By J. Keldron. Mount Senario College.

The lower the baseline level of a substance order sildigra 50mg mastercard, the lower is the amount required to exert a therapeutic effect order sildigra 50 mg otc. A person who is poorly nourished generally requires a lower dosage before an effect is achieved cheap sildigra 50 mg overnight delivery. A primary caregiver with more clinical experience will often be able to correctly judge dosage requirements using volunteered and observed symptoms. Other aspects of the diet can also affect the pharmacodynamics of nutri- tional supplements, just as the proportion of carbohydrates to protein in the diet can change the rate of urinary clearance of drugs. Herb-Drug Interactions Currently, there is much debate about the effects of herbs and nutrients taken with prescribed medications. Some common forms of interaction between drugs and herbs and nutrients are physical interaction, cumulative function, and induction of liver enzymes by herbs. Cumulative function involves an herb or nutrient and a drug having a similar physiologic function. This can mean that the effect of both taken together can greatly increase the intended effect, thereby causing adverse effects. An example of this is serotonin syndrome, which has been reported in patients taking selective serotonin reuptake inhibitors with the antidepressant herb Hypericum perforatum. Hypericum perforatum is believed to act by increasing brain serotonin levels, as do selective serotonin reuptake inhibitors. Serotonin syndrome involves tremors, restlessness, twitching, nausea, and flushing caused by excessive serotonin levels. The difficulty for the primary caregiver is that these side effects are not uncommon when the drug is used in isolation. Thirteen percent of patients in worldwide clinical trials of paroxetine withdrew because of adverse reac- tions. Much of the popular literature on herb-drug interactions focuses on the role of herbs as potent inducers of liver 114 Part One / Principles of Nutritional Medicine enzymes. Although some reports discuss drugs such as those necessary to control transplant rejection, a great many reports involve warfarin. The herbs and nutrients that are theoretically able to interfere with the action of warfarin because of a variety of mechanisms include angelica root, arnica flower, anise, asafetida, bogbean, borage seed oil, bromelain, capsicum, cel- ery, chamomile, clove, fenugreek, feverfew, garlic, ginger, ginkgo, horse chestnut, licorice root, lovage root, meadowsweet, onion, parsley, passion- flower herb, poplar, quassia, red clover, rue, sweet clover, turmeric, willow bark, coenzyme Q10, danshen, devil’s claw, dong quai, ginseng, green tea, papain, and vitamin E. First, a great many diet and lifestyle factors also induce liver enzymes, including consumption of broc- coli,31 alcohol,32 char-grilled beef, and red wine and exposure to cigarette smoke. Second, warfarin is an extremely problematic drug because of its extreme sensitivity to interactions with foods33 and other drugs. Although the question of drug-herb interactions is a valid one for the pri- mary caregiver, the focus should be returned to the drug and its interactions with all dietary, lifestyle, and natural medicine factors, rather than the inter- actions of the specific herb. If this is also true for humans, a higher dosage of tryptophan may be required to exert an effect in older people. Combined with an increased requirement for vitamin D that is associated with aging, this lack of sun exposure may lead to a vitamin D deficiency, and many older people may benefit from vitamin D supplementation. Also, poor dentition and reduced stomach acid may contribute to lower nutrient absorption, from food as well as supplements. Children with learning disabilities have been shown to respond well to sup- plementation. Assuming that a child is a miniature adult with no specific changes to hepatic or renal clearance, children’s dosages can be calculated either by weight or age. Many rules exist for both methods of calculation, such as Clark’s Rule and Young’s Rule. Thinking more broadly about the optimum health of humans can lead to a reevaluation of many medical conditions. Is homocysteine a risk factor for heart disease or a marker for insufficient vitamin B12 and folic acid? Individuals preparing for surgery would benefit from B complex supple- mentation to reduce ischemia. Use of supplements designed to reduce blood clotting, such as vitamins E and C and Ginkgo biloba, should be dis- continued before surgery. Pregnancy The use of herbal medicines and supplements in pregnancy continues to be a source of much controversy. However, in many cases and with the correct advice, these medicines are safer and more effective than prescription drugs, for both the unborn baby and the mother. Data continue to accumulate on the importance and effectiveness of supplements during pregnancy, and this research will continue as rates of infertility, birth defects, and miscarriage rise. The authors propose that gut microflora are a source of natural immunomodula- tors. It is common knowledge that women intending to con- ceive, as well as pregnant women, should take folic acid to reduce the risk of neural tube defects. How much longer will it take before public health pol- icy reflects the importance of all vitamins before conception for the health of both mothers and babies?

However generic sildigra 50mg mastercard, sev- quarter of them had been to secondary school purchase 50 mg sildigra with mastercard, although eral categorical risk factors for marginalization have been more than 95 per cent had been in school at some point shown to be linked to drug use purchase sildigra 120mg, including unemployment, in their lives. The study also found that more than 70 per homelessness, incarceration, sex work and vulnerable cent of the users shared their drug using equipment, a pat- youth (such as young victims of family abuse and 44 tern which raises concerns about the transmission of infec- violence). The margin- by Homeless Link, a charitable company in the United alization and stigmatization of people who regularly use drugs also have a negative impact on their employment opportunities and social relationships. Stigma also contributes to poor mental and 2013 physical health, non-completion of drug treatment and 40 increased involvement in high-risk behaviour such as shar- 51 35 ing injecting equipment. The relationship between drug use and 10 employment status is complex and characterized by recip- rocal causality: drug use exacerbates the risk of unemploy- 5 ment, while unemployment increases the risk of drug use. Conversely, unemployment can cause stress and anxiety, financial difficulties, dissatisfaction and disaffection, which are all risk factors for initiation, perpetuation, intensifica- tion or resumption of drug use. A detailed breakdown of employment status among past- month users of drugs in the United States brings out dif- in terms of the increased likelihood of being a past-month ferent levels of association between drug use and user among the unemployed (compared with employed unemployment across the various drug types. The unemployment rate among past-month methamphetamine and “crack” cocaine were the drugs heroin users was 38 per cent, while unemployed people most closely associated with unemployment, both in terms were almost 10 times more likely to be heroin users than of the unemployment rate among past-month users and people in full-time employment (prevalence rates of 0. Livingston and others, “The effectiveness of interventions cocaine in general (see figures 6 and 7). There are several mechanisms whereby problem drug use 52 Alejandro Badel and Brian Greaney, “Exploring the link between can affect an individual’s chances of finding and keeping drug use and job status in the U. This total includes persons whose status was classified as “other” as well as ment histories, which themselves reduce the competiveness “receiving social benefits/pensioners/house-makers/disabled”. It is likely that these categories include people who are not in the labour force; if this were taken into account, the proportion of unem- ployed people would be higher. Kemp and Joanne Neale, “Employability and problem drug 55 Impacts of Drug Use on Users and Their Families in Afghanistan. In particular, the stigmatizing attitudes towards people who use drugs 8 that may extend to staff in health-care services can get in the way of their ability to deliver effective treatment to drug users. Third, addi- the perceived threat of needle-related injuries and of trans- tional barriers may arise from social circumstances, such mission of blood-borne viruses. Fourth, many people with drug use disorders may for hepatitis C, and 65 per cent reported that such dis- be acutely aware that limited skills, poor or no qualifica- crimination was a result of being a drug user, with females tions, gaps in their work history, particularly related to more likely than males to experience discrimination imprisonment, and a criminal record can make looking because of their status with regard to hepatitis C. Furtado, “Stigmati- zation of alcohol and other drug users by primary care providers in Southeast Brazil”, Social Science and Medicine, vol. Spencer and others, Getting Problem Drug Users (Back) into drug use: the realities of stigmatization and discrimination”, Health Employment (London, United Kingdom Drug Policy Commission, Education Journal, vol. The lead to high levels of incarceration (for a more detailed implementation of evidence-based programmes remains discussion, see the subsection entitled “Criminal at very low levels of coverage in many parts of the world67 justice”). In Myanmar, for example, alternative develop- ment projects in Wa Special Region 2 resulted in several benefits on the health front: vaccinations reduced infant Drug demand reduction efforts and the entire continuum mortality and eliminated leprosy among children; and of care for people who use drugs, when successful, reduce electricity and potable water were brought to some town- drug use and therefore its impact on public health. Drug use prevention programmes have also been in Dir District, Khyber Pakhtunkhwa (formerly North- shown to lead to a decrease in a range of other risky West Frontier Province), resulted in the provision of drink- behaviours, such as aggressiveness and truancy. Alternative devel- but it takes a well-developed framework to implement opment programmes often create and strengthen social them effectively. Even at the level of monitoring the extent organizations and generally enhance the level of organiza- of drug use, developed countries are typically better placed tion of rural communities, enabling progress on various than developing countries to assess the extent of the prob- fronts, especially when such programmes encourage the lem. For example, heroin use in Europe has undergone a direct participation of beneficiaries in the design, planning significant decline in recent years, and this improvement and implementation of projects. The results are also enhanced when the linked to the objective of drug control, which is to ensure interventions employ and expand the use of evidence- access to controlled drugs for medical and research pur- based tools systematically. In the pream- of care interventions can be even more effective when it ble to the Single Convention on Narcotic Drugs of 1961 incorporates evidence-based measures aimed at minimizing as amended by the 1972 Protocol, the parties to the Con- the adverse public health and social consequences of drug vention recognized that the medical use of narcotic drugs abuse, including appropriate medication-assisted therapy continues to be indispensable for the relief of pain and programmes, injecting equipment programmes as well as suffering and that adequate provision must be made to ensure the availability of narcotic drugs for such purposes. Wilson and others, “The cost-effectiveness of harm reduc- 65 “International standards for the treatment of drug use disorders: tion”, International Journal of Drug Policy, vol. Economic aspects can also have an in the management of pain and other medical uses, in impact on the evolution of illicit drug markets, as varia- some countries the strategies in place to prevent the abuse, tions in income levels and purchasing power may influence misuse and diversion of controlled substances may some- drug consumption patterns. Human has an impact on illicit drug markets, the drug problem Rights Watch reviewed the national drug control strategies can also have economic ramifications. The economic cost of 29 countries and found that 25 of them failed to iden- of drug use that is incurred, for example, when drug-using tify the issue of ensuring availability of controlled sub- segments of the workforce do not receive adequate treat- stances for medical and scientific use as an objective or to ment, can impact on productivity. These aspects are discussed below, in the sections on economic development and environmental sustainability. Impact of economic development on the drug problem Furthermore, when the response to illicit drug use neglects the health aspects of drug use and treats the problem exclu- One way to look at how economic development affects sively as a criminal offence, excessively focusing on pun- the drug problem is to compare the latter across different ishment, consequences can ensue for the well-being of countries on the basis of their economic development. These aspects are discussed below, in the sub- multitude of factors that can play a role in shaping the section on criminal justice. Proximity to a drug-pro- Finally, when the response to the drug problem fails to ducing area or to a major drug trafficking route, for exam- take into account the particular needs of women, it may ple, explains more than economic development the higher contribute to undermining the objectives of gender parity than global rates of opiate use in the Near and Middle East and of the empowerment of women and girls. This applies and South-West Asia or the higher rates of cocaine use not only to direct interventions against the drug problem (including “crack” cocaine) in South America and West but also to the monitoring of drug use, as women are likely Africa. Nevertheless, a global macrolevel analysis can still to be under-represented in research identifying prevalence, provide insights into how economic development may needs, risks and outcomes of drug use, leading to a gap in have a bearing on the drug problem, although the rela- tionship between development and the drug problem needs to be viewed in dynamic terms.

With biologic transmission order 120 mg sildigra visa, the vector (for example purchase sildigra 120mg visa, the mosquito) carries the infectious agent within its body order sildigra 25 mg with visa, and the agent passes through the skin via an insect bite. Examples of vector-borne diseases include Lyme disease, plague, and Rocky Mountain spotted fever. Sexually transmitted diseases are spread through sexual contact, either heterosexual or homosexual. Blood-borne diseases are transmitted by contact with blood from an infected patient. This mode of transmission usually occurs in the health-care setting, with infusion of contaminated blood products or by skin puncture with a contaminated syringe. Sharing of needles among injecting drug users also transmits blood-borne diseases. Even when the source of an outbreak is unknown, understanding and interrupting the most likely route of transmission can prevent further disease. Host Immunity and Resistance The host is the person or organism susceptible to the effect of the infectious agent. The general health status of the host, his/her genetic makeup, as well as other factors determine susceptibility to disease. Host defenses that contribute to resistance to infection include: Mechanical barriers (i. Tears, urine, digestive juices, perspiration, and respiratory mucus contain enzymes, acid, and nonspecific antibodies (a type of protein produced by the immune system) that combat infection. Certain cells of the immune system, found throughout the body, that remove infecting organisms from the body by engulfing and destroying them, in a process known as phagocytosis. Competition between normal, non-disease-causing (commensal) microorganisms normally found in the gut or on the skin and pathogenic (disease-causing) organisms to which the host is exposed. These defenses may be overcome by exposure to a large number of organisms or repeated exposure over an extended period of time. Defense mechanisms may 2-6 diminish when another disease-causing infection is occurring at the same time, following previous treatment with antibiotics (which wipes out commensal organisms), or when a breakdown in a barrier exists (such as a skin wound). This type of immunity usually lasts the longest period of time, often for the life of the host. Vaccination with weakened or killed infectious agents leads to active, induced immunity. Injection of antibodies or antitoxin leads to a passive, temporary immunity to an agent. Use of gamma globulin to protect against chicken pox is an example of passive immunity. To find ways to break the chain of disease transmission communicable diseases are prevented by increasing host resistance (through vaccinations); modifying the environment (to eliminate reservoirs or to interrupt transmission); inactivating the infectious agent. Vaccination Seagoing persons should be appropriately vaccinated against all diseases traditionally occurring during childhood (diphtheria, tetanus, poliomyelitis, measles, mumps, rubella, and chicken pox) and should consider vaccination to prevent hepatitis A and B. Though vaccines have reduced the occurrence of many of these diseases worldwide, susceptible travelers may still acquire these diseases. Vaccination against chicken pox is only necessary if there is no history of childhood infection. Vaccination against both hepatitis A and B and an inactivated poliomyelitis vaccine booster should be considered for adults who plan to travel and work in areas where these diseases are more common. Hepatitis A is contacted by the oral fecal route, such as from contaminated food or water. Hepatitis B may be acquired by direct or indirect contact with body fluids from an infected person. Travelers to endemic areas should consider vaccination for hepatitis A, typhoid fever, and cholera. Hepatitis A and/or typhoid vaccines are indicated for persons who travel regularly to less-developed countries and who anticipate eating locally prepared foods or drinking water. Travelers to less-developed countries are advised to avoid eating uncooked food, especially fish and shellfish, and to peel fruits themselves to minimize the risk of acquiring typhoid fever, cholera, hepatitis A, and other gastrointestinal diseases. Currently, no country or territory requires cholera vaccination as a condition for entry. Local authorities, however, may require documentation of cholera vaccination when coming from endemic or epidemic areas; in such cases, a single dose of vaccine is sufficient to satisfy local requirements. Certain diseases transmitted by mosquitos, such as yellow fever and Japanese encephalitis (a disease that occurs throughout eastern and southern Asia) may be prevented through vaccination and by avoiding mosquito bites by wearing appropriate clothing and using repellents and mosquito netting. Yellow fever vaccination is required at 10-year intervals for travel to many tropical American and African countries. Animal-borne disease such as plague and rabies may be prevented by vaccine and avoidance of unknown animals. Meningococcal disease may be prevented with vaccination when traveling to regions of higher risk: the sub- Saharan east-west belt of Africa, the Middle East, and the Asian subcontinent. Every seaman should keep with his or her passport and other papers, written evidence of the vaccines and prophylaxis received. The World Health Organization publishes vaccine cards, which are recommended in order to keep an accurate record of all vaccinations (Fig 2-1).