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By V. Ateras. University of Puerto Rico, Rio Piedras.

A survey found that only 15% of 20-72 year-olds reported no pain during the previous year buy cheap viagra soft 50mg on-line, whereas 58% reported musculoskeletal pain during the previous week and 15% had musculoskeletal pain every day during the last year (32) order 50mg viagra soft fast delivery. Musculoskeletal pain may be a regional or generalized pain problem or be associated with a specific musculoskeletal condition discount viagra soft 100mg with amex. The prevalence of musculoskeletal pain increases in prevalence up to about 65 years of age (34-36), explained partly by a cumulative effect of chronic musculoskeletal conditions, which become more prevalent with older age. A decline in the complaint of pain has been noted over 65 years, a plausible explanation for which could be the decline around the age of retirement of the adverse physical and mental effects of the working place. Musculoskeletal pain is usually associated with limitations of activities and restricted participation (2), which is greater with more widespread pain, back pain and knee pain (37). They have usually included questions about limitations of activities and participation but these questions are not always related to the reason and whether related to musculoskeletal conditions, for example. Some surveys use terms such as rheumatism or diseases of the skeletal system but these is a very non-specific and broad terms that can encompass several conditions. In addition self-reported diagnosis is often asked but the validity of this for some musculoskeletal conditions is not good. Any indicator of musculoskeletal pain needs to identify those with musculoskeletal pain that has a consequence on their activities of daily living (1). The epidemiology of the determinants of musculoskeletal health varies in different societal groups and ethnicities. Osteoarthritis Definitions of osteoarthritis should ideally include both symptoms and radiological changes. The incidence of osteoarthritis is problematic to estimate and there is little data because of its gradual progressive development and difficulties in the definition of a new case. For women 245 the incidence of osteoarthritis is highest among those aged 65 74 years, reaching approximately 13. The largest European study was conducted in Zoetermeer in the Netherlands in the mid 1970s. There are too few comparable studies to draw any conclusions about geographical variation in prevalence. Prevalence studies from 16 countries and incidence studies from 5 countries were identified in the European Indicators for Monitoring Musculoskeletal Problems and Conditions Project (S12. In all studies the prevalence was higher in women than men (the ratio varied from 1. However, these figures are not directly comparable because they are not age standardised but nevertheless. Table 5 Prevalence and incidence of rheumatoid arthritis from individual studies across Europe (1) Sample Country Size Age Age Classification Prevalence Incidence North to Years (to Sample Type Gender bands Group Criteria used % /100,000 South nearest (yrs) 10) Iceland 1974-83 13. The prevalence in women aged 75 and over rose slightly and that in men aged 45 and over rose by around 25% (42). Osteoporosis and fragility fracture Osteoporosis is defined as a systemic skeletal disease characterized by a low bone mass and a microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture. Bone density decreases with age and the prevalence of osteoporosis therefore increases with age in all populations but it varies between populations across Europe. These variations were not explained by differences in body size and may have considerable implications for explaining variations in fracture rate already documented across Europe. In this report the incidence of hip fracture and prevalence of vertebral fracture in European Union member states was compiled from published data or information obtained by personal communication. The data have been obtained from two types of source; survey data (direct assessment of fracture rates in defined populations) and official health services administrative data. Trends The number of osteoporotic fractures is predicted to increase across Europe (45). The aging of the population is the most important factor with the most dramatic changes being seen in the oldest age group (80 years and above), in whom the incidence of osteoporotic fracture is greatest. Using baseline incidence/prevalence data for hip and vertebral fractures and population projections for five-year periods, the expected number of hip and vertebral fractures has been estimated over the period 1990 to 2050. The number of hip fractures occurring each year is estimated to rise from 414,000 by the turn of the century to 972,000 fifty years later, representing an increase of 135%. This increase will be greatest in men and will result in a decreasing female to male ratio. From the year 2035, however, this trend will change; because of the continuous ageing of the European populations and the steeper risk-over-age slope for women, the female dominance in incidence will re-emerge. The prevalence of vertebral fractures is not expected to increase to the same magnitude as for hip fractures; thus the estimated increase is from 23. The female to male ratio is expected to decrease during the first 20 years of the next century, after which it will increase. This is again an effect of the ageing of the population and a steeper slope of risk increase in women. There have been inconsistencies between studies in definitions used for duration when considering acute or chronic back pain making comparisons difficult. Epidemiological data for spinal disorders in general is often reported as low back pain regardless of the diagnosis or cause which makes it difficult to make accurate assessments of the incidence of specific or non-specific back pain. The prevalence of specific causes is estimated in most industrialised countries as ranging between 2% and 8%, the rest being labelled as non- specific back pain. This figure however depends on what conditions are considered as specific since most people as they age will develop degenerative changes but it may not be the cause of their back pain. The population based data may be subject to social, economic, genetic and environmental variables in addition to issues of study technique and back pain definition. There are not many studies of incidence but a large study from the Netherlands reported an incidence of 28. It is estimated that 12-30% of adults have low back pain at any time and the lifetime prevalence in industrialised countries varies between 60% and 85%. There are various determinants (see above) that influence the occurrence of back pain and its impact. Changes in these determinants, such as obesity, 253 psychosocial factors and work-related factors will affect the incidence and prevalence of back pain and its impact. Various health interview surveys have investigated their prevalence, and an example from the Netherlands is given (table 9, figure 5 (52)). Hip replacement is usually a consequence of osteoarthritis or osteoporotic fracture. However hospital discharge data is of limited relevance to most musculoskeletal problems and conditions as they are managed predominantly in primary care or as ambulatory patients. In-patient care is used variably across Europe for the management of active or complicated rheumatoid arthritis. In-patient care may also relate to arthroplasty, most commonly of hip or knee for osteoarthritis, or may relate to fragility fractures, typically of the hip as a consequence of osteoporosis and a fall. Hospital discharge data does not therefore 255 reflect the health resources needed or utilised related to musculoskeletal conditions. A survey was done, as part of that project, about implementation of guidelines which found little awareness by the authors of the guidelines as to whether their guidelines were being implemented or whether they were making a difference in clinical outcomes. A further survey has recently been performed by us to establish whether there are national guidelines for the major musculoskeletal conditions in all member states. It has also been asked who developed them, if they are implemented, whether they have influenced clinical practice and if they have altered clinical outcomes.

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Educating patients with asthma about their disease and how to assess and manage exacerbations reduces urgent care visits viagra soft 100mg on-line, asthma- related health care costs cheap 100mg viagra soft fast delivery, and improves health status and quality of life and adher- ence to medication regimens medication in both younger and older patients [214 217] order 50 mg viagra soft. Instructions, or action plans for routine asthma care should be easy to read and understand for the patient. Treating patients to control their disease and allow for increased quality of life, while minimizing potential medica- tion side effects are a major goal, particularly in older patients who often receive multiple medications and therefore are at a potentially greater risk for side effects. One report suggested that ipatrotropium in elderly asthmatics was associated with a slight increase in mortality, which the authors concluded was secondary to these patients having more severe asthma than those patients not receiving ipatrotro- pium [224]. To decrease the effects of corticosteroids on bone resorption, patients should be encouraged to exercise, avoid excess alcohol intake, and use daily supplemental calcium with vitamin D. Corticosteroids improve asthma control and symptoms in some, but not all older patients. However, some older patients with asthma may have a component of xed airway obstruction [150]. Leukotriene modiers are a class of anti-inammatory agents that inhibit the effects of leukotrienes, which are potent bronchoconstrictors, recruit inammatory cells to the airways and induce mucus hypersecretion. Two studies have investigated the role of leukotriene modiers in patients of different ages with asthma, and have concluded that their effectiveness may be limited in the elderly patients compared with younger counterparts, but continue to improve asthma symptoms without reducing the need for rescue therapy [243, 244 ]. Theophylline) increase intracellular cyclic adenosine mono- phosphate which bronchodilates the airways, and in lower doses have anti- inammatory properties [245]. Its use in asthma, especially in an older group, is limited by its relatively weak bronchodilator properties and many side effects and drug interactions [246]. This pro- gram explored data from animal models and human studies of asthma in older patients and concluded that airway inammation in asthma and its clinical response to therapy in older patients likely differs from younger patients. Since this confer- ence, there are still several remaining unanswered questions regarding asthma in older patients. For example, how do age-related changes in the innate and adaptive immune responses impact airway inammation in older patients with asthma and does it differ from younger patients with asthma? Understanding the pathophysiol- ogy and underlying airway inammation in older adults with asthma and the differ- ent phenotypes and endotypes of asthma in this population is a major unmet need as this group of patients has high rates of morbidity and mortality. Furthermore, with the expected increase in the elderly populations, including elderly asthmatic patients in clinical trials is essential, and particular attention should be paid to also address how differences in inammatory mechanisms affect responses to therapy. Busse 6 Summary Asthma is a major public health problem which is frequently overlooked in the geriatric population. While much has been uncovered about the pathogenesis, course and outcomes of asthma in children and young adults, studies in the aging population have been scarce or non-existent. Asthma in the elderly has at least two distinct phenotypes based on the onset of the disease. While the characteristics of long-standing asthma that starts early in life may be similar to the general asthma population, more studies are needed to uncover details about asthma that develops late in life which can have distinct clinical features and may have different course of response to therapy. Our knowledge about management of asthma in this popu- lation is based on extrapolation from studies in the younger population. Although future studies are needed to investigate the response to existing and novel interven- tions in the elderly, current guidelines recommend that management of asthma in this population should not differ from that of younger patients. Careful monitoring of compliance with therapy and of adverse events to medication is essential in this population. Despite severe symptoms and physiologic impairment, most elderly patients with asthma improve with therapy and can lead active productive lives. Franceschi C, Monti D, Sansoni P, Cossarizza A (1995) The immunology of exceptional individuals: the lesson of centenarians. Svartengren M, Falk R, Philipson K (2005) Long-term clearance from small airways decreases with age. Structural, functional, and lipid biochemical abnormalities in humans and a senescent murine model. Zhou F, Onizawa S, Nagai A, Aoshiba K (2011) Epithelial cell senescence impairs repair process and exacerbates inammation after airway injury. Nair P, Aziz-Ur-Rehman A, Radford K (2015) Therapeutic implications of neutrophilic asthma. Korn T, Oukka M, Kuchroo V, Bettelli E (2007) Th17 cells: effector T cells with inamma- tory properties. Schmitt V, Rink L, Uciechowski P (2013) The Th17/Treg balance is disturbed during aging. Malaguarnera M, Cristaldi E, Romano G, Malaguarnera L (2012) Autoimmunity in the elderly: implications for cancer. Nakazawa T, Houjyo S, Dobashi K, Sato K (1994) Inuence of aging and sex on specic IgE antibody production. Huss K et al (2001) Asthma severity, atopic status, allergen exposure, and quality of life in elderly persons. Zureik M, Orehek J (2002) Diagnosis and severity of asthma in the elderly: results of a large survey in 1,485 asthmatics recruited by lung specialists. Raiha I, Hietanen E, Sourander L (1991) Symptoms of gastro-oesophageal reux disease in elderly people. National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of Asthma, Expert Panel Report 3: Guidelines for the Diagnosis and Asthma and Aging 427 Management of Asthma (2007). Suissa S, Baltzan M, Kremer R, Ernst P (2004) Inhaled and nasal corticosteroid use and the risk of fracture. Garbe E, Suissa S, LeLorier J (1998) Association of inhaled corticosteroid use with cataract extraction in elderly patients. Ernst P, Baltzan M, Deschenes J, Suissa S (2006) Low-dose inhaled and nasal corticosteroid use and the risk of cataracts. National Asthma Education and Prevention Program (National Heart, Lung, and Blood Institute). The airway obstruction progresses with time and exacerbations of the disease tend to arise about once per year [8]. The combination of tissue damage, release of inammatory mediators, cyto- kines, and chemokines leads to the activation of epithelial cells and endothelial cells. In addition, the disease is correlated with accelerated apoptosis of alveolar and pulmonary vascular endothelial cells [18] (Fig. Abnormal or injured epithelial cells secrete growth factors that favor the recruitment of resident broblasts and brocytes that differentiate into myobroblasts [24]. Those epithelial cells also release inammatory mediators that initiate an anti-brinolytic coagulation cascade and trigger platelet activation and blood clot formation. This process is followed by activation of leukocytes at the site of tissue injury. Fibroblasts can trans-differentiate to a myo- broblast phenotype, which are major producers of excessive extracellular matrix.

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In 1991 Directions were made imposing the same obligations on trustees and employees of a National Health Service trust cheap 50mg viagra soft amex. A guide to inter-agency working together to safeguard and promote the welfare of children viagra soft 50mg visa. Simultaneous duties to the individual patient discount viagra soft 50mg fast delivery, their sexual contacts and the community as a whole create numerous dilemmas when the best interests of all cannot be fully accommodated. Choices have to be made about how best to serve a person s interests, or whose interests should receive priority, when there is conflict. The aim of this section is to clarify how an ethical issue might be identified and managed. The main ways of approaching an ethical issue are explained, and the key principles are discussed in relation to common dilemmas. There are no objectively right answers in ethics, but there are valid and non-valid arguments for and against a given action. Familiarity with the concepts and language of ethics will enable health advisers to make decisions, and explain them, with greater confidence. Deontological ethics start from the position that there are certain moral principles that we have a binding duty to uphold. Examples of moral obligations include the duty to tell the truth, keep promises, be fair, respect autonomy and treat people as ends rather than means. An action is considered to be right if the appropriate principles have been honoured. The consequences of an action are not necessarily relevant to the debate, unless certain outcomes are integral to a principle, such as beneficence (see below). All individuals may be said to have certain fundamental human rights, for example to life, liberty and estate that1 cannot normally be legitimately transgressed. In addition to these, some people have rights that are the result of particular circumstances where a tacit or explicit contract applies. The rights of a person requiring a sexual health check therefore confer duties on the health care system and on individual health care workers to do whatever is necessary to honour these rights. Sometimes the duty is to do nothing to refrain from interfering with the person s right to autonomy. Debate arises in duty-based ethics when there is conflict between principles, or confusion about the validity, relevance or meaning of a principle. Teleological theories of ethics, such as utilitarianism, regard actions to be right if they produce desirable outcomes. Moral rules may be useful as rules of thumb, but they are not sacrosanct, and should be disregarded if they are likely to result in an undesirable outcome in the instance. By contrast, restricted or rule utilitarians place more faith in moral rules than the3 judgement of the individual, who may lack the necessary knowledge, experience or wisdom to anticipate the full range of consequences. It is postulated that established moral rules have been created, and have survived, because they tend to lead to positive outcomes. Furthermore, rules offer security and protection: the ability to trust that individuals will behave in certain agreed ways is in everyone s interest. For these reasons, rule-utilitarians believe that the most desirable outcome is more likely to result in the long term if moral rules are followed. The rule-utilitarian commitment to moral principles and rules is based on a perception of their utility, rather than the deontological position that they are intrinsically right. Debates arise in teleological ethics when there is disagreement about which consequences are desirable, for whom they should be sought, and how they might be calculated reliably. The individual has a fundamental obligation to make a judgement about what is right in a given situation, and to act accordingly. The responsibility to be a conscious moral agent, and make choices, is inescapable: in this sense we are condemned to freedom. An action is right only if the person has acted in good faith : that5 is, in accordance with his or her own personally constructed values. The relevance of this doctrine to the ethics of health care is that it explodes the myth that a professional is somehow different from a non-professional. There is no escape from the duty to think for oneself: it is a form of moral dereliction, or bad faith, to pretend to be are enslaved. One reason is that subjective individual judgements would be variable, unpredictable and sometimes unacceptable to the majority. They may be guided by self-interest, warped by prejudice or hampered by the difficulty of grasping moral thinking. The public therefore has a right to be reassured that duties will be performed in full, in an acceptable way, notwithstanding the idiosyncrasies of individual practitioners. Furthermore, practitioners need some guidance: it is unreasonable and unrealistic to expect that we all have the time and capacity to strip down an ethical issue and invent an acceptable response many times each day, without a clear map. Besides, from many ethical perspectives it is part of the nature of morality that we are bound by rules we have not chosen. Health advisers have particular ethical duties attached to their professional role, outlined in the Code of Professional Conduct for Sexual Health Advisers. For example, it may be difficult to offer supportive and non-judgemental care to a person who is known to be seriously abusive to others; the duty to protect confidentiality may oblige a health adviser to be deceitful, or collude with the deception of others; a possible conviction that 210 abortion is wrong is at odds with the obligation to offer impartial counselling to a patient who is considering a termination. An individual health adviser may find a team decision on an ethical dilemma to be personally unacceptable for example, a decision about whether to refer a young person to social services, against their wishes. There may also be occasions where duties attached to other social roles conflict with professional duties. It is important for health advisers to have a safe and supportive arena, such as supervision, where these issues can be ventilated and explored. Some principles, such as beneficence, are consequentialist by nature; consequentialist theories recognise the importance of rules; our professional ethical code contains both rule and goal based elements; all approaches require9 individuals to make personal decisions about what is right in a given situation. It is not possible to address an ethical issue adequately without considering all elements: prima facie principles, consequences, professional obligations and personal integrity. These are described and discussed in relation to a range of ethical choices encountered by health advisers. An autonomous person is a rational being who is free to make decisions and act, or permit actions on his/her behalf, accordingly. For some deontologists, such as Kant and Sartre, it is a requirement of moral agency, and therefore intrinsic to the core value of persons. A person who lacks autonomy therefore potentially has less status as a human being. For this reason, it cannot be violated or surrendered: autonomy is both a right and a duty. Utilitarians have also stressed the importance of autonomy because it enables individuals to pursue their own goals. The assumption here is that the individual is the best judge of what will maximise his or her well- being.

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