Former Reconstructive Foot and Ankle Surgery Fellow and Clinical
Instructor
Department of Orthopaedic Surgery
Division of Podiatric Medicine and Surgery
The University of Texas Health Science Center at San Antonio
San Antonio, Texas
Associate of Foot and Ankle Surgery
VSAS Orthopaedics
Allentown, Pennsylvania
Clinical Assistant Professor of Surgery
Pennsylvania State College of Medicine
Hershey, Pennsylvania
Moreover anxiety 5 things you see safe 25mg atarax, multiple observational studies have shown an inverse correlation between subclinical hypothyroidism and ischemic heart disease anxiety symptoms help generic 25mg atarax amex. This effect can possibly be explained by lower metabolic rate leading to caloric restriction anxiety symptoms skipped heart beats cheap atarax 25 mg, which by itself has been shown to improve mortality rates in animal studies anxiety lump in throat buy atarax 10mg. Occurrence of atrial fibrillation due to hyperthyroidism is higher in the elderly anxiety kids discount 25mg atarax overnight delivery, but other symptoms such as heat intolerance anxiety symptoms even when not anxious atarax 25mg low price, tremors, and ocular manifestations are less frequent. Non- Pituitary-thyroid function Throughout life, thyroid function is imperative for normal development and retaining cognition in human aging. By studying cretinism, caused by deficiencies in iodine and thyroid, the link between thyroid hormones and cognition was observed. With increasing age as well as body weight in more sedentary aging adults, thyroid volume increases slightly. However, because the brain maintains a narrow range of levels of these hormones, even small changes in their quantities with aging may impact cognitive function, potentially having dire consequences on aging adults. In general, whether to treat or not should be decided based on a combination of factors including signs and symptoms, age, risk factors, and other associated comorbidities. Effects of hypothyroidism with aging can lead to lipid accumulation, compromising metabolic activity. In older individuals who fail to down regulate the metabolic rate with age usually have poor health status and shown to have higher risk of mortality, independent of other risk factors such as body mass index, smoking status, daily physical activity, blood pressure and diabetes. More than 70% of men over the age of 70 have free testosterone levels consistent with hypogonadism. Reduced testosterone levels may cause patients to complain of decreased sexual desire and thus activity, mood changes, difficulties falling asleep or staying asleep, reduced energy, and a decline in cognitive abilities. Some studies have found cardiovascular effects linked to low testosterone, such as an increase in systolic blood pressure, greater left ventricle mass, and an increase in overall cardiovascular disease, which is currently under investigation. Low androgen exacerbates co-morbidities such as diabetes mellitus due to insulin resistance. While there is no concrete evidence that testosterone supplementation can cause prostatic carcinoma, it is highly recommended to screen for this prior to the use of testosterone treatments. The corpus luteum produces estrogen and progesterone during the luteal phase of the menstrual cycle. In their mid-30s, women have a gradual decline of estradiol production, which is accentuated during menopause (which occurs at an average age of 51). The decrease in estrogen can also cause genitourinary atrophy symptoms, such as vaginal dryness and dyspareunia. These hormones, in turn, help release estrogen and testosterone in females and males, respectively. Estrogen can be consumed orally or applied topically, with transdermal patch, or intravaginally. Exogenous estrogen side effects include higher risk of cardiovascular disease and elevated serum triglycerides. In addition, risk of stroke increases dramatically, and venous thromboembolism has been found to have a two-fold increase. There is also decreased endogenous vitamin D absorption and synthesis in human skin with age. While the human body utilizes the same mechanisms for storing and retrieving energy throughout life, aging adults adjust the mechanisms to meet their current demand. Age has a primary role in causing declining glucose tolerance, even when data were adjusted for obesity, fitness, and fat distribution. These cells have decreased response to the increased levels of glucose in aging adults. Leptin is a hormone found in adipose cells that serves to decrease food intake and increase activity. This causes accumulation of adipose cells and increases risk of metabolic disorders affecting the circulatory, respiratory, and reproductive systems. Older men have increased adiponectin compared to younger men, while there was no significant change in adiponectin levels with women. The changes in fuel regulation with aging reveal irregularities that will impact aging adults. Decreased glucose tolerance and increased insulin resistance result in higher incidence of type 2 diabetes mellitus in aging adults. Adipokines are increased to help protect aging adults from the metabolic changes that occur due to increased body adiposity. All of the aforementioned studies show the body is attempting to increase adipose storage. For instance, increased insulin resistance along with decreased pancreatic beta cell activity results in hyperglycemia. Leptin, when decreased with aging, will cause increased adiposity as well due to decreased hunger suppression. Helping adults realize these normal changes associated with aging can help aging adults prepare for the future. Healthspan and longevity can be extended by suppression of growth hormone signaling. Prolactin secretion in healthy adults is determined by gender, age and body mass index. The role of Thyrotropin Releasing Hormone in aging and neurodegenerative diseases. Priming of Mesenchymal Stem Cells with Oxytocin Enhances the Cardiac Repair in Ischemia/Reperfusion Injury. Effects of aging on epinephrine secretion and regional release of epinephrine from the human heart. Low serum triiodothyronine and high serum reverse triiodothyronine in old age: an effect of disease not age. High Basal Metabolic Rate is a Risk Factor for Mortality: the Baltimore Longitudinal Study of Aging. Longitudinal Effects of Aging on Serum Total and Free Testosterone Levels in Healthy Men. Effects of gender and age on the levels and circadian rhythmicity of plasma cortisol. Atrial natriuretic peptide levels in the elderly: differentiating normal aging changes from disease. Age differences in the plasma clearance mechanisms for epinephrine and norepinephrine in humans. Vitamin D status and related parameters in a healthy population: the effects of age, sex, and season. Correlation of vitamin D, bone mineral density and parathyroid hormone levels in adults with low bone density. The effect of vitamin D supplementation on vitamin D status and parathyroid function in elderly subjects. Subclinical vitamin D deficiency in postmenopausal women with low vertebral bone mass. Fall relate to vitamin D and parathyroid hormone in an Australian nursing home and hostel. Cancer Incidence and Mortality and Vitamin D in Black and White Male Health Professionals. Reduced Pancreatic B Cell Compensation to the Insulin Resistance of Aging: Impact on Proinsulin and Insulin Levels. Agedependent decline in cell function assessed by an oral glucose tolerance testbased disposition index. Effects of Aging on Visceral and Subcutaneous Fat Areas and on Homeostasis Model Assessment of Insulin Resistance and Insulin Secretion Capacity in a Comprehensive Health Checkup. Leptin and Aging: Correlation with Endocrine Changes in Male and Female Healthy Adult Populations of Different Body Weights. Ageing and plasma adiponectin concentration in apparently healthy males and females. It contains information on early and advanced breast cancer, including the causes of the disease and how it is diagnosed, up-to-date guidance on the types of treatments that may be available and any possible side effects of treatment. Your doctor knows your full medical history and will help guide you regarding the best treatment for you. Words highlighted in colour are defined in the glossary at the end of the document. Special populations Clinical trials Supplementary interventions What are the possible side effects of treatment The earliest stage of breast cancer is non-invasive disease (Stage 0), which is contained within the ducts or lobules of the breast and has not spread into the healthy breast tissue (also called in situ carcinoma). Breast cancer is the most common cause of cancer-related deaths in women and occurs most frequently in postmenopausal women over the age of 50. Breast cancer also occurs in men but is very rare, making up around 1% of all breast cancer cases. Initial investigations for breast cancer begin with a physical examination, mammography and ultrasound scan. If a tumour is found, a biopsy will be taken to assess the cancer before any treatment is planned. Surgery, radiotherapy, chemotherapy, endocrine therapy and targeted therapy are used in the treatment of breast cancer. Radiotherapy is given after breast-conserving surgery but is not usually needed after mastectomy. Endocrine therapy is given to decrease the risk of recurrence (the cancer coming back), as well as prevention of new cancers in both the remaining and contralateral breast. Most patients will then receive adjuvant therapy with one or a combination of systemic treatments, depending on the type of cancer present. Some patients, particularly those with larger tumours, may receive preoperative neoadjuvant systemic therapy to shrink the tumour and improve the likelihood of successful surgical removal of the tumour, or to decrease the extent of surgery (which can also achieve a better cosmetic result). The standard chemotherapy regimens in early breast cancer usually contain anthracyclines. In premenopausal women this is usually tamoxifen alone or in combination with drugs that suppress the ovarian production of oestrogen (called gonadotropin-releasing hormone analogues). In postmenopausal women, aromatase inhibitors or tamoxifen are used, either alone or sequentially. Bevacizumab can be combined with chemotherapy but provides only a small benefit with no impact on survival, and is therefore rarely used. Patients taking endocrine therapy will have regular assessments to monitor the side effects of the treatment. Chest wall Rib Chest wall muscles Lobules Areola Nipple Duct Fatty tissue Skin Anatomy of the female breast. In this type of cancer, the cancer cells are in the ducts of the breast but have not spread into the healthy breast tissue. Lobular neoplasia (previously called lobular carcinoma in situ) is when there are changes in the cells lining the lobules, which indicate that there is an increased risk of developing breast cancer in the future. Lobular neoplasia is not actually breast cancer, and although women with lobular neoplasia will have regular check-ups, most will not develop breast cancer. Invasive breast cancer Invasive breast cancer is the name given to a cancer that has spread outside the ducts (invasive ductal breast cancer) or lobules (invasive lobular breast cancer). These can be further classified by their histology; for example, tubular, mucinous, medullary and papillary breast tumours are rarer subtypes of breast cancer. These cancers are usually operable and the primary treatment is often surgery to remove the cancer, although many patients also have preoperative neoadjuvant systemic therapy. In the vast majority of patients, treatment for locally-advanced breast cancer starts with systemic therapies. Depending on how far the cancer has spread, locally-advanced tumours may be either operable or inoperable (in which case surgery may still be performed if the tumour shrinks after systemic treatment). Advanced breast cancer Advanced breast cancer is a term used to describe both locally-advanced inoperable breast cancer and metastatic breast cancer. Further information regarding the impact of these subtypes on breast cancer treatment will be explained later in this guide in the section: `How will my treatment be determined
While awaiting the arrival of the ophthalmologist anxiety symptoms ruining my life buy atarax 25mg on-line, some low-risk (and potentially beneficial) actions may be taken anxiety 24 weeks pregnant cheap atarax 10 mg otc. Paracentesis of the anterior chamber is no longer recommended as a therapeutic intervention by an emergency practitioner zantac anxiety symptoms generic atarax 25 mg. Chlamydia infection anxiety jury duty cheap 10 mg atarax fast delivery, acquired in the same manner anxiety symptoms not going away generic atarax 10 mg without prescription, is more benign and can be treated as an outpatient anxiety 5 things purchase atarax 10 mg fast delivery. Kawasaki disease: A multisystem disease occuring primarily in children under 8 years. Bilateral conjunctival injection that spares the perilimbic area is one component of the disease. Congenital nasolacrimal duct obstruction and chronic dacrocystitis: Chronic duct obstruction usually resolves by 1 year of age and is managed by instructing the parents to "milk" Table 21. Chronic dacrocystitis requires topical antibiotics and subsequent referral to an ophthalmologist. Suspected shaken baby syndrome (child abuse): Ophthalmology consultation should be obtained to look for retinal hemorrhages, which are pathognomonic for shaken baby syndrome in the appropriate setting. Eye pain, redness and visual loss Immune compromised Patients with diabetes, hematologic malignancies, those on immunosuppressive drugs, and generally debilitated individuals are susceptible to mucormycosis, an aggressive fungal infection. Mucormycosis presents as a unilateral swelling of the eye, accompanied by proptosis and decreased vision. Viral conjunctivitis requires only attention to hygiene, and allergic conjunctivitis may respond to antihistamines, vasoactive drops, or mast cell stabilizers. Only patients with a purulent discharge should be treated with a short course of broad-spectrum topical antibiotics. This common practice is controversial as several studies have demonstrated no improvement in relief of pain with patching abrasions less than 10 mm in size. The red eye, the swollen eye, and acute vision loss: handling Primary Complaints 331 2. Common ophthalmologic emergencies: a systematic approach to evaluation and management. Principles and Practice of Emergency Neurology: Handbook for Emergency Physicians, 1st ed. Eye pain, redness and visual loss 332 Primary Complaints 22 Fever in adults Fever in adults Tamas R. It is popularly felt to be either harmful in and of itself or a sign of an underlying serious disease. Most often young, previously healthy adults suffer self-limited illnesses that are well-tolerated and respond to symptomatic therapy. As opposed to children whose temperature elevations are overwhelmingly likely to be due to infection, adults have a broader differential of both infectious and noninfectious etiologies. Fever may not always be a component of initial concern but may be identified on measurement of the initial vital signs. Patients may also present with a history of feeling "feverish" that has resolved spontaneously or with home therapy. Disease entities that are being considered in febrile patients cannot be ruled out simply by the momentary absence of fever. Healthy elderly persons do not have lower core temperatures as is popularly believed. Taking into account thermometer precision, fever is conservatively defined as a temperature of at least 100. It is generally believed that the fever response has a physiologic upper limit between 105. Infectious causes rarely lead to hyperpyrexia and collapse of compensatory thermoregulatory mechanisms in the normal host. Systemic fever response Normally, body temperature is controlled within a narrow range that predictably varies over the course of a day. Compensatory mechanisms ensure thermal homeostasis through autonomic nervous control by inducing changes in smooth muscle tone, shunting blood flow to and away from peripheral vascular beds, and provoking heat-seeking or heat-avoidance behaviors. Exogenous substances such as bacterial cell wall components (lipopolysaccharides), bacterial breakdown products, endotoxins, drugs, immune complexes, and activated complement factors induce polymorphonuclear cells to release a group of endogenous pyrogenic cytokines. Upon stimulation, efferent discharge increases peripheral heat-generating processes until a new temperature set point is established. Cyclooxygenase Primary Complaints 333 Pathophysiology It is important to distinguish whether a high temperature is from a fever (defined as a deliberate hypothalamus-controlled reflex elevation of body temperature) or hyperpyrexia (an uncontrolled heat accumulation overwhelming compensatory mechanisms). This distinction is typically not difficult but has important immediate diagnostic and therapeutic implications. In order to define fever, an understanding of "normal" temperatures and the circadian cycle is necessary. Clinically, chills (or less frequently rigors) subside within minutes of reaching the newlyestablished febrile set point. During the fever peak, adults may experience a mild delirium that is more prominent in the elderly. Myalgias and arthralgias represent increased muscle tone and circulating inflammatory mediators. Defervescence brings about predominantly heat-dissipating processes, including sweating, facial flushing, and the sense of being uncomfortably warm. Experimental models confirm that fever-inducing agents introduced directly into the bloodstream can generate clinical signs within minutes (Table 22. The orchestrated febrile response enhances host defense mechanisms by increasing neutrophilic migration and T-cell proliferation (cellular immunity). Antibacterial substances such as cytotoxic-free radicals are generated by polymorphonuclear Table 22. Metabolism is shifted away from glucose toward increased protein and fatty acid breakdown. For each degree Fahrenheit of temperature rise, the basal metabolic rate is increased 7%. Increased caloric demands are compounded by increased utilization of less efficient protein and fat fuels. Tissue oxygen demands are also elevated despite a temperature-induced shifting of the oxygen-hemoglobin dissociation curve to the right. Tachycardia occurs from a combination of direct catecholamine stimulation and relative dehydration, as circulation shifts to the periphery. The mechanism of heat rise in hyperpyrexia is independent of pyrogenic cytokine production and does not involve resetting of the thermoregulatory set point. Clinically, high temperatures are not seen until compensatory mechanisms have failed. It is important to act quickly to correct the heat imbalance before irreversible neurological injury, rhabdomyolysis, cardiac dysrhythmias, and circulatory collapse occur (Table 22. This spillover is more likely in areas with a high concentration of immunologically-active cells or that are richly vascular. Classically described changes of the local inflammatory response have been appreciated for centuries. These include rubor (erythema from vasodilatation), dolor (activation of pain fibers), calor (local temperature increase), and tumor (swelling or edema). General characteristics of the fever pattern, magnitude, and duration may be of some clinical value. Intermittent relapsing fevers are characteristic of endocarditis, osteomyelitis, and deep tissue abscesses. The amplitude or maximum temperature reading is an insensitive sign for distinguishing a viral from bacterial source. Patients with high fevers tend to appear more ill and have a higher overall incidence of serious bacterial illness. Most patients who are able to recall their medication describe their daily routine. Patients typically omit mention of medications taken intermittently, inhalers, eye drops, oral contraceptives, nonprescription supplements, and even insulin. Policies of universal precautions including glove, gown, and face-shield use must be strictly adhered to , in order to prevent direct bloodborne pathogen-laden fluid contact. Indirect contact via stethoscope, thermometer, bed railing, or aerosolized droplet may transmit disease. Additional measures such as patient isolation or the use of a negative pressure room are necessary for highly contagious diseases. The amount of history-gathering prior to the initiation of treatment must be tailored to the severity of illness and the potential for lifethreatening processes (Tables 22. All patients should be encouraged to carry an updated list of medications and allergies for their own protection. Immunization status is important and should include questions regarding childhood vaccine series, subsequent titers, hepatitis B series, pneumovax, tetanus boosters, and influenza prophylaxis. Newer vaccines are being developed that will alter our current approaches to certain diseases. Fever in adults Have you been exposed to individuals at home, school, or work with similar symptoms Although most patients can recall a colleague or friend being ill, patterns of similar symptoms in several close contacts may be helpful. High-risk dietary habits include the practice of eating raw or undercooked meats or fish, home canning, and "direct from source" food use (milk, honey, chickens). Associated symptoms Acquisition of a detailed history often points to focal examination findings and identification of the source of fever (Table 22. It therefore makes sense to organize the approach to the history by physiological systems as opposed to anatomical location. Each organ system will have characteristic but non-pathogen specific signs and symptoms. This may be through the inability of the immune system to access the affected part, as in the case of peripheral vascular disease. Defenses are attenuated in individuals with diabetes, or deliberately suppressed in organ transplant recipients. Conditions requiring the use of glucocorticoids further diminish already vulnerable host defenses. Implanted medical devices have great potential for hematogenous contamination in the setting of transient bacteremia. Nonnative heart valves and indwelling vascular and urinary catheters are at greatest risk. Recent surgery, childbirth or exacerbation of chronic conditions may critically lower host defenses. Physical examination A thorough history will often allow the clinician to concentrate on target areas of the physical examination. Local inflammatory-mediated changes provide clues to the presumptive source of fever. If no such associated localizing findings are identified, treatment is based largely upon host factors. Young, previously healthy adults with physical examination findings consistent with benign viral illnesses such as nasal discharge, head congestion, cough, diffuse myalgias and arthralgias, or nonbloody loose stools can be safely discharged with symptomatic therapy only. In contrast, the elderly or immune compromised hosts with few historical or physical examination findings require careful consideration for further work-up and possible empiric antibiotic treatment. General appearance the term "toxic-appearing" applies to those who "look ill from across the room. The inability to sit up in a stretcher or ambulate to the bathroom without assistance is a gross marker of functional impairment. The accuracy of an appropriately calibrated infrared tympanic thermometer is expected to be within 0. Tympanic thermometers have gained popularity because they are noninvasive and calibrate quickly, and do not rely on direct contact with the tympanic membrane. Errors occur through improper positioning, anatomical abnormalities, cerumen, or local inflammatory processes such as otitis media or externa. Fecal impaction and shock states may falsely reduce temperatures, while elevated fecal bacterial counts and proctitis may erroneously increase readings. Sublingual or oral temperature measurements require cooperative patients able to breathe with their mouths closed. Mastication, smoking, recently ingested foods, and respiratory distress may affect readings. Patients at the extremes of age or with significant comorbidity may have a serious infection in the absence of fever. Fever in adults Temperature Factors influencing temperature measurement include environmental conditions, testing technique, anatomical site, and site-specific confounders. The distinction of core versus shell temperature is most important in extreme states of hyper- and hypothermia. Invasive methods to determine temperature are usually not necessary, but include pulmonary artery catheters, and esophageal or urinary bladder probes.
I t has been appointed by the Government to act in the interests o f the port by setting port tariffs and negotiating individual tariffs with shipping lines anxiety 2016 order 10mg atarax overnight delivery. P A J also owns some superstructure assets such as the cranes at the transshipment terminal anxiety episode generic atarax 10 mg mastercard. Concessionaires or contractors operate the assets anxiety 7 weeks pregnant generic atarax 10mg visa, cargo handling anxiety symptoms vs pregnancy symptoms buy atarax 10mg low price, and other activities in the port anxiety symptoms for no reason order 10mg atarax otc. Labor concessions and improved terminal management and equipment have enabled improvements in productivity anxiety symptoms forum cheap atarax 25 mg with visa. For example, negotiations in 1998 reduced the average port gang size from 2 1 to 8 people and introduced flexible staffing hours. In general, air fares increase with distance, but less than proportionately, so that per km costs generally fall with distance, owing to the fixed costs o f landing, standing and taking off. The Dominican Republic, the only Caribbean country to have implemented an open-skies agreement w i t h the U. Most Caribbean airports perform reasonably w e l l o n measures like baggage handling time. Performance indicators such as capacity, baggage handling time, and revenue generation show that publicly owned airports are capable o f p e r f o m i n g as w e l l as those that are privately operated. However, six out o f the seven publicly owned airports reviewed in the region fail to cover their full costs; therefore, they ultimately represent a fiscal burden. In contrast, all o f the privately operated airports cover their full costs, including capital costs. This suggests that private participation, through concession, can effectively maintain and expand services while limiting fiscal risk. Air transport capacity i s also adequate, although liberalization o f air services could significantly increase services and reduce costs. Governments around the world have tightened safety and security standards since the 9/11 terrorist attacks o n the U. A pleasant, uncrowded arrival and departure experience i s vital to sustaining the tourist industry o n which many islands depend. Jamaica has addressed t h i s problem at Sangster International Airport (Montego Bay) through a concession with a private company to build additional facilities and operate the airport (see B o x 8. Some o f these, such as the ports o f Port o f Spain (Trinidad and Tobago) and o f Kingston (Jamaica), need to make significant investments in additional port facilities to serve the growing demand. However, these investments are r i s k y because the transshipment market i s highly mobile and can easily move to another port w i t h lower costs, potentially leaving investors w i t h n o way to recoup their investment. The Airports Authority o f Jamaica prepared a development plan based o n traffic projections and sought to finance the development through private capital. The process was drawn out for a number o f reasons: uncertainty over the nature o f the commercial arrangements, absence o f a structured competitive process to select the private party, dispersion o f responsibility, and a lack o f clarity over the regulatory arrangements. In the end, a consortium o f four companies formed a joint venture company, M B J Airports Ltd. I Guyana and elsewhere, the failure to invest in n expanding mobile communications means that these countries are missing out o n the productivity gains experienced by Jamaica and other countries that liberalized telecommunications and 180 attracted additional investment. In Haiti, the lack o f power, water, and other infrastructure makes it difficult for businesses to succeed and grow. As seen earlier (Chapters 1, & 2), many Caribbean Governments have debts which are at or approaching unsustainable levels. High debt levels mean that traditional Government borrowing to finance infrastructure i s no longer sustainable for highly indebted countries like St. M o s t infrastructure investment w i l l need to be either self-financing, or, to the extent that i t i s not, generate rapid and significant economic growth which can generate increased tax revenues to allow the debt to be serviced. Normally roads, bridges, ports and the like generate returns over decades, and the cost benefit calculus i s one o f economic cost and benefits, not fiscal costs and benefits. Unfortunately, in many Caribbean countries the fiscal situation means that this approach i s n o longer possible. This has a number o f implications: Most new infrastructure finance w i l l need to be serviced f r o m user-charges or higher taxes. There should be bias toward financing o f infrastructure by private providers, for two main reasons: (i) evidence in the Caribbean i s clear that private infrastructure providers are generally the able to operate o n a cost recovery basis, while government providers generally are not; (ii) Keeping borrowing o f f the books will help keep interest rates down, since rating agencies and financial markets find it difficult to assess the likelihood that particular investments w i l l generate returns, and tend to regard all borrowing by a highly indebted country as negative, regardless o f the actual financial and economic implications o f the borrowing; and Justifying public investment in infrastructure will require demonstration o f higher I R R s and quicker payback periods than usual. It i s possible, however, to minimize Government intervention and mitigate fiscal risk through a careful assessment o f risks and financial structuring. The above analysis shows that these factors do explain some o f the differences in the performance in provision o f infrastructure services among the countries, and between the region and comparable countries. For example, these factors cannot explain why Barbados and Jamaica have much higher cellular access than Trinidad and Tobago, why people in Guyana have better access to improved water sources than people in Suriname or the Dominican Republic, or w h y electricity tariffs in St. While the relations between the two are complex, and correlation does not prove causation, it stands to reason that better structures for providing and regulating infrastructure w i l l lead to better results. This i s good news, since policies and institutions are under government control, and so 8. F o r example, privatization o f electricity i s meeting w i t h success in Jamaica, but failed in Guyana. Superficially similar regulatory bodies have reached widely differing levels o f effectiveness and independence in various countries. Competitive electricity markets that worked well in other countries, such as N e w Zealand, played a part in the breakdown o f the electricity sector in the Dominican Republic. Combining these principles and experiences with a good understanding o f individual country specific issues can point the way to 182 institutional reforms that may improve performance. The rest o f this section reviews key issues in each sector, and suggests possible reform strategies. Until recently, the overriding approach to providing widespread service in all sectors has been to require the incumbent monopoly, whether public or private, to expand service to underserved areas. Financing came from cross-subsidies (for telecommunications and electricity) or Government capital subsidies (for water and sanitation). However, as telecommunications liberalization grows, the old model becomes unworkable for that sector. Other sectors may also benefit from considering new approaches to broadening service. Interesting models include: Dominican Republic Telecommunications Development Fund. The fund i s used to provide communication services to rural areas, community tele-centers, pay phones, e-learning, and tele-medicine. In 1975, the Government established the Rural Electrification Company separate from the utility, to create a vehicle for borrowing from multilateral funding agencies to finance line extensions and wiring for low-income households. Actual installation was contracted out, and the total cost o f the wiring was incorporated as a loan to the homeowner to be repaid along with the electric bill in monthly installments over five years. By increasing access and lowering the price o f many services, liberalization made a significant contribution to economic efficiency. Countries that have not yet liberalized their telecommunications sectors, including Haiti, Trinidad and Tobago, Guyana, and Suriname, should consider adopting this model. Such regional regulatory approaches promote effective regulation despite limited national capacity, and could be adapted with positive results to the water and electricity sectors. The greatest gain to intemational transport in the region would come through rapid 8. So far, only the Dominican Republic has an operational "open skies" agreement w i t h the U. The intemational experience i s that liberalization can significantly reduce fares and increase volume, providing a major boost to business and tourism, and it i s recommended that all countries reach open skies agreements with the U. An objective analysis shows that these carriers, whether in public or private hands, are financial liabilities, not assets and that the objective o f lowering prices has by and large not been achieved. This concern could be addressed by asking airlines to bid o n non-exclusive contracts, under which they would commit to provide specific capacities and schedules o n key routes in exchange for a subsidy. Awarding such contracts competitively would assure governments that services would be provided while simultaneously engaging lower and more certain subsidies than the alternative o f supporting national and regional carriers. Just as telecommunications liberalization was initially greeted with skepticism by 8. I t s primary)bjective i s to assist national telecommunications regulators in promoting market liberalization and telecom ompetition in member countries. I t works closely with telecommunications regulators and governments in each state, advising them o n natters relating to the sector, including regional policy, types o f telecommunications services, licensing, ees, pricing, management, and provision o f universal service. Together, the N T R C s are responsible for formulating national elcommunications policy, planning, and managing the radio frequency spectrum, investigating and resolving interconnection disputes, monitoring anti-competitive practices, and managing the universal services fund. The Effects of Regional Regulatory Cooperation E C T E L has had a significant impact o n telecom liberalization in the member countries. I t has helped tc bring about early termination o f existing license arrangements and facilitated competition. Average prices for calls from the region to the United States have been reduced by more than 70 percent since liberalization while regional cellular penetration has increasec from 2. The E C T E L member countries believed i t was beneficial to takc a uniform stand in negotiating with C&W West Indies over the liberalization o f their respectivc telecommunications markets. This is an example o f the way in which regional cooperation can allow eacl country to leverage i t s combined resources to undertake the necessary advisory and reform activities t c make significant progress. Accomplishing the initial task o f telecommunications liberalization was a lengthy process. After f i r s t threatening to exit the region if the markets were opened to competition, C&W signed a Memorandum o f Understanding with E C T E L in April 2001, agreeing to phase-in market liberalization in three steps. The principle o f regional cooperation in regulation has enabled E C T E L member countries to efficiently manage scarce resources and to effectively leverage the inter-member country networks, which has resulted in increased flexibility. Rates for telecommunications services have begun to fall, applications for operating licenses are being processed, and applications to establish call centers have 185 Box 8. This has reduced the burden o n individual regulators and has helped attract investment. For example, Jamaica largely decided to privatize i t s electricity company in 2001 to stop it from being a drain o n the fiscal budget. Lucia, have private providers regulated by license, but n o effective government body to oversee the license. This i s in contrast to the effective regulation o f the electricity sector by independent regulators in Jamaica and Barbados. Establishing a regional regulator similar to E C T E L will help exert additional pressure to come up to efficiency standards o n electricity companies that are not currently subject to regulatory oversight. The electricity sector has n o w run into serious problems that are not necessarily attributable to the decision to adopt a competitive market but rather the failure to put adequate regulatory and supervisory mechanisms in place (see B o x 8. But in any case, i t seems unlikely that any other country in the region possesses the scale and diversity in electricity generation to benefit from a competitive power market. This approach could result in lower tariffs and increased opportunities for co-generation and use o f renewable resources. I t i s difficult to achieve commercial discipline in public utilities in countries where the institutional structure lacks rigor. Privatizing utility operation may help, although t h i s also i s difficult to achieve. In one example, Guyana sold i t s power company, but the private company was unable to make a financial success o f the business, in part because o f problems with the regulatory regime, and ended up withdrawing from the business and retuming the company to public ownership. For the same reason, few investors would be willing to risk significant capital in Haiti. Management contracts potentially could f a i l to provide the oversight team with enough power or incentive to effectively improve the company. Such models could b e adapted from the lease/affermage contracts that are internationally used in the water sector. In these arrangements, the regulatory rules are not written into government or private bylaws but into each individual contract between the company and the government. Access to improved water and sanitation services i s generally lower than access to electricity and telecommunications. The water service providers throughout the Caribbean are owned and operated by government. They are generally inefficient, w i t h unaccounted for water losses (from leakage, theft, and under-billing) equal to more than 50 percent o f production. They are generally overstaffed, financially weak, and unable to finance even routine operations and maintenance and new investment to improve and extend services. Caribbean countries are not short o f engineering know-how, and other utilities, such as electricity and telecommunications, are generally able to provide an adequate level o f service and to generate finance to expand the network tariffs. Even when utility managers try to adopt a businesslike approach, they are stymied by tariffs that are too l o w to recover costs, and a lack o f finance for investment. Jamaica, Barbados, Trinidad and Tobago, and Guyana are all experimenting w i t h it. Regulatory oversight may help provide transparency in setting tariffs and stepping up pressure for efficiency, but it i s not yet clear whether regulation o f state-owned (as opposed to private) utilities can lead to fundamental or lasting improvements. Some options could be: 0 Private participation through operating (lease/affermage)-type contracts that give private f i r m s true management control; require to meet defined targets; and lock-in welldesigned tariff and subsidy regimes. Explicit, targeted subsidies paid for provision o f outputs, to address social concerns in water pricing, and to expand access. Development agency finance o f capital expenditure, either directly, or through loans to establish subsidy funds. Government responsibility for financing some or a l l investments, either directly or through paying o f output-based subsidies to expand service. Performance-based contracts for defined elements o f the service, such as meter reading, Promising new developments in the water sector are the hybrid lease/concession contract 8.
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Recommendation For women with endometriosis who required oophorectomy anxiety symptoms pain atarax 25 mg on-line, combined estrogen/progestogen therapy can be effective for the treatment of vasomotor symptoms and may reduce the risk of disease reactivation anxiety service dog quality 10 mg atarax. Although not well studied anxiety symptoms social order 10 mg atarax with visa, some recommendations can be derived from the literature anxiety zen youtube 25mg atarax with amex. The evidence on which to base recommendations for these women is anxiety while sleeping cheap atarax 25mg on-line, however anxiety wiki generic atarax 10 mg online, sparse. Migraine with aura is a risk factor for ischaemic stroke, which may be greatest in younger women (under 50 years old) (Kurth, et al. A later systematic review from 2007 did not identify any evidence to change this view (MacGregor, 2007). Surgical menopause may be associated with an increased risk of stroke, which appears to be reduced by estrogen replacement (Parker, et al. These studies did not specifically consider any potential confounding effect of migraine. Surgical menopause appears to be associated with the highest prevalence of migraine when compared to natural menopause, presumably because of a sudden reduction of estrogen (see (Nappi, et al. Data for normal postmenopausal women with migraine is also minimal and conflicting. Transdermal estrogen may have the advantage of providing a constant level of estrogen and may be associated with a lower risk of thrombosis. A small, randomised trial of oral versus transdermal estrogen in postmenopausal women showed no increase in the frequency of migraine in the transdermal group but a significant increase in the oral group (Nappi, et al. Continuous combined regimens have the similar theoretical advantage of providing constant hormone levels. However, a large case control study of postmenopausal women over 45 years did not show any difference in migraine prevalence in women taking estrogen alone or estrogen with progestin (Misakian, et al. Although none of the women were clinically hypertensive, physiological therapy was associated with a lower blood pressure (P<0. In hypertensive postmenopausal women, most studies showed a decrease in systolic and diastolic blood pressure after estrogen therapy, although an increase was found in some studies. The effect of different progestins on blood pressure in hypertensive postmenopausal women is not well studied, but in general progestins do not seem to hamper the effect of estrogen on blood pressure. Recent studies have shown promising results for drospirenone, a novel progestin with aldosterone receptor antagonism, and therefore antihypertensive effects. Hormone therapy combining 17-estradiol with drospirenone has been shown to have a blood pressure-lowering effect in postmenopausal women with elevated blood pressure, in addition to effectively relieving symptoms of the menopause (White, 2007). Tibolone is widely used for vasomotor symptoms and it was found to be effective in relieving these symptoms (Formoso, et al. However, data on the long-term safety of tibolone are scarce but raise suspicion of increased risks for breast cancer and stroke (Formoso, et al. The study of Canonico and colleagues showed no significant association of micronized progesterone or pregnane derivatives. In addition, obesity is a risk factor for hypertension and coronary artery disease (see chapter 8), and premature death (see chapter 5). C Fibroids Uterine fibroids (myomas or leiomyomas) are benign tumours arising from individual smooth muscle cells of the uterus. Most fibroids are asymptomatic but some women have significant symptoms including abnormal uterine bleeding, pelvic pressure (urinary frequency, constipation) and pain, and reproductive dysfunction. Studies in postmenopausal women have been summarized in systematic reviews (Ang, et al. The trend of the results was that tibolone did not increase fibroid size significantly. Both reviews stated that none of the studies reported a significant increase in clinical symptoms or adverse effects associated with fibroid growth, and more importantly, most women, even those with growth of fibroids, remained asymptomatic. Treatment with androgens Androgen concentrations fall with advancing age (Davison, et al. There is much debate whether the cessation of ovarian function (at any age) leads to a more rapid decline in androgen concentration. A major pitfall in this research area is the lack of reliable testosterone assays. Although liquid chromography-tandem mass spectrometry seems most precise and sensitive for measuring the relatively low testosterone levels in women compared to men, most available studies on the incidence of androgen deficiency and the efficacy of androgen replacement therapy have applied less reliable assays such as direct radioimmunoassays (Stanczyk, 2006; Janse, et al. Moreover, there is large between-women variability, thereby making the diagnosis of hypoandrogenemia even more challenging (Shiraishi, et al. In contrast, women who underwent oophorectomy at a young age are probably hypoandrogenic due to the lack of ovarian androgen production, which makes up for 25% of the total 127 production in premenopausal women (Longcope, 1986; Sluijmer, et al. It has been suggested that androgen replacement therapy may be used for these indications. This section provides an overview of the available evidence on indications for androgen replacement therapy, possible risks, and routes of administration. All of the studies involved short-term treatment and follow-up, and reported mild or minimal short-term adverse effects of treatment. The efficacy of transdermal testosterone replacement for sexual dysfunction seems to be similar in surgically and naturally postmenopausal women with and without estrogen therapy (Davis, et al. These girls were between 10 and 14 years old and were not using estrogen replacement. In this study, the effect of androgen replacement therapy on neurological function, including verbal abilities, spatial cognition, executive function and working memory, was investigated. Oxandrolone-treated girls showed improved performance on the working memory domain score only after 2 years of treatment as compared to girls receiving placebo (Ross, et al. Studies in the elderly (postmenopausal women and elderly men) have shown conflicting results, and only involved small samples, inducing supraphysiological levels of androgens and without control for confounders (Wisniewski, et al. Bone health Two randomized studies were performed on the effect of adding methyltestosterone (2. However, these have not been described often in studies in which women receive up to 300 micrograms of testosterone per day. The most reported side effect of transdermal testosterone therapy was unwanted (non-scalp) hair growth (9% in the treatment group vs. Endometrial effect Theoretically, androgen therapy could lead to endometrial hypertrophy by peripheral aromatization of androgens to estrogen. A retrospective study on nearly 260 postmenopausal women using estrogen implants as well as testosterone implants identified an endometrial thickness of >5 mm in 17%, in which in almost two thirds an endometrial polyp was found. On the other hand, androgens are also believed to be associated with endometrial atrophy. These findings suggest that androgen replacement probably leads to an increase of endometrial atrophy. When using estrogen replacement along with testosterone treatment, it is advisable to also add progestin therapy for endometrial safety, as was discussed in section 12. Long-term follow-up data of the effect of androgen therapy on the endometrium is not available. Breast cancer risk None of the studies conducted to date showed an increased risk of breast cancer associated with the use of testosterone, but conclusive data on long-term safety are not yet available (Davis and Davison, 2012). After using testosterone patches for over 1 year on average, no increase in breast cancer incidence compared with that of the Australian reference population was identified during a follow-up of six years (Davis, et al. The combination of methyltestosterone with estrogen was associated with an increased risk of breast cancer (relative risk 2. The major complaint in transdermal use of testosterone is application site effects, leading to a discontinuation of the transdermal patches in 4% in a surgically postmenopausal group (Simon, et al. Most studies have only prescribed androgen replacement for the duration of the trial, 6 to 12 months on average, and no evidence on efficacy and safety is available after 24 months. It seems wise to evaluate the baseline testosterone concentration before treatment is started, and continue to measure this every 3 to 6 months. The effect of the treatment should be evaluated and if no improvement of sexual function is seen, treatment should be discontinued. Recommendations Women should be informed that androgen treatment is only supported by limited data, and that long-term health effects are not clear yet. 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