Trandate

Kelly Bookman, MD

• Assistant Professor
• Division of Emergency Medicine
• University of Colorado Denver School of Medicine
• Aurora, Colorado

Physical exam may have to be deferred blood pressure zone buy trandate in india, however hypertension blood pressure readings order generic trandate, take vital signs and perform an exam as clinically indicated hypertension journals order 100 mg trandate. Appearance is remarkable for wearing revealing and likely designer clothes with excessive makeup blood pressure chart south africa purchase line trandate. Mood is described as happy and on top of the world? and affect is elevated and euphoric arrhythmia with pacemaker buy 100 mg trandate with visa. Thought process is disorganized with apparent flight of ideas connected to grandiose delusional themes arrhythmia management plano buy trandate 100mg overnight delivery. Insight is poor and Judgment is quite poor wants to fly to Milan in this state which can lead to unfortunate outcomes. Additional testing may be recommended, if indicated, depending upon the presentation and differential diagnosis. Continue to obtain collateral information Establish a diagnosis and management plan Explain this to the pt. If at any point during the interview or later you feel threatened, leave the room and ask for assistance. At other times, the patient is so agitated that an emergency chemical restraint is necessary before assessment can be completed for the safety of the patient and medical personnel. Make sure there are no acute medical concerns requiring further assessment and treatment. After 30 mins, a Form 1 is filled out and a Form 42 given to Catie, advising her she needs to stay involuntarily upto 72 hours as she is at a risk for physical impairment to herself. She may go the airport in this state and may be accosted by the authorities or meet with a violent incident attempting to fly in this state. Assess capacity usually done after acute stabilization For mania/hypomania doing a Financial Capacity assessment if often necessary and it is the duty of the attending physician to do so. A Form 21 (Certificate of Incapacity for managing property) needs to be filled out and a notice delivered to pt. Counsel and support patient/caregiver/family regarding clinical impression/management Refer the patient for specialized care once stabilized. Psychopharmacology for Acute Management of Mania: Bipolar Disorder Mania and Hypomania Prepared by Dr. Designing a relapse drill (create document with early relapse signs, self-treatment manoeuvres, pre-negotiated treatment approaches)? Connecting patient to other community resources to enhance support and autonomy Bipolar Disorder Mania and Hypomania Prepared by Dr. A Form 21 is also done after discovering she had maxed out her credit cards buying a first class ticket to Milan and designer clothes. Her Bupropion is discontinued and Lithium restarted and titrated to a blood level of 1. She is worried about the wasted money and says she does not remember the events of the past week or so. Has there ever been a period of time when you were not your usual self and? you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble? How much of a problem did any of these cause you like being able to work; having family, money, or legal troubles; getting into arguments or fights? Have any of your blood relatives (ie, children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder? Has a health professional ever told you that you have manic-depressive illness or bipolar disorder? Bipolar disorder is a complex illness, and an accurate, thorough diagnosis can only be made through a personal evaluation by your doctor. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. This instrument is designed for screening purposes only and is not to be used as a diagnostic tool. How to Use How to Score the questionnaire takes less than 5 minutes Further medical assessment for bipolar to complete. Patients simply check the yes or no disorder is clearly warranted if patient: boxes in response to the questions. However, we request when using any of its content that the publication is cited as follows: 2015 Florida Best Practice Psychotherapeutic Medication Guidelines for Adults (2015). The University of South Florida, Florida Medicaid Drug Therapy Management Program sponsored by the Florida Agency for Health Care Administration. The guidelines contain evidence-based recommendations for prescribing psychotherapeutic medication to treat severe mental illness bipolar disorder, major depressive disorder, and schizophrenia. The overarching goal of the guidelines is to inform and support clinicians (specifcally primary care clinicians, who provide the majority of mental health care in the state) in making treatment decisions that are safe and evidence-based, and that maximize beneft and minimize harm to patients. In addition, a section on treating mood disorders in pregnancy was added to help clinicians who often face practice challenges in deciding how best to treat women with psychotherapeutic medications during pregnancy because the evidence to guide decision making is often contradictory and/or limited. As in years past, we sought to produce a document that is sensitive to the realities of clinical practice, and provides care recommendations relevant to both clinicians and patients. It is our intent to support treatment decisions made by clinicians that will be based on empirical evidence and also account for individual variation and patient needs in treating complex and challenging mental health conditions. The 2015 Florida Expert Panel met in Tampa, Florida on September 25-26, 2015 to review and update the adult guidelines last published in 2013. For each disorder, a psychiatrist who is a nationally recognized content expert reviewed the scientifc literature on treatment and made suggestions to the panel on revising the guidelines based on the state of the scientifc evidence. The panel then discussed the guidelines and proposed revisions, and reached a consensus about whether to revise and adopt a particular set of guideline recommendations. Thus, the fnal guidelines are a product of an in-depth review of the literature with an emphasis on the highest level of clinical evidence medicaidmentalhealth. The names of the meeting attendees and meeting presentations are available on the program website at The treatment recommendations for each section are categorized by levels that are hierarchically based on the strength of the scientifc evidence for efcacy and for safety regarding a particular agent or treatment option. Thus, Level 1 treatment has stronger empirical evidence for efcacy and/or safety than Level 2, and so forth. A description of the guideline process and assignment of levels of recommendations was recently published1 and are adapted here to explain the basis for each Level: n Level 1 is initial treatment for which there is established efficacy and relative safety for the treatment recommendations (based on replicated, large randomized controlled trials). Compared to Level 1, the data on treatment efficacy and/or safety in Level 2 is less robust (based on smaller randomized controlled trials, smaller effect sizes, etc. Treatments at this level have more limited efficacy data and/or more tolerability limitations than Levels 1 and 2. It should be noted that the levels are not algorithms in which specifc treatment decisions are mandatory. Instead, the use of the adult guidelines should take into account the individuality of the patient and presenting symptoms. The inevitable changes in the state of scientifc information and technology mandate that periodic review, updating, and revisions will be needed. These guidelines may not apply to all patients; therefore, each guideline must be adapted and tailored to the individual patient. Proper use, adaptation, modifcations, or decisions to disregard these or other guidelines, in whole or in part, are entirely the responsibility of the clinician who uses the guidelines. The authors bear no responsibility for the use of these guidelines by third parties. The integration of measurement scales into routine clinical practice is suggested for each of the conditions covered in this document. Clinicians should use rating scales to assess symptom severity during the initial evaluation/treatment, when medication changes are implemented, and/or when the patient reports a change in symptoms. Internet links to the following scales are available on the program website Antipsychotics are heterogeneous or variable in efcacy: n the risks are not insignificant. For these conditions, antipsychotic utilization should be: F Aimed at target symptoms F Prescribed only after other alternative treatments have been tried F Used in the short-term F Monitored with periodic re-evaluation of benefts and risks F Prescribed at the minimal efective dose medicaidmentalhealth. F If inadequate response, follow with systematic trial of monotherapy with one or more other antipsychotics at adequate dose and duration. F If inadequate response, follow with a trial of clozapine or a long-acting antipsychotic. F Repeated assessment of efcacy using reliably defned treatment targets (use standard rating scales. F Standard protocols customized to individual vulnerabilities/needs and specifc agent. The hotline is funded by the Florida Medicaid Drug Therapy Management Program for Behavioral Health through a contract with the Florida Agency for Healthcare Administration. The primary goals of bipolar disorder care are remission, maintenance of response, prevention of relapse, and full functional recovery. Consider psychiatric consultation, if possible, prior to psychotherapeutic treatment. Level 2A Established efcacy, but with safety concerns*: F Olanzapine + fuoxetine (bipolar I disorder) *Tolerability limitations include weight gain and metabolic concerns. F Lithium (bipolar I disorder) F Lithium adjunctive to lamotrigine (bipolar I disorder) F 2 drug combination of above medications *Efcacy limitations, relatively few positive randomized controlled trials; positive meta-analysis for lamotrigine in bipolar depression. The primary goals of bipolar disorder care are safety, symptomatic improvement, and patient psychoeducation. Example: lithium + (divalproex* or carbamazepine) + antipsychotic *Caution should be used when prescribing divalproex to women of reproductive age due to increased risk in pregnant women of neural tube defects and other major birth defects. Longer-term efcacy data is limited for the following: divalproex monotherapy, carbamazepine (drug interaction risk), antidepressants, electroconvulsive therapy (inconvenience/expense). In elderly, start with lower lithium dose, titrate more slowly, and require lower serum lithium levels. Divalproex In acute mania: Initial loading may be tolerated, but some 5-60 mg/kg/day; patients need initial titration for tolerability. Carbamazepine In acute mania: Initial titration for tolerability due to hepatic auto 200 1600 mg/day induction: Start 200-400 mg/day and increase (serum level 6-12 g/mL) 200 mg/day every 3 days. Lamotrigine In bipolar maintenance: Initial titration to reduce risk of serious rash 100 400 mg/day (Stevens-Johnson syndrome): Start 25 mg/day (12. May be used in some patients with acute bipolar depression (despite acute efcacy limitation) due to good tolerability and depression prevention efcacy. Aripiprazole: 15-30 mg/day Lower doses may be necessary in depressed Antipsychotics patients. The 2015 iteration of the Florida Best Practice Psychotherapeutic Medication Guidelines for Adults (6th update) is a critical component of decision support that attempts to narrow the foregoing gap in health outcomes by fostering precision and consistency, as well as the appropriate selection and sequencing of treatments throughout each stage of the illness. In the interest of consistency from the previous edition of the guidelines, we have retained the three algorithms for acute mania, acute bipolar depression, and bipolar continuation/maintenance with the recognition that for many individuals with bipolar disorder, the illness is highly relapse-prone, chronic in nature, and lifelong. Since the publication of the adult guidelines ffth edition in 2013, there has been only one new U. Notwithstanding, there has been robust and accumulating evidence for greater attention given to clinical aspects of chronobiology, metabolic and physical health aspects, cognitive dysfunction, as well as premature mortality in this population. Thus, clinicians are encouraged to screen for bipolar disorders among adults utilizing healthcare services for afective and anxiety-related symptomatology at index visit and across repeated visits if therapeutic objectives are not achieved. Vigilance for bipolar disorder is warranted among individuals presenting in healthcare settings with depressive symptoms, as depressive episodes are often polarity-frst? as well as polarity-predominant? in individuals with bipolar disorder. The timeliness of accurate diagnosis is underscored by convergent evidence in support of an integrated conceptual pathogenic framework indicating that bipolar disorder has both neurodevelopmental as well as neurodegenerative aspects. In 2015, the American Heart Association consensus statement identifed bipolar disorder (and major depressive disorder) as a Tier 2 risk factor for cardiovascular disease and accelerated atherosclerotic illness. The integrated care of bipolar disorder warrants systematic and routine screening for traditional and emerging risk factors for cardiovascular disease. The foregoing recommendation is a derivative of the morbidity and mortality data directly attributable to medical disorders. As well, emerging evidence indicates that concurrent medical disorders afect the age at onset, presentation, severity of illness, and response to treatment; and therefore, are a reminder that general metabolic disorders may metastasize? to medicaidmentalhealth. When medical disorders are present, contemporaneous management of both bipolar disorder and medical/psychiatric comorbidity is critical. As per previous guideline iterations, all individuals with bipolar disorder must be carefully assessed for ideation/plans of harm to self and others with systematic assessment of risk for suicide. Pharmacotherapy in bipolar disorder is considered a standard of care across all phases of the illness. The observation that functional outcomes in bipolar disorder are uncoupled from symptomatic outcomes has shifted attention towards other dimensions/domains of disturbance including, but not limited to , cognitive dysfunction. For multi episode and late-stage bipolar disorder, functional remediation which targets interpersonal and social competence, and general cognitive function is warranted. There remains a paucity of safe, well-tolerated, and efective agents for the acute phase of bipolar depression. The metabolic hazards of olanzapine justify its recommendation as a Level 2B treatment. Notwithstanding the introduction of the mixed features specifer, there remains an absence of controlled trial data that have evaluated therapeutic outcomes in adults with bipolar depression and mixed features specifer. Replicated evidence indicates that armodafnil is insufciently efcacious in adults with bipolar depression. As per previous iterations, the steps of treatment modality suggested integrate both the likelihood of ofering therapeutic beneft as well as safety and tolerability concerns. The principles of safety, risk assessment, capacity determination, and timely diagnosis are critical. The scientifc evidence is compelling that lithium and divalproex, as well as atypical agents ofer therapeutic beneft in mania. So far, no studies have primarily enrolled individuals meeting criteria for mania with mixed features specifer. The increased risk for additive/multiplicative adverse events warrant recommendations for beginning treatment with monotherapy, recognizing that for some individuals receiving combination therapy.

As commonly used pulse pressure 30 mmhg purchase trandate 100 mg on line, it is only 73 percent efective arteria tapada sintomas discount trandate 100mg free shipping, meaning that 27 of every 100 women whose partners use withdrawal will become pregnant over a year arteria labialis superior trandate 100 mg on-line. Also arrhythmia tachycardia cheap trandate 100mg, a small amount of semen may be released into the vagina before the full ejaculation blood pressure 40 order trandate 100mg overnight delivery, possibly without the man realizing it blood pressure 88 over 60 trandate 100mg on line. Sterilization is appropriate for men and women who are certain they do not want more children. The permanent methods of contraception are female sterilization, also called tubal ligation, and male sterilization, also called vasectomy. Female and male sterilization are close to 100% efective and are considered permanent methods of contraception, although a small risk of pregnancy still remains. Once a woman or man has the procedure, it is very likely that she or he cannot have any more children because generally the procedure cannot be reversed. The couple must talk over the decision to use a permanent method carefully and be certain that they will not want more children. Men and women should understand that other highly efective and reversible contraceptive methods are available if they are not ready for a permanent method. They should discuss the decision with a family planning provider, who will make sure that their decision is voluntary, conduct a physical examination, and decide with the client on a good time to have the sterilization done. A provider can also reassure men and women that sterilization does not afect sexual function and does not make men less masculine or women less feminine. Female sterilization has no side efects, and complications are extremely rare when the procedure is performed by a well trained health care provider. Following surgery, a woman may have some abdominal pain and swelling, which goes away in a few days. If possible, she should return to the health care provider afer about a week to have the incision checked for infection and to have the stitches removed. This keeps sperm out of the semen, the fuid that is released by a man during an ejaculation. The man can still ejaculate and have an orgasm as before, but there will be no sperm in the semen, and so he will not be able to cause pregnancy. Afer the procedure a man may have discomfort, swelling, and bruising in the scrotum. Although a man can have sex 2 to 3 days afer the procedure, vasectomy is not efective immediately. During these 3 months a man or his partner should use another family planning method, such as condoms. Where possible, a health care provider can examine a semen sample under a microscope to see if it contains living sperm. Vasectomy is simpler than female sterilization, recovery is quicker usually a day or two and the method allows men to take responsibility for family planning. Afer this procedure, a man can enjoy sex with his partner as before, except now without fear of pregnancy. After having a baby, it is a good idea to wait at least 18 months before getting pregnant again to maintain the best health for her body and her children. These conditions are associated with infant mortality and other short-term and long-term health complications. A woman may choose a medication or hormonal method (such as the pill, injectables, patch, implants or ring). All of these methods are reversible and allow the woman to resume trying to get pregnant after the healthy 18 month birth spacing period. For more information: For more information, contact the Family Planning Program at (302) 744-4552. The arrival of modern contraception empowered women to take control of their own bodies, of their sexuality and 3 their choice to have or not to have children. However, not all people have equal access to (information on) contraceptives, as this is dependent on their social, cultural or economic status and the country they live in. Access to family planning contributes to more freedom, independency of women and gender equity. Therefore, Rutgers likes to attribute to these rights and to improve reproductive health, by promoting access to contraceptives to all, by delivering proper knowledge, evidence and practice based information and supporting professionals with tools and advice. In this paper, we will first introduce the variety of contraceptive methods, then we discuss the policies and actors related to reproductive health and rights, and we continue this paper with the use, availability and access of contraceptives worldwide, and more specific in the Netherlands. We will also describe the health risks and side effects of contraceptives, the benefits of education and services and developments and innovations. At the end, we will describe some good practices and we will conclude with recommendations for the future. The hormonal short-term contraceptive methods, like the Oral Contraceptive Pill, the birth control patch, the birth control vaginal ring and the birth control injection. Other more natural and more traditional methods of family planning are: coitus interruptus and coitus reservatus. Other more traditional methods are the Temperature and Billing method, mostly used to measure fertility periods and recently supported by online family planning apps. First generation: included norethisterone and norethindrone acetate containing pills b. During the lifetime it is necessary to look at the right match, which is based on personal preferences and medical contra indications, but also on the reasons of women (and partners) for not wanting to become pregnant. It is important to understand the reasons women (and men/partners) have for not wanting to become pregnant. Some of them would like to delay their pregnancy, while others already have the number of children they want (limit births). There are also women who already have one or more children and they want to wait a few years to become pregnant again, they prefer to space their births. Per region the reasons for not wanting to become pregnant differ widely among women as can be seen in the following graphic. Another contraceptive that has been around since 1842 is the diaphragm (Harvey et all, 2004). More modern contraceptive methods like the oral contraception pill were firstly introduced in the 1960s. In the 1950s large scale clinical trials were conducted and the pill was tested on Puerto Rican and Haitian women. The pill appeared to be 100% effective, although some serious side-effects were present but ignored in the beginning. In the Netherlands the pill was introduced in 1964 and in four years four out of 10 Dutch women between the ages of 21 and 34 had used it (Ketting, 1982). With the introduction of the pill, it was the first time that sexuality and reproduction were disconnected and women could enjoy sexuality without worrying about pregnancy. In most countries the pill was only available for married women, but this was still revolutionary. It empowered women to take control over their own bodies, of their sexuality and their desire to have or not to have a child. After the introduction, discussions started if the contraception pill would contribute to a greater freedom and sexual empowerment of women or attribute to more coercion and pleasure for men (Andere Tijden, 2002). In 1967 the controversy around the pill took a new dimension when African-American activists claimed that by providing the pill in poor, minority neighbourhoods, genocide was committed (Blakemore, 2018; Vargas, 2017). The Pearl Index indicates the number of pregnancies that will occur, on average, when a specific method is used by 100 women in one year. The reliability of contraceptive methods is based on 2 indicators, the method itself and the rate of it being used correctly. In the table below you can see the percentages of the perfect use (when the method is always used correctly) and the percentages of the typical use (in reality). If for example 100 sexually active couples will use no contraceptive method for one year, about 85% of the women will get pregnant, therefor the Pearl index is 85%. The Pearl Index is often criticized, as it does not consider that contraceptive failure rates typically decline with continued use. Therefore, a Pearl Index determined by a study of new and short-term users of a method will likely be higher than in a study of long-term users. Demographic factors are also not considered, although they influence method adherence and, in turn, efficacy. Because of variations in study design, study populations, and data collection and analyses, rates of contraceptive failure reported in clinical trials are difficult to interpret and compare. Due to many different studies and interpretations, different Pearl Indexes are available. Long acting reversible contraception and sterilization are associated with the lowest pregnancy rates. Oral contraceptives, the patch and vaginal ring, are also associated with a very low pregnancy rate if they are used consistently and 6 correctly. Other methods of contraception, including diaphragms, cervical caps, sponges, male and female condoms, spermicides, periodic abstinence and withdrawal are associated with actual pregnancy rates that are much higher than perfect use rates. Actual effectiveness is also influenced by frequency of intercourse, age, and regularity of menstrual cycles. Pregnancies are less likely in women who are older, have infrequent sexual intercourse, and have irregular menstrual cycles. Contraceptives reduce the number of unintended and unplanned pregnancies and therefore help prevent pregnancy related deaths and infant deaths. International bodies repeatedly call on states to ensure women have access to contraceptives. Reproductive rights are defined as: Reproductive rights embrace certain human rights that are already recognized in national laws, international human rights documents and other consensus documents. These rights rest on the recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health. Under International Human Rights Law, states have an obligation to provide women with access to a full range of contraceptives and information on the methods and it stipulates that women should have access to female-controlled contraceptives (Shalev, 1998). In the Programme of Action it is clearly affirmed that reproductive and sexual health is protected within the human rights already recognized by both national and international law. Moreover, the complex link between population, growth and gender equality was recognized. During the 1995 World Conference in Beijing it was highlighted, among other issues, that women and men have the right to equal access to education and health care and equal treatment. Although a lot of progress has been made considering reproductive health and rights, much more can and needs to be improved. Education in general has a key role in preventing early and unintended pregnancies. The birth rate declines in most countries were contraceptives are available, affordable and accepted. The core state obligations in connection to the right to health, is to ensure the availability, accessibility and acceptability of contraceptives. Furthermore, International Human Rights law requires health-care facilities, commodities and services to be accessible to everyone without discrimination. This includes physical and economic accessibility as well as access to information. All healthcare facilities, commodities and services must also adhere to acceptability and therefore be respectful of medical ethics, the culture of individuals, minorities and communities and be sensitive to gender and life cycle requirements. Although in most countries a wide range of contraceptive methods are available and provided by most reproductive health services, differences may exist in availability of methods between urban and rural or private and governmental hospitals and health centers. Accessibility is mainly dependent on the cultural, economic and political contexts of individuals and countries. Particularly young people, poorer segments of populations or unmarried people have limited access to contraception. Young and unmarried people in many communities are not allowed or expected to have sexual relationships before marriage. Therefore, prescriptions might not be given without parental consent or health services are not youth friendly. Dutch case: Availability of contraception in the Netherlands In the Netherlands male condoms are widely available at pharmacies, drugstores, supermarkets and vending machines in bars, online or in entertainment venues in the Netherlands. Since a couple of years the female condom is available but only online or at the condom shop and drugstores. The emergency pills (Norlevo since 2005 and Ella One since 2015) are available at the pharmacy without prescription. Since 2015 midwifes may also prescribe contraception and in 2018 they may place and inserts all kind of contraception. They inform adolescents about a wide range of contraception methods, but not all Sense services can deliver or insert all contraption methods. Once a prescription is obtained all modern contraceptives are obtainable at the drugstore. For the pill no repeat prescription is needed once an initial prescription has been obtained. Sterilisation and vasectomy are carried out in hospitals, or licensed sexual reproductive health services or abortion clinics. There are no age restrictions on contraceptives other than those of a medical nature. Under the age of 16 parental consent must be provided unless to require such consent would cause serious detriment. In fact a young person is regarded as acting responsible and should be secured confidentially. In many Southern countries access to contraception is donor driven, particularly in South Asia and sub Saharan Africa. It is difficult to give an overview of how the contraceptive methods are being funded or financed as it differs a lot per country and over time. The price that people have to pay for contraception methods in Europe and in the global world varies extremely and emphasizes the arbitrariness of the prices. In several countries prices are increasing while reimbursement from health insurances has been reduced over the past years.

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There is a direct relation between the bleaching rate and the epithelial damage (Boere et al hypertension lifestyle modifications best trandate 100mg. Basic aspects of fluorescence When a molecule absorbs a photon of a certain wavelength it becomes excited heart attack 6 hours purchase trandate 100 mg with amex. This is an unstable condition and the molecule tries to return to the ground state arteria pudenda externa purchase trandate us, giving away the excess energy hypertension with cardiac involvement purchase trandate 100 mg line. For some molecules arrhythmia bigeminy purchase generic trandate online, it is favourable to emit the excess energy as light when transforming back to the ground state hypertension 39 weeks pregnant purchase 100mg trandate free shipping. The peak wavelength of the emitted fluorescence is shifted towards longer wavelengths compared to the absorption wavelengths due to loss of energy in the conversion process. This light source is preferred in clinical practice since it is very compact and cheap. Lasers have the advantage of producing monochromatic light, which can exactly match an absorption band of the sensitizer in the area of the spectrum where the penetration in tissue is the greatest. One disadvantage is that the area of irradiation is limited, so that the beam has to be scanned. It is believed to be a consequence of the photochemical reaction in the tissue, although the mechanism is not yet fully understood. The following 14 recommendations have been suggested: cold fan, ice water and treating smaller areas at a time. Photoactivation of bacteria Photoinactivation of Gram-positive and Gram-negative bacteria is based on the accumulation of photosensitizers in significant amounts in or at the cytoplasmic membrane, the critical target for inducing irreversible damage to bacteria. It has been established that Gram-positive bacteria are very sensitive to the photosensitizing action of anionic or neutral photosensitizers absorbing visible light. Subsequently, singlet oxygen is produced which results in bacterial destruction (Arakane et al. This formation of porphyrins further increases at higher temperatures (Ramstad et al. Light therapy and Acne Vulgaris Sun exposure is reported to have a beneficial effect on acne by up to 70% of the patients (Cunliffe 1989). Sunlight has been reported to have an anti-inflammatory action in acne, possibly by its effect on follicular Langerhans cells (Cunliffe et al. In order to define the most effective wavelengths for treating acne with visible light, Sigurdsson et al. In their landmark study in the year 2000, the authors reported statistically significant clearance of acne for 10 weeks after a single treatment and for 20 weeks after four treatments. They used red laser light for photoactivation; however, they found contrasting results, i. The postulated mechanism of photodynamic therapy of acne is the photodestruction of P. The most common treatment protocols for light treatment of acne are based on either red or blue light. Red Light Although it has a lower extinction coefficient, red light has better penetration in the skin than blue light. Red light may also have anti-inflammatory properties by influencing cytokinase 16 release from macrophages (Young et al. Blue Light Theoretically blue light has the most effective wavelength for photoactivation of f P. In the clinic the practitioners must sacrifice penetration depth for absorption efficiency and vice versa. There are studies showing a therapeutic effect of blue light in the treatment of Acne Vulgaris (Morton et al. Phototherapy with mixed blue (450 nm) and red light (660nm) has been proposed to be more effective than blue light alone for treating mild to moderate acne, probably by combining antibacterial and anti-inflammatory actions (Papageorgiou et al. Fluorescence Diagnostics Imaging spectroscopy using digital cameras can be used to study fluorescence from tissue. The major advantage of imaging compared to spectral point measurements is that spatial information about skin can be obtained (Svanberg et al. Autofluorescence is the fluorescence obtained from tissue without presence of an external photosensitizer or other fluorescent markers. There are several studies reporting on the use of autofluorescence for demarcating between normal and neoplastic tissue. The equipment needed for fluorescence imaging is a light source for excitation, a digital camera for detection and software for data processing, as illustrated in Figure 10. This method is used in the clinic for demarcation of skin tumours, so-called fluorescence diagnostics. Fluorescence of Acne Vulgaris Due to the presence of endogenous porphyrins, colonies of P. The acne lesions were localized either to the cheeks (10 patients) or to the back of the patients (5 patients). All oral acne treatments were discontinued for 3 months and local treatments for at least 4 weeks prior to study. Patients were asked not to wash or use any emollient during the last 12 hours before each visit. After 3 hours the cream was wiped off from both sides of the face immediately before illumination. Nodular or cystic lesions were prepared using a cannula (1-2 mm) to facilitate cream penetration. The side of the face not receiving illumination was covered when the other side was illuminated. The cheek not receiving illumination or the surrounding skin on the back was covered when the other side was illuminated. Five patients were treated in two areas on their backs with a light dose of 50 J/cm? A sample was taken from the same spot 3 cm lateral to the alar rim on both cheeks at every visit. Patients were informed not to wash or use any emollient during 12 h before each visit. The sebum measurements were performed by briefly pressing a plastic film against the skin for 30 s. A skin surface biopsy was taken by using a quick-setting cyanoacrylate polymer to extract the content of the sebaceous follicles. Microcomedones were cut out of the glass slide with a sterile scalpel and isolated by homogenising the samples in Triton X. The right and the left cheek were treated sequentially, while covering the side of the face not receiving illumination. Fluorescence imaging was performed using a fluorescence imaging device, Photo Demarcation System 1, Prototype 5. This was performed by counting the number of colony-forming units after appropriate dilution on blood agar plates and calculating their number per ml. The light was 2 delivered at 50 Hz in msec pulses, having a pulse energy of 100 J/cm. The average light fluence rate 2 2 was 5 mW/cm, and an accumulated light dose of 7. The excitation was set to 405 nm and the fluorescence emission was monitored in the range of 410-700 nm using a Varian Eclipse spectrophotometer. A distribution-free method was used when calculating the reduction in inflammatory lesion counts. Global severity assessment of acne was graded as moderate in 23 patients and severe in seven at baseline. The non-inflammatory lesions were reduced in both groups, although in this case no statistically significant difference between the groups was observed. All adverse events were resolved within 7 days, with the exception of two cases lasting a few days more. Analysis of pain scores reported by patients at each centre showed that pain scores varied greatly across the centers (median 3. One patient was lost for follow-up and the other was treated with isotretinoin because of severe acne on other localizations. In the nine patients that completed the study there was no difference between 30 J/cm 2 and 50 J/cm at the final evaluation. Also in the patients with acne on their backs, no difference was found between the two doses 50 2 2 J/cm and 70 J/cm at the final evaluation. Adverse events Hyperpigmentation was more common at higher doses of light, and pain was more often experienced when higher doses were used. In two of these four patients, the premature discontinuation was related to treatment failure. One patient had to discontinue the study due to military service, and another patient had an accident and required treatment with oral antibiotics. The reduction in number of cysts observed at follow-up was only significant after 10 weeks. In 4 of these patients the fluorescence images revealed an apparent photobleaching. Two patients got a hyperpigmentation, which was resolved after 3 months for one patient and after 5 months for the other. Evaluation of fluorescence images Fluorescence images, obtained at baseline and before treatment procedures, showed no significant correlations between the number of highly fluorescent pores (Figure 12), acne severity, and the number of lesions or the amount of P. Figure 12: Fluorescence image illustrating presence of highly fluorescent pores on the cheek of one patient with severe acne before treatment. Larger and more inflammatory lesions were observed to exhibit a higher fluorescence. After the treatment with red light only, the number of highly fluorescent pores was assessed, as presented in Figure 13. No correlation between the decreased number of highly fluorescent pores and treatment efficacy was found. No significant 2 2 differences between red light at the dose 99 J/cm and blue light at the dose 7. Two consecutive illuminations at an interval of 24h between treatments caused a decrease in the viable count of the culture by five or more magnitudes. Evaluation of fluorescence spectra Porphyrin amounts were found to increase as a function of growth time. Spectral peaks were found at about 580 nm and 620 nm, and a small shoulder at about 635 nm. This acne score is one of the most accepted for grading acne, but still it is not a precise scale and the judgment could differ between the three investigators when comparing patients? acne with images of different acne scores. It is not always obvious how to grade an acne lesion appropriately as papule, pustule, nodule/cyst or comedone. The results might have been more reliable with two independent investigators at each center. The patients were enrolled between October 2004 and May 2005, summer excepted, which could have affected their acne status. There was no control of whether the patients were tanning from sun exposure or using sun beds. The acne patients were asked to quit their acne treatment 3 months before the study, but patient compliance was not monitored. Split face studies involving light are difficult to assess, as it is difficult to control the effect of cytokines which may be released but not necessarily localized to the treated area only. Nodular or cystic lesions were prepared using a cannula (1-2 mm) to facilitate cream penetration, and in some patients a small bleeding occurred. This could theoretically decrease the light reaching into the lesion and the photodynamic reaction would be less effective. Information given to the patients by study personnel is therefore likely to have affected patients? perception of the treatment. However, we chose this scoring because the Leeds score would be too detailed in these small groups of patients. The reasons for leaving the study were different, but patients with acne belong to that age when life changes a lot. A number of the patients had so many things going on in their lives that they had problems with attending the follow-up visits. One has to consider that it could be a selection of patients who dropped out from the study, but one does not know if they are the good or the bad responders to treatment. In these split face studies the systemic effect cannot be eliminated, as mentioned in paper I. These clinical trials were designed with uncontrolled before?after design, which does not take the intrinsic volatility of acne into account. However, the tool has been used at our clinic earlier with good results, which is the reason why we chose this technique. It is possible that the sampling method was inadequate, making it difficult to detect changes in P. This short period was used because we wanted to include as many patients as possible and patients were eager to receive treatment. None of the patients had been on isotretinoin during the last year before inclusion. In some cases there was too much background light in the room when the fluorescence images were taken. When all the images were analyzed, several fluorescence images were overexposed and had to be excluded. The fluorescence images were limited in number and hence there could be a risk of introducing a type 2 error, i. It is known that autofluorescence can be detected from the porphyrins in a pilosebaceous-rich skin.

In the 1950s pulmonary hypertension 50 mmhg order trandate without prescription, the main sources of information on abortion were hospital and emergency room records heart attack piano order trandate 100mg visa, which were recognized as seriously understating the issue pulse pressure different in each arm buy cheap trandate 100 mg line. Plaza and Briones (1962) conclude that abortions represented 41 percent of discharges from emergency rooms and 8 percent of total discharges from hospitals in their study arteria uterina buy trandate 100mg mastercard. The treatment of abortion-related issues consumed about one-quarter of all obstetrical resources prehypertension systolic blood pressure discount trandate 100 mg. In addition blood pressure medication missed dose generic 100mg trandate with mastercard, hospital statistics indicated an enormous increase in hospital izations following abortion from 8. In the late 1950s and early 1960s, the first community studies in Latin America were carried out in Chile and provided a better idea of the situation in relation to abortion. Estimates indicated that about one-third of all pregnancies ended in abortion (Tabah and Samuel 1961) and that between 75 and 90 percent of these were induced. Another household survey in 1962 in Santiago indicated that 26 percent of the 20 to 44-year-old women interviewed had had an abortion and that about one out of three abortions resulted in subsequent hospitalization (Armijo and Monreal 1964). In the 1960s and through the 1980s, the original 1938 legislation on abortion (Article 19 of the Health Code) was in effect and allowed abortion only for thera peutic reasons,? yet despite its illegality, in most cases it was seldom denounced or prosecuted. Even though societal norms looked down on abortion, there was a tacit understanding that people resorted to it and that it was a personal, if unfortunate, decision. In 1989, during the Pinochet dictatorship, the language of Article 19 was replaced as follows: No action may be executed that has as its goal the inducement of abortion. Denunciations and prosecutions of induced abortion became more frequent, but they continued to be rare overall except in a few hospitals, where they were clearly linked to the presence in those hospitals of a few overzealous physicians. Women who needed care following an abortion quickly identified those hospitals and stopped going to them. In a well-known paper, Requena (1966) describes a pattern whereby abortion will increase during the first stages of family planning pro grams as the motivation for small families exceeds the availability of contraception, but then gradually declines as contraception becomes more established. Some researchers decided to study the impact of a well-designed family planning program on abortion, births to multiparous women, and infant mortality. For that purpose, they set up a research project in 1965 in San Gregorio, a working-class neighborhood in Santiago with a population of 36,000 people. The researchers undertook a baseline population survey using a random sample of 20 percent of the households to determine levels of fertility, abortion, and other basic characteristics of the population. The program emphasized reaching women who had previously resorted to abortion, because of the likelihood of repeat abortions. The educational component of the program consisted mainly of talks to groups or individuals. Two years later, a second survey was car ried out and showed that during 1966, the use of contraception had increased from 12. These were encouraging results, but doubt remained as to whether family planning programs on a larger scale would achieve similar results given real-life program conditions compared with a small, resource-rich social experiment of short duration. Thus, while family planning can and does help people prevent unwanted pregnancies effectively, abortion remains a frequently used option. In Chile in 1987, that is, 27 years after the beginning of organized family planning, esti mates indicate that abortion was still a method of fertility regulation. During that year, some estimates indicate that about 195,000 abortions occurred, of which 90 percent, or 176,000, were induced. For any practical purpose, only women who have already become pregnant have had easy access to the program. Even some successful pro grams directed toward teenagers, like one started in 1981 by the Department of Obstetrics and Gynecology in northern Santiago, worked mainly with young girls who became pregnant and their friends. Perhaps if an effective sex education and family planning program aimed at young teenagers before they became sexually active had been in place, this would have had a positive influence in reducing the large number of pregnancies and out-of-wedlock births among young women in Chile. The number of out-of-wedlock births has remained consistently high over the years, and because the number of total births has declined, the proportion of out-of-wedlock births to total births increased from 17. More than half of births to women under age 20 were out of wedlock in the mid 1980s (Viel and Campos 1987). Fertility has declined less among teenagers that among the rest of the population, and by 2000, births to teenagers accounted for 16. This has been attributed to limited access by that group to sex education and services (Ministry of Health 2006). In addition, Chile has tended to view family planning as a medical issue rather than a social issue. Most discussions have concentrated on technology and logistics; on providers and patients; and on effectiveness, side effects, and means of operation of contraceptive methods. This is where the feminist movement has been instrumental by questioning the medical orthodoxy and empow ering women in need of information, counseling, and services. In recent years, both public and private sector organizations and individuals have sought to address these issues and deal with the associated problems. Unlike what happened in other countries, Chile never had a vertical program focused exclusively on family planning. Although the participation of several indi viduals, mostly doctors, was crucial from the beginning, the country never had a sin gle major leader in the field. The process was always conducted following an insti tutional approach, and the services were integrated into existing health networks. A good family planning program will improve the lives of those it touches directly and will buy some precious time for the nation as a whole to attack the root causes of poverty and establish the basis of development. Family planning obviously does not operate in isolation, but within social contexts and policy frameworks that can facilitate or hinder people learning about and having access to it. It works better in societies where people have freedom of expression and decision making, where the government and the private sector invest in education and health and in better living conditions in general, and where women have access to broad participation in society. Since the end of the military dictatorship in 1990, freedom of expres sion and of political decision making have made momentous strides. Because of good financial management, Chile is currently perhaps the most solvent country in Latin America. It has demonstrated a concerted effort to fight poverty that has been showing positive results, although a wide gap between the haves and the have-nots still persists. The country enjoys some of the best indicators on the continent in relation to maternal, perinatal, and infant mortality, and to a large extent this can be attributed to the continuity and success of family planning. The Chilean program is using the lessons learned from the international family planning experience and is actively incorporating concepts of quality improvement and gender analysis. The rights of individual clients to receive free and informed choice of contraceptive methods and respectful and confi dential treatment from well-trained service providers will, without doubt, go a long way toward extending coverage to those in need. In an attempt to decrease unwanted pregnancies among teenagers, the government recently approved free distribution of emergency contraception for women starting at age 14. This decision engendered a great deal of controversy, but as of this writing, the president and her minister of health have remained firm on the subject. Resultados de una Encuesta sobre Planificacion Familiar en el Area Occidental de Santiago. To say that these changes were revolu tionary is not hyperbole, and a case could be made that the events of the 1960s and 1970s rival other dramatic shifts in public policy in previous centuries, such as the public provision of safe water and sewage disposal. Within this overall context, few scholars or observers would have given much credence to the notion that Colombia, among the most conservative and religious countries in Latin America, would be the first nation on that continent to adopt an explicit population policy advocating a reduction in the population growth rate and the widespread availability of family planning methods, especially to the poor. Fortunately, the context, process, and sequence of events have been documented in a series of articles and books (see, for example, Daguer and Riccardi 2005; Echeverry 1991; Ott 1977; Perez 1976; Perez and Gomez 1974). This chapter, drawing heavily on the aforementioned works and supplemented by the authors? observations, attempts to summarize the extraordinary events that occurred in the 1960s and 1970s and draw lessons that could be appli cable to similar issues currently and in the future. In 1973, Colombia was the fourth most populous coun try in Latin America with a population of 22. Fertility declined well in advance of the formulation of a national population pol icy and the development of a national family planning program. The Ministry of Health sets up the Maternal and Child Health Program and begins providing family planning services. The National Planning Department, which entered the population field in late 1968, presents a draft national population policy to the National Council on Economic and Social Policy. The Lleras Restrepo government approves the national population policy, aimed, among other things, at changing the population growth rate by lowering fertility. However, as Ott (1977) points out, the usual concomitants of a push for a fertility control policy?negative impact on economic growth, popula tion density, and inability to provide services to growing cohorts?were not, in gen eral, salient issues in Colombia. Indeed, the Colombian church hierarchy had a formidable reputation as the most powerful and least pro gressive in Latin America. How then did Colombia turn out to be a pioneer and leader in the formulation of population policy in the Latin American context? The answer appears to lie, to a large degree, in the actions of a small number of talented and committed Colombians and the often unpredictable course of the policy process (Bauer and Gergen 1968; Measham 1972; Ott 1977). Former president Alberto Lleras Camargo strongly advo cated measures to control population growth in an August 1965 Pan American Assembly on Population held in Cali, Colombia. That set the stage for the major role in population policy development played by Carlos Lleras Restrepo, who was presi dent from 1966 to 1970. Apart from Lleras Camargo (Ross 1966) and Lleras Restrepo, most of the small coterie of people responsible for the massive policy change consisted of physicians in the oft-noted Latin American tradition of physi cians playing leading roles in many aspects of national life. Population Policy Development: 1964?70 the policy process is usually complex, idiosyncratic, and impossible to analyze in a rigorously scientific way (Lindblom 1968). Whether success would have been achieved without the weight of his office is doubtful, not to mention his training in economics and his bold and visionary style. Well before he became president, Lleras recognized the macro economic implications of population growth? (Ott 1977, p. In addition, he recognized the inte gral role of population trends in development planning. At roughly the same time that Lleras was preparing to take over the presidency, the physicians mentioned earlier were laying the groundwork, analytically and opera tionally, for a national population policy and a national maternal and child health and family planning program. Mendoza, a man distinguished by his intellect, tough-mindedness, and enormous capacity to work? (Ott 1977, p. Mendoza used this evidence to establish the existence of a population problem and the need to do some thing about it. The church, for its part, was awaiting the papal encyclical Humanae Vitae, which was proclaimed in 1968. The Ministry of Health was the last, though not the least, major player to join in the provision of family planning services, within its Maternal and Child Health Program, beginning in 1969. Even earlier, how ever, the administration of Guillermo Leon Valencia (1962?66) had approved the use of U. What is known is that all seven physician leaders knew each other well, communicated fre quently, and shared a strongly held motivation to make family planning services widely available, especially to the poor, and to have their country adopt an explicit population policy. The experience of one of the seven, Lopez-Escobar, suggests that the seven worked closely together in pursuit of their common cause. All seven physi cians who played such major roles in this narrative were highly regarded, elite mem bers of their profession, with strong reputations and extensive social networks among the Colombian elite. These attributes no doubt accounted in part for their boldness and their ability to withstand the criticism and attacks that were to come, notably from the church and the political left. Ordonez was a natural, statesmanlike spokesman, the voice of moderation and reason, which was ideally suited to his exposure to criticisms from both advocates and critics of the unfolding events. Tamayo was fiercely independent, did what he thought was right for his country, and challenged all and sundry to try to stop him. Mendoza also possessed strong political and strategic instincts, but was more inclined to take a confrontational stance when he thought it was appropriate. Tragedy and Conflict: 1968 Just as developments looked highly propitious for the adoption of a population pol icy and the expansion of the nascent national family planning program, a series of setbacks occurred in rapid succession. On July 29, 1968, the Vatican issued the encyclical Humanae Vitae banning the use of artificial? methods of contraception; the pope visited Colombia on August 22?24, 1968; and Mendoza died suddenly of lung cancer on August 28, 1968. These events clearly reduced the momentum toward the develop ment of a population policy and national family planning program. Ott (1977) inter prets the ensuing slowdown as reflecting two factors: the centrality of political considerations in the evolution of policy and the extent to which the gathering momentum had been substantially dependent on a single person, namely, Mendoza. Adoption of a National Population Policy, 1969?70 Subsequent developments attest to the momentum that had been achieved up to August 1968 and to the main players? determination not to be thwarted in their aspi rations. From 1969 onward, the Min istry of Health provided family planning services within its Maternal and Child Health Program, which was delivered in most of the nationwide network of 1,200 health centers and posts, and within a postpartum family planning program in approximately 30 regional hospitals (Rizo 1978). In 1974, approximately 550,000 cycles of oral contraceptives were sold monthly, with the private sector accounting for more than half of the sales. By 1978, preva lence was estimated to have risen to 48 percent, an increase of 20 percentage points in less than a decade (John Ross, personal communication to Anthony Measham, 2006). So rapid was the decline in fertility that the birth rate predicted for 1985 may have already been reached by 1975 (Perez 1976). The crude birth rate fell from 45 live births per 1,000 population in the 1950s to 32 in 1973 and the infant mortality rate declined from about 100 deaths per 1,000 live births in 1964 to 76 by 1973. By 1971, the crude death rate had declined to 10 deaths per 1,000 population from 15 in 1964, resulting in a population growth rate of approximately 2. In approximately two decades, these demographic shifts resulted in a quantum increase in human welfare. The extent to which the increased avail ability of family planning services contributed to these changes is still being debated; however, the contribution was no doubt substantial. A Closer Look at the Context A critical question is how, in just a few years, did Colombia manage to develop a national population policy and fertility reduction program in an inhospitable envi ronment grounded in religious and cultural traditions? In particular, the high incidence of abortion and the sizable gap between desired and actual family size suggested a substantial unarticulated demand for family planning? (Ott 1977, p. Critically, Mendoza and his colleagues recognized that the challenge they faced was essentially political: a population policy and family planning program would only be possible in the event of a nationwide change in the way family planning was viewed and, even more important, that the government was responsible for providing the neces sary services. In particular, the extensive use of external assistance made the effort vulnerable to accusations of U. Nevertheless, it is hard to argue with success and hard to second-guess a carefully conceived strategy that worked, and even survived the death of its principal architect long before the battle was won. Mendoza himself aptly summarized the strategy: The Division of Population Studies of the Colombian Association of Medical Schools believes that when some one is capable of [forcefully] and vehemently demonstrating the existence of a serious and threatening phenomenon, it is possible to create a favorable national reaction.