertebrates, are described. These approved substances, representative of very wide chemical diversity, together with several other natural products or their analogs undergoing clinical trials, continue to demonstrate the importance of compounds from natural sources in modern drug discovery efforts. The selection of studies, data extraction and validation were performed independently by at least two reviewers.

Strains may produce one or more of the In this chapter the term ‘food poisoning’ is restricted to the toxins simultaneously discount zestoretic 17.5 mg on-line. Enterotoxin A is by far the most common in diseases caused by toxins elaborated by contaminating bacte- food-associated disease cheap zestoretic 17.5 mg overnight delivery. Intensive supportive antigenically distinct polypeptides treatment is urgently required and complete recovery may types: A take many months. Improvements in supportive care have B human disease reduced the mortality from around 70% to approximately E 10%, but the disease, although rare, remains life-threatening. Culture of feces or identified, but of these only three are associated with human wound exudate for Cl. They Polyvalent antitoxin is recommended as an are antigenic and can be inactivated and used to produce antitoxin adjunct to intensive supportive therapy for in animals. It is not practicable to prevent food becoming contaminated with botulinum spores so prevention of disease depends upon preventing the ger- mination of spores in food by: • Maintaining food at an acid pH. Helicobacter pylori and Gastric Ulcer Disease Helicobacter pylori is associated with most duodenal and gastric ulcers It is now well established that the Gram-negative spiral bac- terium H. Diagnosis is usually made on the basis of histologic examination of biopsy specimens, although non-invasive tests such as the urea breath test (H. The action of the toxin is to block neuro- pylori produces large amounts of urease) are being increas- transmission (see Chapter 12). Infant botulism is the most common form of The mechanism of pathogenicity has still to be identi- botulism fied, but cytotoxin production has been described. The There are three forms of botulism: large amounts of urease produced by the organism may • Foodborne botulism. The most botulism, the organisms are respectively ingested or promising regimens to date employ the combination of a implanted in a wound, and multiply and elaborate toxin in proton pump inhibitor and two antibiotics (e. Infant botulism has been associated with feeding zole with amoxicillin and metronidazole or clarithromycin babies honey contaminated with Cl. The most Ascaris lumbricoides important parasite species are highlighted in Ancylostoma duodenale bold type. These will form the focus of indeed, in many parts of the world, intestinal parasitism is this section. Transmission of intestinal parasites is Protozoan infections maintained by the release of life cycle stages Three species are of particular importance: in feces • Entamoeba histolytica. In most cases new infections depend either directly or indi- • Cryptosporidium parvum. These parasites are therefore usu- Entamoeba histolytica ally acquired by swallowing infective stages in Entamoeba histolytica infection is fecally-contaminated food or water. Worm parasites, with particularly common in subtropical and two major exceptions (pinworms and tapeworms), produce tropical countries eggs or larvae that require a period of development outside Infections with Entamoeba histolytica occur worldwide, but the host before they become infective. Transmission routes are most often found in subtropical and tropical countries are more complex here: where the prevalence may exceed 50%. The trophozoite • Some species are acquired through food or water contam- stages of the amebae live in the large intestine on the mucosal inated with infective eggs or larvae, or are picked up direct- surface, frequently as harmless commensals feeding on bac- ly via contaminated fingers. Reproduction of these stages is by simple binary fission, • Some have larvae that can actively penetrate through the and there is periodic formation of resistant encysted forms, skin, migrating eventually to the intestine. These cysts can survive in the • Others are acquired by eating animals or animal products external environment and act as the infective stages; asymp- containing infective stages. Infection occurs when food or drink is contaminated The clinical manifestations of E. The cysts pass intact through the stomach Infections with commensal forms of the ameba are asymp- when swallowed and excyst in the small intestine, each giving tomatic. Under certain conditions, still unde- superficial ulcers or involve the entire colonic mucosa with the fined, but including variables of both host and parasite origin, formation of deep confluent ulcers (Fig. The former Entamoeba can become pathogenic, the amebae invading the causes a mild diarrhea, whereas more severe invasion leads to mucosa and feeding on host materials including red blood ‘amebic dysentery’, which is characterized by mucus, pus and cells, giving rise to amebic colitis. Dysenteries of amebic and bacillary origin can be distinguished by a number of features (Fig. Complications include perforation of the intestine, leading to peritonitis, and extraintestinal invasion. Trophozoites can spread via the blood to the liver, with the formation of an a b abscess, and may secondarily extend to the lung and other organs. Trophozoite found in the acute stage of the Charcot–Leydon disease, which often contains ingested red blood cells. The broad chromatid bar is a blood and mucus yes yes semicrystalline aggregation of ribosomes. The genus Giardia be found in cases of dysentery (when the stools are loose and is widely distributed in mammals and there is suggestive evi- wet), but they are fragile and deteriorate rapidly; specimens dence for cross-infection between certain animal hosts (e. Much of this is circumstantial, but case immunologic tests are available, but only indicate whether reports provide more direct evidence. Recent data suggest patients have been exposed to infection at some time in their that Giardia may also be transmitted sexually. Mild Giardia infections are asymptomatic, more severe infections cause diarrhea Acute E. Recovery from infection is usual and there is some immunity • Chronic, and develop into a serious condition, particularly to reinfection. Treatment may fail to clear the infection com- in patients with deficient or compromised immunologic pletely and the passage of infective cysts can continue. Metronidazole is useful against the extraintestinal sites of It is thought to arise from inflammatory responses trig- infection, but if these become secondarily infected with bac- gered by the damaged epithelial cells and from interference teria, additional antibiotics and drainage are necessary. Characteristically the stools Prevention of amebiasis in the community requires the same are loose, foul-smelling and often fatty. Diagnosis of Giardia infection is based on identifying cysts or trophozoites in the stool Giardia lamblia Repeated examination is necessary in light infections when Giardia was the first intestinal microorganism to be observed concentration techniques improve the chances of finding under a microscope. Duodenal intubation or the use of recoverable swal- Leeuwenhoek in 1681, using the microscope he had lowed capsules and threads may aid in obtaining trophozoites invented to examine specimens of his own stool. Like Entamoeba, Giardia has only two life cycle stages The two life cycle stages are the flagellate (four pairs of flag- ella) binucleate trophozoite and the resistant four-nucleate cyst.