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Close monitoring of interleukins (6 or 1) blockers: remdesivir toxicity or diminished Some Chinese heart attack 50 years generic diovan 40mg on-line, Italian and efficacy of concomitant drug is (very limited) Belgian clinical recommended blood pressure medication orthostatic hypotension discount diovan 160mg on-line. Check also for experience (unpublished) interaction with remdesivir at suggest a favorable effect in blood pressure chart sample buy discount diovan 40 mg. At this moment however pulse pressure 48 cheap 160 mg diovan with mastercard, this class of drugs should only be used in clinical trials or within Belgian/international cohort studies if possible. The drug could be considered on an individual basis in patient with persistent inflammation. Annexes Annex 1: Procedures Emergency Compassionate use procedure (as stated in art 107/1 (link)) At this moment Compassionate use is only available for pregnant women and children <18y old and severe manifestations (see criteria Table 2). When using Remdesivir for compassionate use (application at Gilead rdvcu. A sworn statement from the physician that the informed consent was obtained in accordance with the law of 22 August 2002 on patient rights. Please discuss the indication of the patient as well as the previous treatments that the patient received, the unmet need and the benefit/risk balance of treatment along with the urgency for this treatment. If you have problems obtaining the medicinal products in this guideline, please contact coronashortages@fagg-afmps. Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro. In vitro inhibition of severe acute respiratory syndrome coronavirus by chloroquine. Design and Synthesis of Hydroxyferroquine Derivatives with Antimalarial and Antiviral Activities. Broad-spectrum antivirals for the emerging Middle East respiratory syndrome coronavirus. Oseltamivir treatment for influenza in adults: a meta analysis of randomised controlled trials. A Drug-Disease Model Describing the Effect of Oseltamivir Neuraminidase Inhibition on Influenza Virus Progression. Clinical evidence does not support corticosteroid treatment for 2019-nCoV lung injury. Epidemiological Characteristics of 2143 Pediatric Patients With 2019 Coronavirus Disease in China. Cox Family Practice Residency, Springfield, Missouri Peripheral vascular disease is a manifestation of systemic atherosclerosis that leads to significant narrowing of arteries distal to the arch of the aorta. The most common symptom of peripheral vascular disease is intermittent claudication. At other times, peripheral vascular disease leads to acute or critical limb ischemia. Intermittent claudication manifests as pain in the muscles of the legs with exercise; it is experienced by 2 percent of persons older than 65 years. Physical find ings include abnormal pedal pulses, femoral artery bruit, delayed venous filling time, cool skin, and abnormal skin color. Most patients present with subtle findings and lack classic symptoms, which makes the diagnosis difficult. The standard office-based test to determine the presence of peripheral vascular disease is calculation of the ankle-brachial index. Magnetic resonance arteriography, duplex scanning, and hemodynamic localization are noninvasive methods for lesion localization and may be helpful when symptoms or findings do not correlate with the ankle-brachial index. Lifestyle therapies focus on exercise, smoking cessation, and dietary modification. In addition, patients with contributing disorders such as hypertension, diabetes, and hyperlipidemia need to have these conditions managed as aggressively as possible. Surgical therapies include stents, arterectomies, angioplasty, and bypass surgery. Preventive Services Task Force A handout on peripheral the presence of systemic atherosclero has recommended against routine screening arterial disease and 4 claudication is available sis in arteries distal to the arch of the for peripheral arterial disease. The greatest modifiable pression of the cauda equina, which results risk factor for the development and progression in pain that radiates down both legs. The laboratory work-up at time of diagnosis should include a complete blood count with platelet C 12 count, fasting glucose or A1C, fasting lipid profile, serum creatinine, and urinalysis for glucosuria and proteinuria. Exercise has been shown to increase the walking time of patients with claudication by 150 percent A 16. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease oriented evidence, usual practice, expert opinion, or case series. Table 1 Differential Diagnosis of Claudication Characteristics Does exercise Effect of body position Condition Pain location of pain cause pain? Effect of rest on pain on pain Other comments Baker cyst, Behind knee and down Tender to touch, Yes None; pain is present at rest None Constant symptomatic calf associated swelling Calf claudication Calf muscles Cramping Yes Subsides quickly None Reproducible Chronic compartment Calf muscles Tight, throbbing Yes Subsides slowly Subsides more quickly Common in heavily muscled athletes syndrome with elevation Foot arthritis Foot and arch Aching Yes, with varying Subsides slowly Aided by not bearing Varies, may relate more to activity degree weight level or weather changes Foot claudication Foot and arch Severe, deep; Yes Subsides quickly None Reproducible associated numbness Hip arthritis Hip, thigh, and gluteal Aching Yes, with varying Subsides slowly More comfortable Varies, may relate more to activity region degree sitting level or weather changes Hip claudication Hip, thigh, and gluteal Aching, associated Yes Subsides quickly None Reproducible region weakness Nerve root Down one leg and Sharp, stabbing Yes, almost Subsides slowly Usually relieved by History of back problems compression posterior immediately changing position Spinal stenosis Hip, thigh, and gluteal Some pain, but Yes, after some Subsides after some time; Relieved by lumbar History of back problems region weakness time, includes accompanied by position spine flexion predominates standing change. In addi tion, later in the course of the disease, patients may Characteristics Does exercise Effect of body position present with night pain, nonhealing ulcers, and skin Condition Pain location of pain cause pain? Recent trials have Foot claudication Foot and arch Severe, deep; Yes Subsides quickly None Reproducible 7 added chronic renal insufficiency, elevated C-reactive associated numbness protein levels,8 and hyperhomocysteinemia9 to the list of Hip arthritis Hip, thigh, and gluteal Aching Yes, with varying Subsides slowly More comfortable Varies, may relate more to activity risk factors. They may include absent or diminished pulses, in thigh and groin with elevation thrombosis, signs of venous congestion and edema abnormal skin color, poor hair growth, and cool skin. Laboratory studies to be abstinence from cigarette smoking is the most impor ordered at the time of diagnosis include complete blood tant factor related to outcomes in patients with inter count with platelet count, fasting glucose or A1C, fast mittent claudication. Among patients ultrasonography, magnetic resonance arteriography, and angiography are indi cated for determining lesion localization Table 4 and are best used when invasive or surgi Differential Diagnosis of Acute Limb Ischemia cal intervention is a possibility. Changes in functional sta disease paresthesia, and paralysis similar to acute limb tus may prompt the physician to repeat ischemia; angiography does not show occlusion. It has been shown to increase walking dis heparin) have not shown any benefit in treating patients tance by 35 to 109 percent in several randomized, blinded with intermittent claudication. Pentoxifylline (Trental) is a rheologic modula tality in patients with acute limb ischemia while they are tor that also has antiplatelet effects. Food and Drug Administration for the treatment of Beyond medical therapy for intermittent claudication, intermittent claudication. However, critical reviews20,21 patients who progress to critical or acute limb ischemia have found limited evidence of effectiveness, which the face several treatment options. Hypercholesterolemia eral arteries through local catheters intended to reduce clearly is related to atherosclerotic disease. One system restenosis following percutaneous transluminal angio atic review22 and a recent clinical trial23 have shown lipid plasty), and bypass grafting. Factors to be considered of these findings remains an issue until clear patient in such situations are location of lesion, patient-related oriented trials are conducted. Considering the number risks, surgery-related risks, type of clot, and contra of patients with conditions that merit lipid-lowering indications to thrombolysis. One study30 showed an all cause mortality the American Diabetes Association standard of blood rate of 3. Effects on the risk of peripheral vascular complications, myocardial infarction and mortality. Collaborative meta-analysis of City, and completed a residency in family practice at Spartanburg Family randomised trials of antiplatelet therapy for prevention of death, myo Medicine Residency, Spartanburg, S. Effect of cilostazol on walking distances in patients with intermit tent claudication caused by peripheral vascular disease. A comparison of cilostazol and pentoxifylline for treating intermit intermittent claudication: the Framingham Study. Peripheral arterial disease detection, awareness, and cation: results of a randomized, multicenter trial. Screening for peripheral Effects of simvastatin on walking performance and symptoms of inter arterial disease: a brief evidence update for the U. Preventive Services mittent claudication in hypercholesterolemic patients with peripheral Task Force. Management of peripheral arterial dis patients with peripheral arterial disease and type 2 diabetes.


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People didn’t know how easy pomegranates are to blood pressure bottom number cheap diovan 80 mg on-line juice so they would eat some seeds or use the fruit for table decoration blood pressure bottom number low order 40mg diovan with mastercard. We will describe the fresh use of the fruit and discuss the easiest method to blood pressure medication list a-z cheap diovan line remove the arils pulse pressure 70 generic diovan 160 mg overnight delivery. We hope that the recipe section that follows will expand your use of the pomegranate. Cut your pomegranate in half if you have a large citrus press and press out the juice as you would an orange. If you have the standard citrus press you may need to cut the pomegranates into quarters and then press out the juice. When you have finished juicing your pomegranates let the juice set in the refrigerator a few hours. There will be a small amount of cloudy material in the bottom of the container that needs to be discarded and you will then have beautiful tasty pomegranate juice ready for drinking or any use. A warning: Do not use a citrus reamer as it will get some of the tannin from the skin and partition material into the juice and that is not desirable. Take the pomegranate and roll it around a little, until it gets soft, then cut apart the pomegranate under water. Wrap them in cheesecloth or jelly sack then use your hands to squeeze out the juice into a bowl, squeezing gently as you do not want to squirt yourself. Follow the instructions for removing the arils and then process the seeds in a food processor or blender. Let the juice settle a few hours and remove any cloudy material from the bottom of the juice container. Another method that is used in Iran: Roll the pomegranate around, giving good pressure, but not enough to break the skin. It’s an art to push hard enough to break the arils inside without breaking the skin. When soft, carefully open a hole in the pomegranate and place a straw in and suck the juice out or just bite a bit of the skin out, spit it out and suck out the juice. The partition material and most of the skin will float to the top and the arils will go to the bottom. Another method is to cut the pomegranate in half over a large bowl then place half the fruit in the palm of your hand and squeeze gently (try not to squirt yourself). Then take a heavy wooden spoon or pin or other clean wooden object and tap the half where you have the arils loosened (it may take a hard tap); tapping the loosened arils into a bowl. The simple fact is that most pomegranate recipes for using the juice are based on two basic recipes – heavy and light pomegranate syrup. But you can get creative with some very special recipes of your own by using these basics and then adding your own ingredients. If you are using fresh pomegranates for these recipes, you can usually count on one pomegranate making about 1/2 cup of juice, depending on size of fruit. We would like to note that there seems to be some confusion of just how pomegranate grenadine is made. First, grenadine that is used in drinks nowadays is not made from pomegranates as it was; it is artificially flavored. In the Mediterranean area and the Middle East where the heavy and light pomegranate syrups are used frequently, they are referred to as Pomegranate Molasses and Pomegranate Concentrate. You can also buy this 79 Plant and Fruit already made in most Middle Eastern markets; the syrup was used in Middle Eastern cooking in much the way that wine is used in western cooking. That’s how simple it is to make pomegranate syrup yourself and it will keep in your refrigerator in a sealed jar for about four months. Pour in clean jars and use prepared clean canning rings and lids, then process in a water bath canner for 15 minutes. Pomegranate Concentrate – Light pomegranate syrup the difference between this and pomegranate molasses is that you do not use any sugar in this recipe and you have a more intense pomegranate taste. It can be used for many of the same things as pomegranate molasses— it is just a question of flavor, this being the less sweet and more tart of the two. Ingredients:  Pomegranate Juice (that’s all) If you want 2 cups of syrup start with 4 cups of pomegranate juice, as it reduces by about ½ of the amount you start with. Pour juice into sauce pan and bring to boil over high heat, then reduce heat to maintain boiling action for about 25 minutes or until it thickens, stirring to prevent sticking. When juice starts to thicken, check it to see if it is ready by lifting out the spoon. This can be canned and processed the same way that you would can 80 the Incredible Pomegranate pomegranate molasses, or it can be frozen. When bottled and stored, the syrup stays good in a refrigerator for up to 2 weeks. Note: If you want a heaver syrup you can reduce it as far as 3 cups juice to 1 cup syrup— it will just take a little longer cooking time. Pomegranate Meat Sauce this sauce is used to baste meats and chicken in the latter stages of cooking, usually added in the final 1/3 of the cooking time. Or just to add to the meat juices, especially if vegetables are also cooked with the meat. Ingredients:  1 cup pomegranate juice  ½ cup of lemon or orange juice (your choice, the taste will be a little different)  2 tablespoons sugar  Salt and pepper to taste In the sauce pan combine all ingredients, except salt and pepper and bring to boil on high heat. Ingredients:  1 cup thick ketchup  1/3 cup pomegranate molasses  1 teaspoon of cumin  2 teaspoons of powdered garlic or minced garlic  1 teaspoon of Louisiana hot sauce 81 Plant and Fruit In saucepan combine all ingredients and simmer 5 minutes on low heat. Pomegranate Desert Sauce this sauce can be used to dribble over many desert dishes such as plain cake slices, ice cream, pancakes and many others, just use your imagination. If you use the sweet-tart type of juice you find in the grocery store you will have a sauce that has that good pomegranate taste. If you grow your own pomegranates, the sweet-tart or sour varieties are best for this sauce. If you grow or use one of the sweet pomegranates varieties reduce the sugar to 2 tablespoons. Ingredients:  1 cup pomegranate juice  1/2 cup of sugar  1 1/2 tablespoons corn starch In small saucepan combine ingredients over low heat. When combined and smooth, turn the heat to medium and bring to boil stirring constantly. Boil 1 minute, you will see it turn to a thick sauce in just a few seconds when it starts boiling; keep stirring, do not let it scorch. Try this sauce poured over thin slices of plain white cake (unfrosted) or pound cake. Ingredients:  4 cups of pomegranate juice 82 the Incredible Pomegranate  7 ½ cups of sugar  ¼ cup of lemon juice  6 fluid ounces of liquid fruit pectin (this is one bottle of any brand of pectin) Combine all ingredients except pectin in large saucepan. Sugar  2 Lemons, juiced  2 Gallons of water  Wine yeast and nutrient Remove the arils from the fruit. In primary fermentation vessel combine pomegranate arils, sugar and lemon juice and stir until mixed. Pour the water through a strainer, off the barley water mixture (while still hot) and onto the mixture in the primary fermentation vessel. Then strain the mixture into the secondary fermentation jar and fit with fermentation trap. With a good variety pomegranate produced and fermented under good conditions you will get a great fruity taste and aroma. They can be added to meat dishes to give them a nutty pomegranate flavor; usually after the meat is cooked as a garnish. Here is one interesting recipe: Pomegranate Rice Pilaf Ingredients:  ½ cup pomegranate juice  ½ cup pomegranate arils  6 oz. As written earlier, it is best to do this under water in a big enough bowl that you can easily get your hands into the bowl to break apart the sections of the fruit. When you are finished and have gotten the arils drained away from the other material, try to get as much water as possible away from the arils. Put them in a plastic freezer bag and place in the fast freeze section of your freezer. By freezing the arils with as little as water as possible they will not stick together too badly and be loose and ready to use. The juice taste will vary depending on which of the many different pomegranate varieties you have chosen or are growing.

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The kidney is small but has a normal echo pattern A hypoplastic kidney cannot be distinguished from a small ischaemic kidney blood pressure value ranges purchase diovan with a visa. Due to blood pressure hypertension generic 40mg diovan fast delivery chronic renal disease heart attack feat thea austin purchase diovan 40mg with amex, small ‘end-stage’ kidneys usually blood pressure under 60 generic 160mg diovan otc, but not always, have an abnormal echo texture. This cannot be assessed by ultrasound but can be determined by intravenous urography or an isotope study. The non-function of dysplastic kidneys cannot be assessed by ultrasound but can be determined by intravenous urography or an isotope study. Ultrasound is ofen diagnostic, but confrmation by excretion urography may be necessary. Ptotic kidney In this condition, the kidney lies lower than normal in the abdomen and may be malrotated. If it is malrotated, the kidney appears obviously abnormal, although at frst it may not be clear why (Fig. The kidney lies low on the psoas muscle and is malrotated 276 Horseshoe kidney this condition involves fusion of the lower poles of the two kidneys (rarely the upper poles). Teir ascent appears to be confned by the inferior mesenteric artery crossing the isthmus. A thick isthmus is seen as a midline mass and may be mistaken for a retroperitoneal tumour. Horseshoe kidneys are more prone to trauma, pelviureteric junction obstruction, renal calculi and Wilms tumours in children. On ultrasound, the kidney appears long, and there may be a waist between the two fused kidneys. On ultrasound, there is no kidney in the normal position, and the thoracic kidney itself is not visible. Other conditions Compensatory hypertrophy A single functioning kidney will hypertrophy to compensate. In scarred kidneys, the normal parenchyma can hypertrophy, producing pseudotumours. Renal sinus lipomatosis The fat in the renal sinus can proliferate, producing a larger central echo complex, and may be associated with cortical loss. Pathological fndings Renal cysts Simple renal cyst More than 70% of renal cysts are due to benign cystic disease. Tese cysts occur in up to one half of people over 50 years of age and may be bilateral. Longitudinal view of left kidney (arrows point to increase in renal sinus fat) They are usually cortical but may be medullary or in the renal sinus. Renal sinus cysts can be confused with hydronephrosis; however, in the latter condition, dilated calyces should be demonstrated to be communicating with a dilated renal pelvis. Up to one half of these are malignant; the rest are haemorrhagic cysts, infected cysts or multi locular cystic nephromas. If the cyst contains thin septa (less than 1 mm) or fne calcifcation, it may be considered benign. Irregular thickened septa, calcifcation, mural nodules, thick walls or a multiloculated appearance are indicative of a cystic or necrotic neoplasm. Tese changes and cyst debris can, however, occur in haemorrhagic or infected cysts. Bosniak category 4 renal cyst with a thickened wall Autosomal dominant polycystic kidney disease this inherited disorder is bilateral, although early in the course of the disease only one kidney may appear to be afected sonographically. Most of the cysts are simple; however, calcifcation and haemorrhage into cysts occur, as does infection. In at-risk individuals, the following criteria are consistent with autosomal dominant polycystic kidney disease: < 30 years of age: two or more renal cysts 30–59 years of age: two or more cysts on each kidney ≥ 60 years of age: four or more cysts on each kidney. Since multiple simple cysts occur with increasing age, the diagnosis can be difcult. There is a risk for malignant change in these cysts, although the risk is not as great as early research suggested. Calcifcation or hydronephrosis, depending on the etiology of the renal failure, may also be present. If calcifcation is a feature of a particular infection, excretion urography may be helpful. Renal enlargement and focal hypoechoic or hyperechoic areas may occur, which is termed ‘focal pyelonephritis’ or ‘focal nephronia’. Loss of the normal central renal sinus renal parenchyma interface may occur, as may loss of corticomedullary diferentiation. In this case, it has reduced echodensity (arrow) a b c 283 Emphysematous pyelonephritis Emphysematous pyelonephritis is an uncommon, life-threatening condition, which is more frequent in patients with diabetes. It is an infection with gas-forming organisms, resulting in gas in the collecting systems (emphysematous pyelitis), renal parenchyma and sometimes the perinephric space. On ultrasound, the gas produces ‘dirty’ acoustic shadowing, as opposed to ‘clean’ shadowing from renal calculi (Fig. On ultrasound, there is usually a dilated collecting system containing echogenic material or debris (Fig. The dilated moiety contains echogenic pus 284 Renal and perinephric abscesses A renal abscess consists of a collection of pus lying in the renal parenchyma. Perinephric abscesses have a similar appearance to renal abscesses but lie adjacent to the kidney. Tere may be extension into the perinephric tissues, and the condition is frequently mistaken for a tumour. The cyst walls may be fully or partially calcifed and contain debris (hydatid sand). Disseminated infections can produce multiple abscesses in both kidneys and other organs. Any opportunistic infection, but particularly fungal infections, can cause thickening of the epithelial layer. Tuberculosis Astuberculosis and brucellosis have similar imaging features, the latter is not discussed separately. Later in the disease, progression to autonephrectomy, or a ‘putty’ kidney, may occur, when the kidney becomes densely calcifed. They can, however, have enlarged, echogenic kidneys (more echogenic than adjacent liver or spleen) with bilateral pelvicalyceal thickening. Tere can be loss of corticomedullary diferentiation and a decrease in renal sinus fat. On ultrasound, the kidney may contain hypoechoic masses or less commonly be difusely infltrated and enlarged (Fig. Retroperitoneal lymphadenopathy can displace the kidney or ureter, rarely causing hydronephrosis. The incidences of pyelonephritis and of genitourinary tuberculosis are also increased. Renal scarring Renal scars can be due to previous refux, infection, surgery or trauma. Characteristically, they lie above the renal pyramids, whereas fetal lobulation causes indentations between the pyramids. Although it may suggest that a tumour is benign or malignant, unfortunately, it is usually not possible to diferentiate them reliably. As they cannot be distinguished reliably from renal cell carcinoma by imaging, they should be excised, if appropriate. The tumour is round, and an anechoic central scar is just visible (arrow) Angiomyolipomas: Tese tumours contain fat, blood vessels and smooth muscle elements in variable proportions. Small angiomyolipomas are invariably found incidentally; larger ones may present with fank pain secondary to haemorrhage. As angiomyolipomas have a high fat content, they have an echodensity similar to that of renal sinus fat (Fig. If fat can be demonstrated within the tumour by other imaging modalities, it is likely to be an angiomyolipoma. They appear as small, round, evenly echo-dense lesions and are usually assumed to be angiomyolipomas (although, rarely, one may be a hyperechoic renal cell carcinoma; see below). Multilocular cystic tumours (cystic nephromas): Tese tumours have an unusual age and sex distribution: they occur in boys under the age of 4 years, 90% of whom are under 2 years of age. Although the septa are regular rather than nodular, it is not possible to distinguish them reliably from renal cell carcinoma.

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These habits consisted mainly of chewing Tamil Nadu and Karnataka) had experimented betel quid with tobacco heart attack 29 year old female generic diovan 160 mg mastercard. Excluding those and family members were most influential in this who chewed tobacco by itself and including those regard prehypertension treatments and drugs discount 80mg diovan free shipping. Tobacco and health: India and South Asia 423 Acquisition of tobacco habits was studied in a 10 comes from some of the Pacific islands pulse pressure aortic regurgitation order diovan 40 mg otc, such as Palau heart attack 5 year survival rate diovan 40 mg. Throughout Palau, single chews, which rural areas (Ernakulam, Kerala; Srikakulam, Andhra are sold in many retail stores, consist of half a tender Pradesh and Bhavnagar, Gujarat). A study habits for the first time, reflecting the already estab conducted in Palau in 1995 on a purposive sample of lished area-wide patterns of chewing or reverse 1110 residents aged 5–74 years in Koror and Airai smoking for women and smoking for men. Tobacco was added to the quid It is popularly perceived that the chewing of betel by 65–96% of the respondents in the different age quid with tobacco is becoming a less common habit groups (83% in the total sample), and by 87% of chew in India and that it is more confined to the elderly. The two younger generations have readily taken up the use of youngest age groups (5–14 and 15–24 years) rarely mixtures of areca nut and tobacco. In a survey of 95 Smokeless tobacco use in South Asia is believed to be boys and girls in the 8th and 9th grades of a small a significant contributor to excess mortality. The evi town private school in Gujarat, 16% of boys used dence is available from three cohort studies. In a village community in Gujarat, 72% of A large cohort study in Mumbai showed elevated males under 26 years of age used tobacco, mainly relative risks of death for both male and female bidis and gutka, and 50% of females used tobacco in users of smokeless tobacco (mainly in the forms of the forms of gutka and tobacco toothpaste. Interim results were based mately one-eighth of 476 high school students in the on 5–6 years of follow-up of 52 000 persons, with 10th to 12th standards in Patna, Bihar, used pan 114 980 person years for female and 57 890 for male masala. The age-adjusted relative Punjab, in a recent survey of 100 rural school-going risk for smokeless tobacco users compared with teenagers in five villages, two-thirds of respondents non-tobacco users among men was 1. Assessment of the use of tobacco Andhra Pradesh, 10 169 persons were followed for 10 and areca nut products among medical and dental years. The predominant habit was reverse chutta students is important because of the impact of the smoking but there were some tobacco chewers example they will set for their patients as future car among the men with 41 deaths recorded during 1460 egivers and the unlikely prospect that they would person-years of observation, giving an age-adjusted counsel their patients against using tobacco, a major relative risk of 1. There are some research results on the impact of smokeless Significant dose–response trends were observed for tobacco on blood pressure and cardiac disease. In frequency of chewing per day in all 10 studies, and for addition, use of areca nut, often chewed with tobacco, duration of habit in seven of them. Retention of the can predispose to diabetes mellitus and aggravate quid overnight, analysed in another study, showed a 36-fold increased risk. Epidemiological evidence from selected studies on the relationship of smokeless tobacco use In a case series study from Bangladesh, the site of with various diseases is summarized below. Two large hospital-based 250 000 out of a total of 700 000–900 000 new cancers case-control studies from India and Pakistan, diagnosed each year. However, all these studies population-based registries (Bangalore, Barshi, Bho lacked adjustment for smoking and betel-quid hab its. In six of the studies from India, relative risks of oral cancer for men who were risk of 1. In contrast, for men who were current bidi smokers the relative risks varied from response for the frequency and duration of chewing 46–51 was reported in another study. Relative risks of oral cancer for women who currently chewed pan with Laryngeal cancers: One case-control study from tobacco varied from 30. Urgent public health measures are adjusted odds ratio for the lower third of the oesoph required to curb this new but avoidable epidemic. Smoking was also profile, although perhaps to a lesser extent than found to pose elevated risks for oesophageal cancers smoking. In three recent case-control had higher values for total cholesterol, low-density studies (in Bhavnagar, Gujarat; Nagpur, Maharasthra; lipoprotein cholesterol, very low-density lipoprotein and New Delhi) over 70% of the cases were under 35 cholesterol and triglycerides, as compared to the no years of age. Thus smoking and tobacco chewing both frequency and duration of chewing were analysed, demonstrated comparable adverse effects on lipid frequency of chewing rather than the total duration of profile and could increase cardiovascular risk. The absence of betel some evidence that the same relationship may hold leaf in pan masala and the proportionately higher dry for smokeless tobacco use as well. A comparison of the age-specific inci acetylcholine-like (parasympathetic) actions. In 1990, the ity and efficacy of anti-tobacco education for the Government of India issued an Executive Order pro community in high tobacco-chewing areas through hibiting smoking in all healthcare establishments, controlled intervention studies. In June 1999, Indian Railways, operating under the Intervention studies Government of India, banned the sale of tobacco on railway platforms. In September 2000, the Govern Tobacco habits are widely prevalent in Kerala in the ment amended the Cable Network Rules and banned form of bidi smoking and betel-quid (pan) chewing. Overall, tooth-related problems (48%) and peer In order to curb the use of tobacco in India, there group influence (38%) were reported to be common was a long-standing demand for comprehensive initiating factors for tobacco use in Ernakulam dis legislation on the advertisement, sale and use of trict. These included the district of after passage through both houses of Parliament in Ernakulam (Kerala), and two other areas. It also the intervention cohort, at baseline, in Ernakulam prohibits smoking in public places to protect non District consisted of 12 212 tobacco users 15 years of smokers, especially children, from environmental age and older in the intervention group and there smoke. It disallows the sale of tobacco in any form to were 6075 subjects in a non-concurrent control persons under 18 years and within 100 yards of edu cohort. Clear health warnings in local tobacco use by trained investigators, and subjects languages and in English have been made manda were examined for the presence of oral lesions tory on all packages, with a pictorial warning of a by dentists and subjected to 10 annual follow up skull and cross-bones. Issues of enforcement will have to be tackled were bidi smokers, 6% were cigarette smokers, 16% next, and this will require the strong voice of promi were chewers (mostly betel quid with tobacco) and nent and knowledgeable citizens, including health 12% had multiple habits. The percentages were Since 1987 in India, beginning with the state of somewhat similar in the control cohort. At baseline, Maharashtra, a few other states (Goa, Delhi) have the prevalence of leukoplakia was 2. Prohibition of the sale of tobacco using photographs and pictorial booklets and products within 100 metres of educational institu addressed the factors that can influence continuation tions and on railway platforms has been passed by of tobacco use. The first ning orders have been issued in several more states film imparted information on the relationship against the sale, manufacture and storage of gutka, between tobacco use and oral cancer and the second and in some states other forms of chewing tobacco one addressed the reasons for initiation and tips on and pan masala as well. Cinema slides, posters, folk dra been taken by several other state governments but mas, radio programs and newspaper articles were industry opposition through the courts has forced also used, with content based on feedback received these states to modify the ban or postpone its from the field. At the request of the population, ces implementation until the Supreme Court reaches a sation camps were conducted, with group discus decision. The potential for this is discussed were conducted after the baseline survey, covering a in the next section. In the control cohort (1966–1977), no in the intervention than in the control cohort. The active programme of health education was under relapse rates were much lower in the intervention taken, but during the surveys, the dentists routinely cohort than in the control cohort. The overall inci explained the association of tobacco use with oral dence of leukoplakia in the control group was 40% cancer and advised against tobacco use, more force higher (Table 4) than in the intervention cohort and fully so if the individual had a precancerous lesion. The rate tobacco use, it was shown that it led to a substantial of regression of leukoplakia among those who had fall in the incidence of leukoplakia. For female chewers this was After 5 years of follow up, the percentage stopping 0. The fact that their tobacco use (of every type) was higher in the all ratios were below unity implied a reduced risk intervention cohort compared to the control cohort: of oral cancer after cessation of tobacco use, since 3% in the control group versus 9% in the intervention oral leukoplakia demonstrated a high premalignant cohort, but for chewers in particular, 10. Furthermore, the reduction in ing the use of tobacco, in increasing quit rates and tobacco use by continuing users was much higher in decreasing relapse rates. This study the rate ratio for the protective effect of the interven was felt to have demonstrated the feasibility and tion against leukoplakia ranged from 0. In a multiple logistic government system, in one experimental and two regression analysis of the first 5 years of intervention control areas with similar populations. Health education women tobacco chewers in the intervention cohort methods included screening of films, exhibits, and had discontinued their tobacco use, as compared to personal contact with a display of photographs of the 2. Community surveys (with seriousness of tobacco control among participants out comparison groups) conducted in Karnataka and and non-participants connected with the event. In Karnataka, nearly 6% of meetings or workshops that it sponsors or that are tobacco users reported quitting the habit, as did 4. Each tobacco advertisement should be crossed out with a black Methods of communication used in the Ernakulam marker and a notice displayed on the cover debunk intervention study included personal communica ing the claims of glamour and machismo associated tion, films, posters, newspaper articles, folk dramas, with tobacco use and declaring that tobacco destroys radio programmes, exhibits, group meetings and health, makes one poorer and leads to premature cessation camps. Health professionals in areas lows: (i) tobacco cannot cure toothache, but can with South Asian immigrants should become aware cause oral cancer; (ii) tobacco can harm the heart of the effects of betel-quid chewing. The tell-tale and make you die earlier; (iii) tobacco use during staining of gums and teeth can alert an observant pregnancy may harm your child; (iv) chewing practitioner. Such a pro not last long; (vii) children are more likely to use gramme, conducted through a large cancer hospital tobacco if their parents do; (viii) tobacco use is over the last several years, approximately doubled harmful to health and is expensive (part of the the outpatient attendance for oral examination and expense is in treating the diseases it causes. Children are a potentially powerful motivating force for health and against tobacco use.

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