Associate Professor, Department of Orthopedic Surgery,
Samsung Medical Center, Sungkyunkwan University School
of Medicine, Seoul, Korea
She and Nor- the Rape of Emergency Medicine Page 33 man liked filling in the blanks of the schedules from the table in their kitchen buy erectile dysfunction drugs uk purchase 50mg fildena otc, and they became the first "kitchen schedulers" of emergency medicine erectile dysfunction protocol free ebook cheap 150mg fildena visa. Carolyn very much liked having Norman around on weekends erectile dysfunction nicotine purchase fildena 100mg with visa, enjoying his new found enthusiasm erectile dysfunction pumpkin seeds proven 50mg fildena. She was glad he was out of the corn flakes factory and underneath erectile dysfunction young age treatment purchase fildena 150 mg with visa, she was relieved he was out of clinical medicine altogether erectile dysfunction pain medication cheap fildena 25 mg mastercard, but Norman Lyle and the former Carolyn Skanks were releasing a movement from their otherwise sensible kitchen that was to have epic consequences on organized emergency medicine. He felt quite savvy, depositing the check into one of the new interest-bearing checking accounts from which he paid the residents monthly, thereby earning a few kopeks of interest in the meantime. For literally generations, ambulances were Cadillacs, white Cadillacs that brought patients from their homes and accident scenes to the hospitals. Lyle remembered the white Cadillac that picked up his dying grandfather, taking him to the "accident room," the old name for the emergency department. Black Cadillacs bringing patients from the hospital to the funeral home, the Rape of Emergency Medicine Page 34 and from the funeral home to the cemetery, were the same makes and models as the white ones, and curiously enough, usually owned and run by the same funeral homes. There was no conflict of interest since the patients in the white Cadillacs usually ended up in the black Cadillacs after their ordeal in the "accident room. Lyle looked inside, seeing a kaleidoscopic array of equipment including oxygen ports built onto the walls, intravenous solutions waiting to be hung, cardiac monitors, in those days weighing fifty pounds, and plastic airways that could be inserted right there in the Econoline. She was wearing a "tool" belt with pouches for her industrial-sized scissors, a stethoscope, a Swiss Army Knife, and a flashlight. After all, the ambulance driver only had to know a few pressure points, how to drive, get to the hospital, maybe take a short cut or two. With intervention at the scene we can produce better patient outcomes, especially with heart attacks and trauma. Thousands of heart attacks strike every day in this country with most of the deaths occurring in the prehospital setting. After he and Carolyn arrived in Atlanta, the site of the 1974 meeting, he first went to the exhibit area, looking at the latest medical and surgical textbooks, noting nothing new on hot sugar burns. The physicians who did emergency room work full-time were called the "scrubs," and more than a few of the "scrubs" had finished residency-training programs, some in surgery, some even in urology and ophthalmology, but mostly internal medicine or family practice, many looking for their niche. They were a slightly bizarre group of physicians from a bazaar of medical backgrounds now in search of a specialty, and these young, fledgling physicians were perfect pigeons for the new group of kitchen schedulers arising in different parts of the country. He became confused when he heard a group of physicians from the Rocky Mountain region and the Detroit area talking about raising emergency medicine to the full status of a medical specialty. The cross-sectional information needed to treat the full spectrum of diverse emergencies is encyclopedic. He continued to note with much more interest a different kettle of fish, a whole gallery of kitchen schedulers from different parts of the country, and he began to feel an uneasy kinship with these M. He sat with his new lodge brothers, and while exchanging pleasantries Lyle ascertained most of the kitchen schedulers to be washouts of various residency programs, obvious second raters with a flimsy background of a one-year rotating internship under their belts. They seemed to be mostly disgruntled physicians who for nebulous reasons had gone to medical school, undistinguished men of fairly modest gifts who, in other times in other specialties, would have remained mere footnotes. Norman Lyle readily saw through their overdrawn claims to be "pioneers" of a new specialty called emergency medicine. However, they did all go to a fine set of haberdashers, wearing suits instead of the sackcloth scrubs. In fact, they proudly distinguished themselves from the hippie "scrubs" by their "suits. Lyle almost burst out laughing when Goldman began speaking about the "perils of debt" for Lyle knew there was no investment, no need to bet the ranch. All one needed was a little seed money for a kitchen and a phone, and with a little hustle, one could kitchen schedule "scrubs" to fill in blanks. But Lyle felt the better part of his thinly-capitalized kitchen scheduling valor was stealth, and even though that ancestral feeling began to surface again, Lyle caught hold of himself. Besides, Lyle was bemused, watching the founding of a medical specialty domineered by groups of individuals having no intention of ever practicing the specialty. Even more than that, he could feel the power, a slight sense, but ever so invigorating. Goldman blamed other physicians in other specialties for ignoring emergency medicine, and said that controls would have to be placed on the medical community. Goldman was laying the foundation to blame others for the wreckage, the wreckage they were all about to create in the systematic transfer of wealth and power out of the hands of those physicians who evaluated and treated patients into the hands of those who kitchen scheduled. Lyle was in ecstasy with a broad smile on his face when suddenly Goldman pointed at him, thinking the grinning Lyle had a question, but Lyle thought Goldman wanted him to make a statement. That chance remark stuck to Lyle, and many years later he would grow to regret the offhand remark very much. The next day he moved about, listening carefully to talk of the recently enacted 1973 Emergency Medical Services Systems Act. The "suits" were buzzing about it, half of them fearful they might be found out, but the other half with a boomtown hysteria, speaking of the huge sums of money the United States Congress had appropriated. A half a billion dollars was the figure being bantered around with twenty million for New England alone. They had to be somewhat careful to dance on the edge of the rules, both written and unwritten. Lyle began to see the importance of this new organization with its original draftsmen in keeping information rationed and the rules unwritten. He noted the membership tables set up everywhere in the large hanger of the exhibit area extolling physicians to become members of the Academy. Lyle immediately saw how important it was for the "suits" to claim the mantle first, to become officialdom, be the spokes people for emergency medicine before the "scrubs" or academics started their own organizations. The Rape of Emergency Medicine Page 41 Norman said to Carolyn, "This could be an important career move. I think we should personally pay the annual dues of the physicians who work for us to belong to the Academy. Institutions are just the same everywhere, Boston politics, Tammany Hall, and now the party bosses of the American Academy of Emergency Physicians. The hospital administrators were perfect knockovers for the flimflam kitchen scheduling men eager for quick profits in this new specialty mushrooming overnight. The kitchen schedulers were soon making so much money in their kitchens they would never pick up stethoscopes again. Several dropped out of lucrative ophthalmology and radiology practices just so they could make out schedules for emergency departments. Some maintained Ear, Nose and Throat practices while their wives made out the schedules on the side with their imprimatur on them. While it was true a physician could make a good living practicing medicine in an emergency room, the real bullion was in scheduling. The Rape of Emergency Medicine Page 43 Kitchen scheduling soon became the fastest-growing specialty in medicine, a growth industry comparable to fast food or video rental stores, only the latter two had industry standards. The kitchen schedulers, now formally freed from background checks by the Academy, placed dermatology residents in pediatric trauma hospitals, radiology residents in cardiac hospitals, just kitchen scheduling any Tom, Dick, or Harry into any blank, anywhere, anytime. Of course, Doctors Tom, Dick, and Harry had to have an active, unrevoked, state medical license. After all, they had to have some written guidelines, and there were certainly no standards of integrity forthcoming from the thumbs up their asses at the now well-funded American Academy of Emergency Physicians. The "suits" also noticed they had huge amounts of time on their hands, many completing their schedules in the first week of the month. With the constant infusion of money and limitless time, they took law and business classes learning all about corporations and partnerships. They learned how to bill insurance companies up the ying-yang, optimize if not slightly upcode, milk Medicare and, of course, fleece the "scrubs. The Rape of Emergency Medicine Page 45 Chapter Four: Origin of a Species "To see patients without reading is like a ship without a rudder, to read and not see patients is like never having gone to sea. He felt somewhat guilty about beginning the odyssey without Shelly, plus Mahoney, after finishing a one-year fellowship in pediatric emergency medicine, had moved back to the Boston area. He felt mildly uneasy about being the only physician on the premises after midnight in a one-hundred-bed community hospital. Conditions like tension headaches, coughs, constipation, ligament sprains, insect bites, minor fractures, anxiety, weakness, shoulder aches, and even uncomplicated vaginal discharges were all like new diseases to him. Walsh explained that "de Leon" was just waiting for a prescription, and could be released as soon as the medication arrived from the pharmacy. His mind was intuitive, and his overall abilities had evolved to the point of reflexes, instinctual and glandular. He was a diagnostic animal, a jaguar or leopard always on the prowl for afflicted prey. It went completely unnoticed the Rape of Emergency Medicine Page 47 by everyone, the nurses, his teachers, and even his family, but not to the big Cat. Steinerman introduced himself to the family, letting them know he wanted to look the patient over one more time before they left. The nurses were pissed because de Leon was already "treated and streeted," but his family was grateful. One of the nurses had already written a note commenting on the delayed discharge on the "quality assurance" forms Pyramid, Inc. They knew they were being cheated as they were people who bought the five-hundred-dollar cars with the one-hundred-dollar monthly interest payments. They were used to getting the shit kicked out of them, and instinctively knew Walsh was a shit doctor giving them a bullshit prescription, and instinctively trusted the big Cat. De Leon was short of breath because of the Rape of Emergency Medicine Page 48 anxiety? De Leon was referred that night to a pediatric cardiac surgeon, Doctor Christine Kull. She wanted to know where Steinerman had done his electives in pediatric cardiology, and he laughingly replied, "Nowhere. Doctor Christine Kull had suddenly met one of the large Cats in emergency medicine. Steinerman saw over twenty patients on his twelve-hour night shift, most of them with minor complaints, staple illnesses. One twentytwo year old had pruitic (itchy), papules (bumps) on his penis, a dead giveaway for scabies infestation. In the land before time before antibiotics, old men used to die of pneumonia long before they became senile and had to linger in the intensive care unit through the "onehundred-thousand-dollar funeral. They were doctors who had over seventy file cabinets full of the proper responses to refuse any patient from any of the uniformed services with any disease. The next day Steinerman called Mahoney for lunch, but Mahoney had to testify on a rape case. The staff gynecologist was tied up in the operating room, and Mahoney proceeded with the formal rape exam according to the guidelines Delorenzo had set up in Hershey, Pennsylvania. Joe Delorenzo established the sexual-assault examination procedures while in his emergency medicine residency program, and it was becoming the nationwide standard of care for the medical rape exam. Its methodology and chain of evidence protocol were also becoming legally acceptable for conviction in all fifty states. The young woman had surprisingly little vaginal bleeding secondary to a broken Coke bottle placed into her vagina after the assault. Mahoney had taken a swab of the vaginal drippings, looking at it himself under the microscope. Mahoney stabilized the young woman, assisting as the victim was taken to the operating room because there was too much reactive spasm in the vaginal walls to remove the glass without general anesthesia. They needed perfect relaxation of the vaginal musculature which came only under "general. She had a full stomach but there was no way around surgery now, regardless of the risk she might vomit and aspirate the vomitus into her lungs. Fortunately, they did take her into the operating theater that night because one of the longer pieces of glass had penetrated the vaginal wall perforating the peritoneum. She required exploration of the belly where they found a punctured ovary and several bleeding vessels, along with a tear in the wall of the colon with extravasation of fecal contents throughout the peritoneal cavity. She did well in surgery, but required a colostomy, having to spend six months with a bag of shit zippered to her belly, and was now well enough to testify. The Rape of Emergency Medicine Page 53 "If there were a Chinese girl and a Caucasian girl walking down the street together, both with black shiny hair, and if they wore an identical set of clothing from head to toe, and were exactly the same height, and were walking right next to each other, one might say they looked very much alike. But if you asked me which one was the Chinese girl and which one the Caucasian girl, I think you could believe me if I said I could distinguish them beyond a reasonable doubt. Steinerman felt a growing respect for these residency-trained emergency physicians. A new breed of Cats was on the horizon, but someone needed to eliminate the poachers before these agile jaguars were here today and gone tomorrow, extinct, gone to other specialties, specialties without pledge drivers, "suits," or thumbs up their asses. The Rape of Emergency Medicine Page 54 Chapter Five: Crips and Bloods "These fellas did what Senators have been doing for a long time. He and Carolyn, along with the other kitchen schedulers, had never liked their name, so they and the Academy changed it to "managers. Although the medical staff would rubber stamp an individual physician in order to grant him or her hospital privileges, the actual hiring and firing of the "management" group was done solely through the hospital administrator, and this was the only specialty in medicine where the administrator held such power over the doctors. They pretty much on-the-job-trained themselves for their positions, thus earning the nickname of O-J- the Rape of Emergency Medicine Page 55 Ters. Many were quite good, running pretty tight ships, and more than few had a gift for fundraising. But many were somewhat buffoonish and sometimes, many times in fact, one had to think there were bands of number-crunching accountants and assorted pointy-heads in the basements of many, many hospitals keeping the ships afloat. The "suits" problems all began within a three hundred square mile of the country whose name will be withheld to protect the innocent, just in case there are any. The anonymous midwestern "region" (surrounded by an area where a very famous auto race is held every year) contained twenty hospitals, all with active emergency rooms.
Policies and procedures related to forest concessions viagra causes erectile dysfunction buy 150mg fildena free shipping, logging licences and taxation systems were revised and new policy initiatives were introduced erectile dysfunction pills wiki generic fildena 50 mg with visa, including increased attention to conservation within production forests erectile dysfunction pump canada discount fildena 100mg overnight delivery, community participation and log export bans erectile dysfunction caused by lack of sleep fildena 100 mg on line. However antihypertensive that causes erectile dysfunction buy fildena 150mg amex, illegal logging is still rampant erectile dysfunction statistics cdc order 150 mg fildena with mastercard, and communities receive little or no benefit from the exploitation of forest products. Kowero et al (2003) evaluated the linkages between forest policies and other major policies for the miombo woodland countries and observed that state-owned forests, typical of much of the region, are associated with weak forest governance and unsustainable timber exploitation. Agricultural policies, economic reforms and trade liberalization were identified as influencing the shape of forestry policies and their implementation. Legal and policy strategies addressing timber harvesting in sub-Saharan African countries have focused on five main aspects: 1. This strategy aims to increase access to forest resources and encourage investments through providing long-term exclusive access rights (Sitoe et al, 2003). This measure is expected to increase resource use efficiency and reduce the impact of illegal logging. Forest operators, however, see this as a constraint, making it too expensive to invest in forest concessions. It is regarded as contradictory, when at the same time, annual logging permits are allowed. The international market, and particularly China, favours low cost unprocessed logs. This focus is part of national capacity building to improve the management of forests. Countries have also implemented national stakeholder fora to improve public participation in forest governance. Low wages and poor working conditions in forest departments, as well as corruption and politically driven decisions, undermine these efforts (Kowero et al, 2003). While colonial legislation limited local communities to subsistence use of forest resources, the new policy measures open up possibilities for communities to derive benefits from timber, either directly through being part of the business or through a variety of benefit sharing arrangements. Wily (2000) found that Tanzania had the most effective community access to forest resources in eastern and southern Africa. Forest concessions Forest concessions and annual logging licences are two logging regimes commonly used in tropical forests, including dry forests and woodlands. In contrast, forest concessions promoted value-addition, community participation, resource use efficiency and long-term commitment. Forest zoning and allocation Forest inventories are needed to define areas with productive forests that can sustain long-term timber production. The forestry institutions must have detailed information of these areas so as to be able to negotiate with concessionaires and establish an appropriate value of the forest. Forest concessions must be allocated in a transparent way and competition should be promoted to capture the appropriate revenue. In countries like Mozambique, the concessionaire conducts the inventory and submits a request for a concession to the forest department. The allocation of the concession is therefore not competitive and is based on who first submits the request (Sitoe et al, 2003). Dry forests and woodlands with low growth rates require large areas to maintain timber production on a sustainable basis. Revenue and taxes Grut et al (1991) found that African countries captured a very small proportion of the real value of the timber. The plans should include an ecological evaluation of the resource, a socio-economic assessment of local communities and financial aspects of the forest business, among other aspects (Table 6. The estimation of this requires adequate forest inventory, information on tree growth rates and the definition of the cutting cycle. Forest inventories by themselves are not sufficient for good decision-making and they are difficult to undertake because of cost, limited human capacity and the management plans derived from forest inventories being seen as a mere bureaucratic step towards getting a forest concession (Box 6. But even where there are management plans, they may not be implemented because of limited capacity and negative attitudes towards the planning process. In 2006, Mozambique had 111 authorized forest concessions, covering an area of about 4. It requires that appropriate statistics are kept and that reporting systems are in place within the concession system. Lack of transparency with information and procedures typifies forest concessions in many sub-Saharan countries. Independent monitoring systems have been introduced in some countries to improve the quality of information but they do not function in countries with high levels of corruption and political influence. It is sometimes called timber certification, forest product labelling or forest management auditing. This process is currently carried-out by both non-profit and for-profit organizations, and is characterized as being an independent, objective and third-party process. However, only a small number of schemes are operational at present and the volume of timber covered by them is minor (Baharudin, 1995). The largest concentrations of certified forests are in North America (49 per cent) and Europe (45 per cent). Lesser-known timber species the growing concern regarding the sustainability of timber resources in African dry forests has motivated researchers to identify lesser-known species with potential to substitute the species that are under pressure. Among the identified species, bamboo was found to be of high potential not only because of its properties but also considering its wide occurrence over the dry forest and woodland countries of Africa, but this resource is underutilized. Taquidir and Cuco (2006) conducted an inventory within a 5000km2 coastal area in Mozambique and found 2000km2 of pure bamboo stands (Oxytenanthera abyssinica). Boko (2007) indicates that Oxytenanthera abyssinica, Bambusa vulgaris and Andurinaria aplina are the most common bamboos found in African woodlands. Kenya has large bamboo plantations, with 63,000ha of Arundinaria alpina (Boko, 2007). In addition to bamboo, there are hundreds of other potentially valuable tree species whose physical and mechanical properties and end-uses are little known. These trees make up a larger portion of dry forests and woodlands than the currently utilized species (see above). For example, Brachystegia spiciformis was introduced to the European market as parquet strips. Alberto et al (2001) also assessed the technical feasibility of some Mozambican secondary species for the manufacture of woodcement composites. The study resulted in the identification of species compatible with cement without needing any treatment, such as Amblygonocarpus adongensis, Brachystegia spicifomis and Brachystegia bohemii, as well as the species becoming compatible after treatment of particles, such as Erythropheum suaveleuns, Albizia adianthifolia and Sterculia appendiculata. Although there are limited studies on the real impact and the characteristics of this sub-sector, its role in national poverty reduction strategies shows that it is highly significant and needs to be properly evaluated. The introduction of environmental measures to protect African dry forests and woodlands is sometimes seen as an impediment to attracting investments in the timber sector. On the one hand it is a measure to improve profitability while at the same time it assists in the protection of the depleted traditional valuable species. But on the other hand, since little is known about the utilization of these species, their use may also result in further reduction of forest cover, risking the degradation of forest ecosystems. The challenge is to undertake adequate studies to evaluate these species before bringing them under full exploitation. The general perception about the timber industry in African dry forests and woodlands is that little is known about it. The fact that policies have been in place but their implementation is not effective suggests that there are information gaps that constitute impediments. Information availability can improve implementation and reformulation of existing policies. There is also need to assess requirements for training people and building capacity in sustainable forest management. Access to modern or commercial energy sources by households is very low, at about 10 per cent, and the energy future does not appear bright for the majority of the African people. Woodfuel (firewood and charcoal) will therefore play a significant role in the livelihoods of the majority of the people in the region. In spite of the over-dependence on woodfuel, significant problems remain in estimating the amounts consumed. Methods of determining the amount of wood consumed vary considerably and the majority of statistics tend to be unreliable. This chapter attempts to describe the woodfuel situation and its dynamics in dry forest and woodland countries of sub-Saharan Africa. The chapter also considers options for sustaining the woodfuel system as the region struggles to expand household access to commercial energy sources. Except in wood deficit areas, firewood used in rural areas is obtained from dead wood or wood cut for other purposes and therefore represents a waste product from the forest. In contrast, firewood and charcoal consumed in urban areas are mainly produced from wood cut to supply urban markets. For example, the government of Burkina Faso issued decrees against charcoal production in 2004 and 2005 in order to reorganize the charcoal industry but these have since been revoked. Nevertheless, due to its easy transportation and storage, charcoal is increasingly becoming the preferred urban household cooking fuel in many major cities. For example, of the 30 or so major cities in sub-Saharan Africa, charcoal is the main household cooking fuel in 70 per cent of these cities. Much of what follows in this chapter will therefore be on charcoal with only occasional reference to firewood. There is very little international trade in firewood but potential exists for charcoal export. However, international trade in charcoal has generally been discouraged in most countries because of its impact on forests and woodlands. For example, Kenya banned charcoal exports to countries in the Middle East in the 1970s because of the extensive deforestation that it caused in the coastal regions of the country. In Tanzania, for example, firewood constitutes 97 per cent and 4 per cent of cooking and lighting fuel, respectively, in rural areas (Kaale, 2005). Subsistence firewood consumption in the miombo woodlands surrounding Kitulanghalo Forest Reserve in eastern Tanzania is 1100kg per capita per year (Luoga et al, 2000). In Nigerian urban areas approximately 97 per cent of households buy their firewood and only about 3 per cent collect it, while in the rural areas 45 per cent buy their firewood, and 55 per cent collect it (Alabe, 1994). In Kenya, firewood is the most common type of energy with close to 89 per cent of rural and 7 per cent of urban households reporting regular use of firewood, giving a national average of 68 per cent of all households. The average annual per capita consumption is approximately 741kg and 691kg for rural and urban households, respectively. In the Luapula Province of Zambia the total firewood consumption in 1996 was estimated at 353,100 tonnes (Kalumiana, 1996). Of this, 5539 tonnes are used for fish smoking annually, representing about 2 per cent of total consumption. Urban households consume 3 per cent of firewood, while rural households consume 95 per cent of firewood. The per capita annual consumption is estimated at 1025kg in rural areas and 240kg in urban areas (Kalumiana, 1996). In Botswana firewood is the main source of biomass fuel used and total consumption was estimated at 1. Because of the very low access to commercial energy sources the growth in charcoal demand is directly linked to growth in the urban population. For example, charcoal production increased by one-third from 1981 to 1992 (Kammen and Lew, 2005). However, level of urbanization varies from region to region: 23 per cent in eastern Africa, 36 per cent in central Africa, 39 per cent in southern Africa and 40 per cent in western Africa. Of the total urban population in sub-Saharan Africa, almost 65 per cent is in countries in which dry forests and woodlands cover a significant percentage of the country. In western Africa urban population grew sixfold from 1960 to 1990, from about 13 million to 78 million people, and the predicted future growth is that the urban population will reach 275 million in 2020 (Arnaud, 1993). Urbanization is occurring without industrialization and therefore is characterized by high levels of unemployment and dependence on traditional energy sources. People leave rural areas because of declining agricultural productivity, lack of employment opportunities and lack of access to basic physical and social infrastructure. However, the expectation of higher incomes and standards of living in urban areas is rarely realized. For urban dwellers charcoal is preferred to firewood because it is easy to store and more convenient to handle. Since urbanization is affecting all towns, irrespective of size, each urbanizing area is depleting forest resources in its hinterland or catchment area. Often the source areas for woodfuel for larger towns may include catchments of one or more smaller towns. Many factors influence spatial and temporal dynamics in charcoal supply areas of major cities in sub-Saharan Africa, including forest depletion, regulation of charcoal production, land use and tenure, history etc. The charcoal industry supplying large cities in sub-Saharan Africa operates over large areas and shifts when production areas are depleted, as in Senegal, Mozambique, Tanzania and Sudan. Similarly charcoal for Khartoum in Sudan comes from the more wooded southern regions (Khalifa, 1982). It is evident that the charcoal for large towns in dry forest and woodland countries can come from very distant source areas. However, what is most worrying about urbanization is that every 1 per cent increase in the level of urbanization is estimated to result in a 14 per cent increase in the consumption of charcoal (Hosier et al, 1993). The impact of urbanization has serious implications for the long-term well-being of rural communities. Sustainable forest management has a key role to play in maintaining charcoal supplies to urban areas while also supporting forest-based rural livelihoods. Although it is generally recognized that dry forests and woodlands provide the bulk of resources for wood energy, the land use status of supply areas is rarely known. In contrast, firewood in Kenya is mainly from agroforestry or on-farm sources (84 per cent), trustlands (8 per cent) and gazetted forests (8 per cent) (Theuri, unpublished). Most of the charcoal in Tanzania and Mozambique is produced from general land under village control while in Burkina Faso, Mali and Niger communal and state forests are managed to supply woodfuel to major cities.
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In contrast circumcision causes erectile dysfunction order 100mg fildena overnight delivery, Chiaki (1996) observed savannah elephants from Tsavo National Park in Kenya choosing grasses erectile dysfunction 22 discount fildena 100mg amex, shrubs erectile dysfunction at age 28 generic fildena 25mg with amex, and herbs as the main part of their diet erectile dysfunction type of doctor purchase 25 mg fildena amex. Using spoor analysis erectile dysfunction doctors new york purchase fildena 100mg without a prescription, Tchamba and Seme (1993) found the diet of forest elephants in Cameroon to consist mainly of grasses and fruits erectile dysfunction adderall discount 25 mg fildena mastercard. By use of observation, Sukumar (1989) found that just 25 species of plants, ranging from grasses, bamboo, trees such as Acacia spp. The influence of season on the extent of grazing was observed in Uganda where grass consumption ranged from 28. Similarly, for Asian elephants the proportion of time spent grazing ranged from 10 percent to 94 percent, while browsing time ranged between 6 percent and 90 percent in southern India, with variation depending on habitat, time of day, and season (Sukumar 1989). During the wet season, elephants tend to be preferential grazers, using sedges and grasses at a time when the protein content of these species is high. However, more browsing occurs in the dry season when the protein content of grass decreases to less than 2. Seasonal effects on dietary crude protein levels, examined in Uganda, indicate variation from 5. Brown and White (1979) reported a low urea concentration in elephant plasma, which correlated with low dietary protein, during the dry season. A diet low in browse, such as the diet of elephants from Murchison Falls National Park, Uganda, which was reported to contain 1. Fatty acid profiles from elephant diets show the concentration of saturated palmitic acid to be approximately 1. At the same time, the mean plasma cholesterol levels in the elephant has been found to be low, which is attributed to the overall small amount of total lipid in the elephants diet (McCullagh 1969). Mineral analysis of elephant diets resulted in significant variations recorded both between seasons and among plant species. Calcium, which has received more attention than other minerals, has been found to range from 0. McCullagh (1969), however, believes elephants are unlikely to be deficient in calcium on a diet comprising green vegetation, and should be able to meet calcium requirements without consumption of bark. Furthermore, species differences in circulating levels, and perhaps metabolism, of this nutrient are becoming apparent between Asian and African elephants. Nonetheless, overall vitamin E nutritional status of elephants in North American zoological facilities has been raised significantly over the past decade through emphasis on dietary supplementation. Biotin supplementation has been reported as beneficial in preventing foot problems in elephants but has not been studied in detail. A single investigation of the kinetics of plasma biotin in supplemented elephants demonstrated that the vitamin was cleared very rapidly from the system, questioning the usefulness of large doses of biotin (Ullrey et al. The few data that do exist on mineral composition of native forages suggest that dietary mineral concentrations determined as adequate for horses would be roughly suitable for elephants at varying physiological stages. Calcium requirements of 8 to 9 grams per day have been 216 Elephant Husbandry Resource Guide determined for proper tusk growth in male elephants, and McCullagh (1969) and Sukumar (1989) calculated that a lactating cow would require up to 60 grams of calcium daily to meet the growth needs of her calf. However, there have been no other published reports of calcium, phosphorus, or vitamin D being problematic in other elephants fed typical zoo diets. The animal appeared to show an immune deficiency and other symptoms of zinc deficiency-for example, skin problems. Subsequently, the animal was treated with dietary zinc supplementation and the foot problems subsided. Although hair and serum samples were analyzed for zinc, no correlation could be drawn. Authors stressed the importance of meeting probable requirements for dietary zinc in elephants (Schmidt 1989), based again on equine recommendations. Loss of molars is a natural occurrence in elephants since normally the plates flake and molars are replaced. However, permanent loss of molars, especially the sixth molars can be particularly devastating in an animal consuming a highly fibrous diet. Decreased mastication will not allow for proper particle size needed for digestion. Thus, the elephant will not be able to extract the nutrition it needs (Reichard et al. The symptoms present similar to that of the horse-laying down and standing back up, stretching, kicking at the belly, inappetance. Most often the symptoms appear to be alleviated by decreasing the fermentable carbohydrates in the diet (produce items and bread) and increasing the fiber. Since the grass hay that most institutions use is fibrous, offering grass hay alone will provide good fiber. At times, wheat bran is added to the diet to decrease the incidence of colic or treat bouts of colic. The animal was treated with enemas and a fiber powder and supervised to decrease clay ingestion. Ingestion of earth is a common occurrence in free-ranging elephants and may be helpful to them in supplying minerals in the diet (Warren et al. With a nutritionally complete diet supplied in captivity, there should be no nutritional reason for the elephants to consume soil, clay, or sand. Sixty-three severely malnourished young elephants were examined in 1984 (Ullrey et al. A diet change was put into effect, which substantially improved the health and status of these animals. Nutrition 217 hen trained and habituated to transport, elephants are easily relocated and travel with no ill effects (Toscano et al. Working elephants, such as those in circuses, may change location daily or multiple times in a week for a portion of the year. These elephants are walked into and transported in specially designed trailers or rail cars. The movement of these elephants is well coordinated in regards to equipment, weather, and itinerary. The elephants are healthy and suited to travel, are accompanied by their handlers and are under the direction of veterinarians, and the regulations of the United States Department of Agriculture. An elephant in a zoological facility is often moved only to improve breeding opportunities or to establish a new social group. In this case, the movement of the elephant to another facility permanently, or for an extended period of time, requires planning. Prior to the shipment, elephant managers and veterinarians at both the shipping facility and the receiving facility should establish clear lines of communication. Knowledgeable elephant handlers from the W Transporting receiving facility should travel to the shipping facility and observe the elephant to be received. All site and elephant inspections should be done well in advance of the move, and all questions should be resolved prior to Have Trunk Will Travel When trained and habituated to transport, elephants are easily relocated and travel with no ill effects. This specially designed trailer includes a ventilation system, complete insulation, and sliding screen doors for comfort. It is strongly recommended that the physical transport of the elephant be arranged with an individual experienced in and properly equipped for transporting elephants. Contacting other facilities that have had experience moving elephants for references is suggested. Once the elephant transporter has been chosen, the elephant managers from both facilities, facility veterinarians, and the transporter should develop a written plan to move the elephant. It is also strongly recommended that elephant holding facilities along the route be contacted prior to the move to arrange for their assistance in the case of an emergency. If the elephant is transported in a trailer, it is important that the trailer be reinforced for elephants. Trailers should be constructed so that the elephant can comfortably stand, the floor should be reinforced to support the weight of the elephant, and drainage holes should be provided so urine does not puddle where the elephant stands. An elephant can also be trained to enter a specially designed crate and then the crate is placed on a trailer. Acclimation to the crate or the trailer may require two to six weeks, although many institutions, depending on the tractability of the animal, have trained an elephant in seven days or less. If the elephant does not completely acclimate to entering the trailer or the crate, partial immobilization or sedation may be needed. The usual preimmobilization procedures- fasting, detainment in an adequate holding area, etc. If chemical immobilization is used, it is recommended the elephant be held at the loading location for up to 24 hours for observation or accompanied by a veterinarian during transport in the event of a drug-induced health problem or renarcotization. Complications brought on by sedation can be handled more easily and effectively in-house than enroute. The use of tranquilization agents must be fully investigated if the transport of the elephant is by air. Most, if not all, commonly Two views of a crate used to transport an elephant overseas. If sedatives are handler access to the elephant to provide feed and water, used, the name of the drug and the time and route of although the bars must be placed close enough together to administration must be clearly marked on the container. A prevent the elephant from extending the majority of its copy of the record must be attached to the crate. The ability to detect antibodies will permit assessment of exposure status in asymptomatic elephants. Based on extrapolation from other related herpesviruses, it is assumed that animals that have been infected and shown clinical signs will become carriers and mount a life-long antibody response. Serologic testing on a routine basis will create a database that can be used to develop more informed epidemiological guidelines for movement and other management purposes. Other risk factors such as age, exposure to other elephants, health status, and herd histories should be taken into consideration. The ventilation openings must prevent any part of the elephant protruding resulting in injury to the elephant or humans. The decision as to when this primary handler should return to their facility should be based on the behavior and demeanor of the elephant, and the ability of the elephant handlers at the receiving facility. Whenever possible, preshipment testing should be performed within 30 to 90 days of the anticipated shipping date (note: mycobacterial cultures require 60 days for final results). Additional tests are recommended to increase baseline information to determine their significance to elephant health. The final decision for specific procedures should be made in partnership between the shipping and receiving institutions. Any abnormal findings should be communicated to the receiving institution in a timely manner. Anamnesis-summary of information regarding previous health screens, medical problems, diagnostic test results, and treatment. A hard copy and disk of the complete medical record should be sent to the receiving institution prior to shipment. It is possible for an elephant unaccustomed to being transported to damage the trailer or crate and injure itself in the process. Elephants should be provided with fresh hay periodically during the transport and if the trip lasts more than 16 hours, they should be provided with an opportunity to drink water. The primary elephant handler should stay at the receiving facility for a period of time after the transport to Transporting 223 b. Enteric pathogen screen-Aerobic culture of feces for enteric pathogens should include special media for the detection of Salmonella spp. Since Salmonella organisms may be shed intermittently, at least three to five fecal cultures should be performed (may be done on consecutive days). Samples for cultures must be collected under the direct supervision of a licensed veterinarian. Three trunk samples should be collected on separate days within a one-week period. Buffalo Zoo If the elephant is transported in a trailer, it is important that the trailer be suitably reinforced. The elephant may be trained to walk into the trailer, or the elephant may be slowly guided into the trailer using restraints and a winch. Tetanus toxoid-Current vaccination (within 12 months) is recommended using a commercial equine product. Rabies vaccine-Vaccination with a commercial killed rabies product approved for horses should be considered if the animal resides or will be traveling to an endemic area. Reproductive tract examination-A complete reproductive examination should be conducted to include transrectal ultrasound, semen collection and analysis, cytology and microbial cultures of the lower urogenital tract (to be screened for bacteria, chlamydia, protozoa, and herpesvirus). Herpesvirus has been identified in biopsies of vaginal lymphoid patches in an African elephant. A high prevelance of uterine leiomyomas has been observed in captive Asian elephants and could be detected via transrectal ultrasound. Since both of these conditions have potentially significant effects on reproduction, a careful evaluation is warranted if the animal is being considered for breeding 11. Quarantine Guidelines for Elephants December 2002 Due to the size, strength, and social nature of elephants, it may be logistically difficult to maintain isolation from other elephants during arrival and quarantine. Most zoological institutions will not have facilities available to safely house and manage a newly arriving elephant. However, every attempt should be made to maintain some degree of physical separation from the resident elephants. Current quarantine practices recommend a minimum 30- to 90-day quarantine period for most species found in zoos and aquaria. Social concerns, physical facility design, and availability of trained elephant staff may dictate a modified quarantine protocol.
This should be conducted according to the standards of care expected in Dentistry and Medicine in chronic pain treatment what medication causes erectile dysfunction buy 50mg fildena with mastercard, 4-6 erectile dysfunction pills over the counter purchase fildena 100mg. Gross and functional anatomy including the musculoskeletal and articular systems of the orofacial icd-9-cm code for erectile dysfunction order fildena 150mg on-line, head erectile dysfunction caused by sleep apnea buy cheap fildena 100mg, cervical and upper quarter structures impotence at 60 purchase fildena 100 mg free shipping, with assessment of common dysfunction and pathophysiologic effects lloyds pharmacy erectile dysfunction pills trusted fildena 25 mg. Functional neuroanatomy of the brain, cervical nerves, and cervical system with a particular emphasis on pain and common pathophysiological effects. Reading of current pain science and applied pain literature in dental and medical science journals with special emphasis on pain mechanisms, orofacial pain, head and neck pain, and headache. Muscle, joint, bone, oral mucosal and other soft tissue pathophysiology and common pathology, with emphasis to pain. When appropriate, screenings should be requested for medical and psychological problems that contraindicate proposed chronic pain treatment, or certain pain medications, or that require co-treatment, or pre-treatment. Also establishment of a close association with physical medicine services provided for cervical spine, upper quarter and back problems as they are related to orofacial pain, 5. This should include judicious selection of medications directed at the presumed pain mechanisms involved, as well as adjustment, monitoring and reevaluation. Students should demonstrate skills in verbal and timely written communication with other health care professionals and patients. Students should understand the legal guidelines governing licensure and dental practice, and the scope of practice with regards to orofacial pain disorders. Students should receive instruction in the regulatory requirements of chronic opioid maintenance. Diagnostic and treatment assistance can be provided for tooth-site pain of nonodontogenic origin and for complex pain and dysfunction issues if requested. The Orofacial Pain program will refer treated orofacial pain patients to the appropriate dental and surgical disciplines as needed when stabilized. However, this experience must not compromise the didactic or clinical Sample of Curricula currently used Provide a representative sample of curricula currently used in several existing programs. The examples provided should reflect the various approaches for structuring advanced education in the proposed specialty. Sample curricula from institutions presently training Orofacial Pain dentists are provided here from the Schools of Dentistry from University of California, Los Angeles, Rutgers University, and University of Minnesota. You are required to maintain an up-to-date listing of the courses you are taking for each quarter with the Section secretary in order to receive a course completion or grades. Course are expected to be taken for credit unless an exception is made for auditing. Advanced credit for courses can only be given with agreement of the course director, or by a pretest if available. The residency program courses are required courses unless stated as Selectives or Electives. Clinic Rounds Schedule: Monday, Wednesday and Friday 7:30-9:00 (120 hours per clinic year) Course Description: Clinic Rounds are held every Monday and Friday prior to the clinic day. Patients scheduled for the day are discussed by the resident before the attending faculty. The residents keep notes and directions in the patient chart to help them optimize patient response to treatment. The residents learn how to efficiently perform the neurological examination including fundoscopy, neurosensory, motor and reflex evaluations. Introduction to Orofacial Pain Schedule: 1st year Summer Quarter (2 hours per session on 2 consecutive Tuesday mornings) Course Description: this summer introductory course covers the basic conditions included within the scope of orofacial Pain. The course reviews musculoskeletal, neuropathic, neurovascular and related neurologic disorders commonly seen in an orofacial pain clinic. The pathophysiology of these conditions is discussed and linked with the examination procedure required to form a differential diagnosis and focus on a primary diagnosis. Psychological assessment instruments are reviewed and related to patient presentations and response to treatment. In addition, clinic experience with assigned patients is monitored by the course director. Each muscle group in the orofacial, cervical and shoulder girdle is review in detail including insertion, attachments, innervations and referral patterns. Introduction to Pain Pharmacology Schedule: 1st year Summer or Fall Quarter (2 hours) Course Description: the 1st year residents are introduced to the medications that are used to mediate chronic pain disorders. These medication include the medications for neurovascular disorders, medication for neuropathic pain disorders, medications for musculoskeletal pain and psychotropic medications that are used for adjunctive therapy to improve response to pain management. Oral Medicine Clinic Rotation Schedule: 1st Year Summer and Fall Quarter Wednesday Morning 9-12 (16 hours) Course Description: Each resident rotates into the Oral Medicine Clinic on Wednesday Mornings for the Summer and Fall quarters of the 1st year. The resident shadows the oral medicine clinicians, observing the examination and evaluation of oral lesions, burning mouth syndromes and other pathological conditions seen in the oral environment. The residents also assist in obtaining biopsies, closing wounds and other oral medicine procedures. Basic Neuroanatomy of the Orofacial Region Schedule: 1st Year Summer and Fall Quarters. The neurologic exam is also reviewed for each of the nerves and the relevant pain and dysfunction problems seen in an orofacial pain practice. Course Description: the residents and faculty director review journal articles on subjects related to orofacial pain taken from peer reviewed journals. The subject matter includes Headache Disorders, Neurologic disorders, Sleep disorders, Orofacial Pain disorders. Residents are assigned to read the articles and prepare reviews of the articles that are presented in a class format. Course Description: the residents rotate in Dental Radiology to review radiographs of patients referred to the Radiology Clinic. Additionally, time is spent evaluating airway problems associated with obstructive sleep disordered breathing. Course Description: Residents shadow in the orofacial pain faculty practice, participating in the evaluation and treatment of the private patients. Rotation and Shadowing in Cedar Sinai Pain Center Schedule: 6 consecutive weeks in the second year of residency. Residents do intakes of the patients, prepare patients for procedures, give patient instructions for home care. Papers are assigned to the residents who will develop powerpoint presentations to discuss the main points of the papers. Literature assignments are given to the residents who will review and critique the papers with the course director. The residents are taught the concepts of pain in relationship to time and culture with key figures who contributed to the development and understanding of pain and its treatment through the ages. An in depth review is made of medications used to treat musculoskeletal disorders, headache disorders and neuropathic pain. Rutgers School of Dental Medicine Program in Orofacial Pain Orofacial Pain Dentistry is concerned with the prevention, evaluation, diagnosis, and management of persistent and recurrent orofacial pain disorders. The orofacial pain dentist is responsible to understand pain mechanisms and for the diagnosis and treatment of patients in pain that is often chronic, multifactorial, and complex. It is the responsibility of the orofacial pain dentist to accurately diagnose the cause(s) of the pain and decide if treatment should be dentally, medically, or psychologically oriented, or if optimal management requires a combination of all three treatment approaches. Among the essential armamentarium is the knowledge and proper use of pharmacologic agents. Students pursue a Master of Science in Dentistry or a Master of Dental Science as their degree. The Master of Dental Science program is designed to give students a more in-depth understanding of the biological processes underlying their clinical specialty. The objective of the program is to enable the students to become critical thinkers and evaluators of best practices in dentistry or for those who may desire a career in research. To accomplish these objectives, each student must complete thirty credits of the didactic, clinical and research-based program. Upon completion of the program, the postdoctoral student receives the Master of Dental Science or Master of Science in Dentistry degree and meets eligibility requirements for the American Academy of Orofacial Pain Board examination. The curriculum is comprised of didactic assignments, clinical experience, medical and dental rotations, and teaching responsibilities. Different types of learning experiences include seminars, lectures, workshops, and self-study activities. Each post graduate student is required to complete a series of courses and rotations designed to provide the necessary scientific background for management of patients with orofacial pain. An important part of the program is clinical experience that continues across the entire program commencing in the first quarter. The faculty will assess competence in the field of orofacial pain on a regular basis. Knowledge of basic sciences and material presented in didactic lectures will be assessed by a series of written examinations at the end of the program. Each post graduate student will be responsible for a specific reading assignment and will lead the seminar. An informal seminar setting is used to encourage stimulating discussion from all the participants. Emphasis is on diagnosis and management strategies with all clinical decisions validated and supported by the scientific literature. In addition, monthly Grand Rounds are held with the New Jersey Neuroscience Institute of Rutgers School of Medicine where our residents interact with and present case to neurologists, neurosurgeons and their residents regarding orofacial pain. Orofacial pain post graduate students are required to prepare case presentations or lectures on various orofacial pain topics either of their choosing or by assignment from the faculty. Their presentations are given to the Division of Orofacial Pain faculty and students. Post graduate students are also required to complete a paper of publishable quality for submission to a refereed scientific journal on a topic to be mutually determined by the student and program director. The didactic coursework is as follows: Head and Neck Anatomy Physical Diagnosis and Evaluation Seminars in Orofacial Pain Principles of Research in Orofacial Pain (Current Literature) Orofacial Pain Clinic During the following semesters, students take more in-depth courses related to orofacial pain, as well as continue with additional coursework in related areas. They continue to work in literature review and orofacial pain seminars in each semester and will take thesis credits. Rotations through other clinics are arranged during the summer and fall of the second year of study and are part of the clinic course in Orofacial Pain. During this time they work on clinical interviewing skill acquisition, head and neck examination skills, gaining solid diagnostic skills. They will also begin to work with splints (insertion and adjustment), physical medicine techniques, health psychology and pharmacotherapy. At this time, they must begin keeping track of patients seen and procedures performed in order to acquire the number and types of experiences necessary to meet program standards. The following is a list of rotations for the Orofacial Pain Residents: Otolaryngology Rheumatology Chronic Pain Service, Neurology and Acupuncture Sleep Medicine Physical Medicine and Rehabilitation Neurology Oral and Maxillofacial Surgery Movement Disorder Clinic Research All students are required to engage in research activity. They are also required to develop and complete an independent research project under the guidance of a thesis committee approved by the University of Minnesota Graduate School. Students not participating in a 113 Graduate School administered degree program are required to either complete their own research project, or participate in research being conducted be the Orofacial Pain Faculty. Students are also encouraged to develop abstracts for presentation at local, state and national meetings. Pain Management Best Practices InterAgency Task Force Report: Updates, Gaps, Inconsistencies, and Recommendations. Thilander, Prevalence of symptoms of functional disturbances of the masticatory system in Swedish men. Czarnecka, Results of epidemiological examinations of the temporomandibular joint in adolescents and young adults. Egermark-Eriksson, An evaluation of the need and demand for treatment of craniomandibular disorders in a young Swedish population. Newbrun, Comparison of trends in the prevalence of caries and restorations in young adult populations of several countries. Carlsson, Sick-leave in patients with functional disturbances of the masticatory system. Reinhardt, the behavioral management of chronic pain: long-term follow-up with comparison groups. Curriculum guidelines for the development of pre-doctoral and post-doctoral programs in temporomandibular disorders and orofacial pain. Analyses of anamnestic and clinical recordings of dysfunction with the aid of indices. Proceedings of the National Academy of Sciences of the United States of America, 1977. Fields, Endogenous pain control systems: brainstem spinal pathways and endorphin circuitry. Herdegen, Control of Gene Transcription by Jun and Fos Protiens in the Nervous System. Mense, Blockade of nitric oxide synthase differentially influences background activity and electrical excitability in rat dorsal horn neurones. Perl, Excitation of marginal and substantia gelatinosa neurons in the primate spinal cord: indications of their place in dorsal horn functional organization. Hawker, the prevalence of altered sensation associated with implant surgery (see comments). Pharmacological approaches to the treatment of chronic pain: new concepts and critical issues. Srinivasa, Is Nociceptor Activation by Alph-1 Andrenoreceptors the Culprit in Sympathetically Maintained Pain? Reeves, Quantification of changes in myofascial trigger point sensitivity with the pressure algometer following passive stretch. Craniomandibular disorders: guidelines for evaluation, diagnosis, and management.
