CG Nanda Kumar MBBS FRCA

• Consultant anaesthetist, Calderdale and
• Huddersfield NHS Foundation Trust,
• Huddersfield
• Honorary senior lecturer, University of Leeds,
• Examiner for RCS Glasgow, UK

It is theoretically linked to his theory of the "critical conditions for change allergy medicine at walmart purchase quibron-t 400 mg line," which states that clients change when they are engaged in a therapeutic relationship in which the counselor is genuine and warm allergy testing vega machine quibron-t 400 mg amex, expresses unconditional positive regard allergy medicine for asthma 400 mg quibron-t sale, and displays accurate empathy (Rogers allergy medicine zantrex order quibron-t 400 mg with mastercard, 1965) allergy medicine psoriasis cheap quibron-t 400 mg fast delivery. Evocation elicits and explores motivations allergy testing qmc order quibron-t 400mg without a prescription, values, strengths, and resources the client already has. Avoid arguing with or trying to persuade the client that your position is correct. The original four principles have been folded into the four processes as refective listening or strategic responses to move conversations along. Resistance is an expression of sustain talk and the status quo side of ambivalence, arising out of counselor­client discord. Strategies to lessen sustain talk and counselor­client discord Change talk Decisional balancing is used to help clients make a decision without favoring a specifc direction of change. It may be useful as a way to assess client readiness to change but also may increase ambivalence for clients who are contemplating change. Rolling with resistance Self-motivating statements Decisional balancing is a strategy to help clients move in one direction toward changing a behavior. It is a style of being with people that uses specifc clinical skills to foster motivation to change. It is a collaborative partnership between you and clients to discover their motivation to change. It respects client autonomy and self-determination about goals for behavior change. It is normal for people to feels two ways about making an important change in their lives. Frequently, client ambivalence is a roadblock to change, not a lack of knowledge or skills about how to change (Forman & Moyers, 2019). As clients move from Precontemplation to Contemplation, their feelings of confict about change increase. View ambivalence not as denial or resistance, but as a normal experience in the change process. If you interpret ambivalence as denial or resistance, you are likely to evoke discord between you and clients, which is counterproductive. Sustain Talk and Change Talk Recognizing sustain talk and change talk in clients will help you better explore and address their ambivalence. Sustain talk consists of client statements that support not changing a health-risk behavior, like substance misuse. Change talk consists of client statements that favor change (Miller & Rollnick, 2013). Sustain talk and change talk are expressions of both sides of ambivalence about change. Client stuck in ambivalence will engage in a lot of sustain talk, whereas clients who are more ready to change will engage in more change talk with stronger statements supporting change. Greater frequency of client sustain talk in sessions is linked to poorer substance use treatment outcomes (Lindqvist, Forsberg, Enebrink, Andersson, & Rosendahl, 2017; Magill et al. Be aware that both sides of ambivalence (change talk and sustain talk) will be present in your conversations with clients. A client may express resistance in sustain talk that favors the "no change" side of ambivalence. The way you respond to sustain talk can contribute to the client becoming frmly planted in the status quo or help the client move toward contemplating change. Client sustain talk is often evoked by discord in the counseling relationship (Miller & Rollnick, 2013). This is an opportunity to respond in a new, perhaps surprising, way and to take advantage of the situation without being confrontational. This new way of looking at resistance is consistent with the principles of person-centered counseling described at the beginning of the chapter. A New Look at Resistance Understanding the role of resistance and how to respond to it can help you maintain good counselor-client rapport. Open questions are questions that invite clients to refect before answering and encourage them to elaborate. Open questions facilitate a dialog and do not require any particular response from you. They encourage clients to do most of the talking and keep the conversation moving forward. Closed questions evoke yes/no or short answers and sometimes make clients feel as if they have to come up with the right answer. One type of open question is actually a statement that begins with "Tell me about" or "Tell me more about. If you use these skills, you will more likely have greater success in engaging clients and less incidence of discord within the counselor­client relationship. As you read these examples, imagine you are a client and notice the difference in how you might receive and respond to each kind of question. However, if you use open questions-"Tell me about the last time you used methamphetamines"-you will often get the information you need and enhance the process of engagement. During assessment, avoid the question-and-answer trap, which can decrease rapport, become an obstacle to counselor­client engagement, and stall conversations. Ask one open question, and follow it with two or more refective listening responses. By affrming, you are saying, "I see you, what you say matters, and I want to understand what you think and feel" (Miller & Rollnick, 2013). Using affrmations in conversations with clients consistently predicts positive client outcomes (Romano & Peters, 2016). When affrming: There may be ethnic, cultural, and even personal differences in how people respond to affrming statements. Do not confuse this type of feedback with praise, which can sometimes be a roadblock to effective listening (Gordon, 1970; see Exhibit 3. Holding an awareness of client strengths instead of defcits as you formulate affrmations. Refective Listening Refective listening is the key component of expressing empathy. Refective listening (Miller & Rollnick, 2013): · · · · Communicates respect for and acceptance of clients. Establishes trust and invites clients to explore their own perceptions, values, and feelings. It is both an expression of empathy and a way to selectively reinforce change talk (Romano & Peters, 2016). Expressions of counselor empathy predict better substance use outcomes (Moyers, Houck, Rice, Longabaugh, & Miller, 2016). Your attitude should be one of acceptance but not necessarily approval or agreement, recognizing that ambivalence about change is normal. Consider ethnic and cultural differences when expressing empathy through refective listening. These differences infuence how both you and the client interpret verbal and nonverbal communications. Clients may begin the relationship asking questions about you the person, not the professional, in an attempt to locate you in the world. As part of a democratic partnership, clients have a right and, in some instances, a cultural expectation to know about the helper. This spirituality is expressed and practiced in ways that supersede religious affliations. Young people pat their chests and say, "I feel you," as a way to describe this sense of empathy. In other words, the therapeutic counselorclient alliance can be deepened, permitting another level of empathic connection that some might call an intuitive understanding and others might call a spiritual connection to each client. What emerges is a therapeutic alliance-a spiritual connection-that goes beyond what mere words can say. The more counselors express that side of themselves, whether they call it intuition or spirituality, the more intense the empathic connection the African American client will feel. Native Americans generally expect the counselor to be aware of and practice the culturally accepted norms for introducing oneself and showing respect. For example, during the frst meeting, the person often is expected to say his or her name, clan relationship or ethnic origin, and place of origin. Physical contact is kept to a minimum, except for a brief handshake, which may be no more than a soft touch of the palms. Refective listening requires you to make a mental hypothesis about the underlying meaning or feeling of client statements and then refect that back to the client with your best guess about his or her meaning or feeling (Miller & Rollnick, 2013). Gordon (1970) called this "active listening" and identifed 12 kinds of responses that people often give to others that are not active listening and can actually derail a conversation. Trying to persuade the client that your position is correct will most likely evoke a reaction and the client taking the opposite position. These statements contain such words as "should" or "ought," which imply or directly convey negative judgment. These messages imply that something is wrong with the client or with what the client has said. Giving advice, making suggestions, or providing solutions prematurely or when unsolicited 4. Agreeing, approving, or praising Praise or approval can be an obstacle if the message sanctions or implies agreement with whatever the client has said or if the praise is given too often or in general terms, like "great job. These statements express disapproval and intent to correct a specifc behavior or attitude. They can damage self-esteem and cause major disruptions in the counseling alliance. It is human nature to want to reassure someone who is in pain; however, sympathy is not the same as empathy. Such reassurance can interrupt the fow of communication and interfere with careful listening. In fact, intensive questioning can disrupt communication, and sometimes the client feels as if he or she is being interrogated. Although shifting the focus or using humor may be helpful at times, it can also be a distraction and disrupt the communication. However well intentioned, these roadblocks to listening shift the focus of the conversation from the client to the counselor. Complex refections invite clients to deepen their selfexploration (Miller & Rollnick, 2013). Move the conversation along, Highlights selected but more slowly than meaning or feeling. The frst step in making a complex refection of meaning or feelings is to make a hypothesis in your mind about what the client is trying to say (Miller & Rollnick, 2013). If the client says, "I drink because I am lonely," think about the possible meanings of "lonely. Offer a refective listening response-"You drink because it is hard for you to make friends. If the client continues to talk and expands on the initial statement, you are on target. Follow open questions with at least one refective listening response-but preferably two or three responses-before asking another question. A higher ratio of refections to questions consistently predicts positive client outcomes (Romano & Peters, 2016). Summarizing Summarizing is a form of refective listening that distills the essence of several client statements and refects them back to him or her. Transitional summary: Wraps up a conversation or task; moves the client along the change process. Ambivalence summary: Gathers client statements of sustain talk and change talk during a session. This summary should acknowledge sustain talk but reinforce and highlight change talk. It is useful during the transition from one stage to the next when making a change plan. This opportunity lets the client correct or add more to the summary and often leads to further discussion. Clients hear change talk once when they make a statement, twice when the counselor refects it, and again when the counselor summarizes the discussion. This change is a shift away from a linear, rigid model of change to a circular, fuid model of change within the context of the counseling relationship. These opening strategies ensure support for the client and help the client explore ambivalence in a safe setting. Research supports the link between your ability to develop this kind of helping relationship and positive treatment outcomes such as reduced drinking (Moyers et al. Counselor: So your wife has some concerns about your drinking interfering with your relationship and harming your health. You have been having trouble concentrating and remembering things and are wondering if that has to do with how much you are drinking. Common traps to avoid include the following (Miller & Rollnick, 2013): · the Expert Trap: People often see a professional, like primary care physician or nurse practitioner, to get answers to questions and to help them make important decisions. You have knowledge and skills in listening and interviewing; the client has knowledge based on his or her life experience. In your conversations with a client, remember that you do not have to have all the answers, and trust that the client has knowledge about what is important to him or her, what needs to change, and what steps need to be taken to make those changes. Avoid falling into the expert trap by: - Refraining from acting on the "righting refex," the natural impulse to jump into action and direct the client toward a specifc change. Such a directive style is likely to produce sustain talk and discord in the counseling relationship. Arguments with the client can rapidly degenerate into a power struggle and do not enhance motivation for change.

As an example allergy symptoms nasal discharge buy quibron-t 400 mg on line, the actions of a cisgender woman refusing to assist in the change of a policy that would permit gender-nonspecific housing or gender-neutral restrooms on a college campus would not be able to be classified under the term ``sexism allergy forecast wilmington nc cheap quibron-t 400 mg free shipping,' but such actions would be able to be captured under ``cisgenderism allergy medicine home remedies generic quibron-t 400mg with visa. As such allergy shots maintenance phase buy quibron-t 400mg fast delivery, the growing use of the term more accurately reflects a specific and pervasive cultural and systemic ideology allergy herbs buy 400 mg quibron-t. This in turn offers researchers allergy medicine 6 year old buy 400mg quibron-t amex, the transgender community and allies, and society at large a tool for continued discourse toward deeper transformation. Mistler is associate dean of students at Ringling College of Art and Design in Sarasota, Florida. This simple (and simplistic) definition belies a raft of social, psychological, and philosophical issues. However, cross-dresser, the preferred term, requires for its existence a set of very strong institutional precepts the violation of which must be societally condemnable. The first requirements involve the instantiation and supervision of a strong bi-gender system such as we have in our culture. More, there needs be a social or formal set of standards for gendered appearance that distinguish between the two genders and, ipso facto, the two sexes. Were there no limitations or restrictions on what an individual could wear, there would be no cross-dressing. Indeed, while cross-dressing has a long history going back to ancient times -for example, in Rome and India (Bullough and Bullough 1993: 3­112) -it has always been present and has gone through different levels of prohibition (Stryker 2008: 17­18). While some cultures, including India, the Philippines, Thailand, and some aboriginal tribes, have a space and role for cross-dressing members though often without really embracing it, contemporary Western cultures by and large do not tolerate it. In cultures where the prohibition is strong, there are two requirements: first, a strict bi-gender system, and second, a prohibition, legal and/or social, against gender ``impersonation. It is quite remarkable that these widely different activities fall under the same umbrella. Often a cross-dresser, especially one with experience, will receive little or no sexual frisson from cross-dressing and certainly will not maintain a state of arousal during the entire episode. What I have called the ``committed cross-dresser' is Downloaded from read. Females as well as males have been involved in cross-dressing, but there is often a different judgment laid upon them. The Western patriarchal subordination of women means, on one hand, that it makes sense for a woman wanting freedom from oppression to try to pass as a man; but, on the other hand, she may well be attacked for trying to rise above her ``rightful' place. Men, on the other hand, have no such justification, since by cross-dressing in a patriarchal society they are placing themselves lower on the power ladder, a move that is specifically against the very idea of masculinity and hence traitorous. Nonetheless, the question remains as to the source of the disapprobation in our culture. Why should there be such societal angst regarding the person, woman or man, who wants to sometimes appear as the ``opposite' gender? Stephen Ducat points out that taboos exist when there is an attraction to an activity that society wants to stem. His point is that no one wants to have sex with cheese, and, if someone does, no one else cares. This points to the attraction of males to femininity, to the temporary abandonment of the responsibilities and burdens of masculinity as construed societally. The bi-gender system outlines rigid rules of behavior for each gender, and not everyone is comfortable in their assigned role all the time. Contemporary western society is slowly making room for and improving the lot of the transsexual. More laws are being eased, and more accommodation made, though there is still very far to go. The cross-dresser, however, receives little protection or benefit from these advances, because the cross-dresser, unlike the transsexual, is in constant violation of the bi-gender regime. He or she is not seeking admission into the non­birth-designated sex but only a temporary visa, so to speak, one good for several hours or a few days, confounding many social constituencies. Transsexuals often view cross-dressers as dilettantes, wannabes, or unsophisticated amateurs. The fact that a huge number of transsexuals began their life as cross-dressers seems immaterial. Feminists often deride cross-dressers for picking and choosing those parts of femininity they want and ignoring the Downloaded from read. Cis-women often find cross-dressers interesting, while men become very uncomfortable. The bottom line is that in Western Euro-American cultures there is a sense in which the cross-dresser, especially the out cross-dresser, is the true gender outlaw. Of all the members of the transgender community, broadly understood as those who defy the identity of birth-designated sex with lived gender, she or he refuses one gender and moves back and forth at will, thereby demonstrating the constructed and essentially artificial nature of the bi-gender dichotomy. Unfortunately, the censure laid on cross-dressers keeps the majority firmly in the closet where they are politically unable to become the sort of force needed by the transgender movement. Should the walls between the genders weaken and become more permeable, it is the cross-dresser who will demonstrate that one can have more than one gender. Cultural competency refers to the ability to understand, communicate with, and effectively interact with diverse populations, and it can be measured by awareness, attitude, knowledge, skills, behaviors, policies, procedures, and organizational systems. Culture is defined as ``the integrated pattern of thoughts, communications, actions, customs, beliefs, values, and institutions associated, wholly or partially, with racial, ethnic, or linguistic groups, as well as with religious, spiritual, biological, geographical, or sociological characteristics' (Office of Minority Health 2013). Cultural groups can include people who share racial and ethnic affiliations, linguistic characteristics, generation, geographic residence, socioeconomic status, physical ability or limitations, sex, sexual orientation, gender identity and expression, and other characteristics, and they can be population groups that share a defined set of cultural expressions and expectations. Transgender cultural competency is imperative across the board for improved health, social service, legal, faith-based, employment, and educational outcomes. The phrase ``multicultural competence' first surfaced in a mental health publication by psychologist Paul Pedersen in 1988, a decade before ``cultural competence' came into popular use. While health care institutions were the first to promote the concept of cultural competency, and undoubtedly continue to be the most common field that recognizes the need, all fields can benefit from a cultural competency perspective. Behavioral health, public health, social services, educational institutions, criminal justice, law enforcement, faith-based organizations, government services, employers, and other organizations, businesses, and institutions can certainly improve their knowledge, skills, behaviors, policies, and procedures to create a welcoming and nondiscriminatory environment for transgender and gender-nonconforming individuals and families. Rather than a body of knowledge that can be learned in an afternoon workshop, training series, or course, cultural competency is a lifelong process of engagement. Critiques of the concept of cultural competency highlight concerns that people sometimes view the work as short term or that power imbalances are not Downloaded from read. Indeed, intersectionality, or multiple systems of oppression and discrimination (Wikipedia 2013a), exists for many transgender people. Systematic injustice and inequality occur not just based on gender identity and expression but also within overlapping experiences of race, gender, socioeconomic class, ability, sexual orientation, health status, linguistic capability, migration, and other characteristics. Transgender cultural competency requires recognition and commitment to genuinely understanding and working to address the multiple parameters that impact so many transgender lives. Within this framework of intersectionality, transgender cultural competency involves an understanding of terms, identities, and concepts associated with transgender and gender-nonconforming communities, including utilizing culturally appropriate language and behavior for addressing and working with transgender populations; broadening understanding of the myriad socioeconomic, health, and legal issues that transgender people face; and developing and implementing culturally appropriate systems and service approaches for working with transgender individuals and families. Cultural competency issues are addressed worldwide through many avenues for an array of audiences. On a global level, approaches to transgender cultural competency issues are informed by the economic situation, legal issues, and whether there is a historical cultural framework for understanding trans and gender-nonconforming people. Organizations in their respective locales as well as such far-reaching Downloaded from read. In Kampala, Uganda, where it is illegal to be gay or associate with gay people, with trans people considered to be ``gay' (Wikipedia 2013b), activists are working to ensure that trans people are not turned away from the emergency room at the local hospital and that they can establish relationships with doctors who are willing to treat them (Kopsa 2012). The organization Gender DynamiX in Cape Town, South Africa, is working to improve competence in the police force (Gender DynamiX 2013), while South Africa, Chile, several European countries, and others are educating government agency workers who handle identification changes (Shlasko, pers. In Argentina, where the 2012 landmark Gender Identity Law enabled trans people to change their identification documents without medical intervention and access transition-related care ґ through public and private health insurance, the organization Nadia Echazu works to improve trans access to education and employment beyond the sex industry (Baird 2013). In locales such as Thailand, India, Pakistan, and the Yucatan region of Mexico, where there is an indigenous tradition of gender diversity, stigma and marginalization persist throughout society, yet not the level of cultural incompetence at which providers are unaware of the existence of trans people. Finally, in locations with dire economic conditions, where basic survival is paramount and primary health care is not available to poor trans people, health care institutions are not necessarily the first priority with regard to addressing cultural incompetence. Indeed, approaches vary around the world, with Europe relying almost exclusively on a medical model, while much of the global South relies on a human rights model (Shlasko, pers. This includes people who identify as male or female as well as people who identify as something between or beyond male and female. It is also important to understand the various ways in which trans and gender-nonconforming people want to be addressed and to be equipped to successfully navigate appropriate name and pronoun use. Also key is the ability to respectfully obtain this information when it is unclear what is appropriate and to recover gracefully when a mistake is made. Trainees in transgender cultural competency benefit from a firm grasp of social and medical transition, including the routes and barriers to transition- Downloaded from read. Indeed, the lack of coverage for transition-related care under most health insurance plans for what are often cost-prohibitive procedures contributes to significant financial hurdles. In the United States, many jurisdictions prohibit discrimination based on gender identity and expression in public accommodations such as health services. Organizations, government services, and educational institutions can develop trans-inclusive policies and procedures to identify, respond to , and appropriately serve this population. They can update their written forms to ascertain and document transgender status; implement trans-inclusive policy for genderspecific environments including restrooms, locker rooms and shower facilities, housing accommodations, dress code, support groups, and urinalysis; and develop clearly written nondiscrimination policies that specifically protect against discrimination based on gender identity and expression. Systems should be in place to address grievances and poor-quality treatment so that staff persons can receive additional training and/or appropriate sanctions if necessary. School district policies for accommodating trans and gender-nonconforming students, such as the one developed in Toronto, Canada, recommend systems that emphasize dignity, respect, privacy, safety, and curriculum integration in educational settings free of bullying, harassment, and discrimination (Toronto District School Board 2011). Colleges and universities can support transgender and gender-nonconforming students by incorporating transgender issues into the curriculum across fields and providing trans-affirming academic, social, medical, and mental health programs. Many are confused about how to navigate social interactions and work with individuals with complex, nonbinary identities. Challenging scenarios can be addressed by researching Internet resources, developing effective partnerships with colleagues who serve this population, and Downloaded from read. With awareness, compassion, attention to knowledge and skills development, and a commitment to updating organizational systems, health service providers, educators, government agencies, law enforcement, faith-based organizations and others throughout society can build the capacity of their organizations to create nondiscriminatory service environments for transgender individuals and families. His publications include ``Working with Transgender Persons' (Psychiatric Times, September 2012) and contributions in the forthcoming Trans Bodies, Trans Selves and Manning Up. His memoir Born on the Edge of Race and Gender: A Voice for Cultural Competency is also forthcoming. The ``medical model' refers to the concept that trans people are entitled to medical care and legal identity document change based on medical diagnoses. The ``human rights model' refers to the concept that trans people are entitled to basic human rights so that they can participate fully in society, as in, for example, the Yogyakarta Principles (2007), a ``universal guide to human rights which affirm binding international legal standards with which all states must comply' with regards to sexual orientation and gender identity. The Application of International Human Rights Law in Relation to Sexual Orientation and Gender Identity. Meanwhile, trans people are exposed worldwide to dynamics of stigmatization, discrimination, social exclusion, and transphobic violence, including forms of physical and institutional abuse. Within the context of the current revision processes of Downloaded from read. Relevant aspects inherent to activistacademic depathologization discourses include the questioning of the current diagnostic classification of gender transitions, the demand of a recognition of trans rights, among them legal and health rights, the revision of the trans health care model, and the claim of an acknowledgment of gender/body diversity. This demand is based on the observation of structural interrelations between dynamics of psychiatrization, discrimination, and transphobia and on an acknowledgment of the negative effects that a psychiatric classification has on the citizenship rights of trans people. The frequent requirements of a gender-transition­related diagnosis, hormone therapy, and, in some countries, genital surgery, sterilization, and divorce in order to attain legal gender recognition are denounced as contradicting fundamental human rights recognized by the Yogyakarta Principles (2007) and other international resolutions. Indeed, the trans depathologization framework introduces a paradigm shift in the conceptualization of gender identities: from conceiving gender transition as a mental disorder to recognizing it as a human right and expression of human diversity. From this perspective, the conflict is not situated in the individual trans person but in a society characterized by transphobia and gender binarism. Thus the contemporary concept of trans(s)exuality is analyzed as a culturally and historically specific construction. Furthermore, the ethnocentric and neocolonialist character of Western-biased psychiatric classifications is put into question for rendering invisible the cultural diversity of gender expressions Downloaded from read. Trans depathologization discourses include awareness of the diversity of gender conceptualizations, expressions, and trajectories worldwide as well as the presence of context-specific circumstances and priorities within international trans activism. A central issue in discussions about trans depathologization is the question of how to introduce a depathologization perspective without risking access to trans health care. Given that in some health care contexts, illness-based diagnostic categories are the requisite for public coverage of transition-related health care, there is a fear that depathologization would put access to these health care services at risk, thus fostering social inequalities in the access to trans health care. Trans depathologization activism conceives the right to depathologization and the right to health care as two fundamental human rights, suggesting various strategies in order to facilitate access to state-covered trans health care within a depathologization framework. Most recently, the approval of the Argentinian Gender Identity Law in June 2012 created a precedent for legal gender recognition and public coverage of trans health care from a human rights perspective. In the academic context, throughout the last decades an emerging trans scholarship has ruptured the traditional discursive exclusion of trans people from academia, thereby contributing critical revisions of pathologization dynamics in health care, social, legal, and academic contexts as well as new theoretical ґ frameworks and conceptualizations (see, among others, Misse and Coll-Planas 2010; Stryker and Whittle 2006; Thomas, Espineira, and Allessandrin 2013). In addition, trans artists have created new imaginaries for gender/body diversity beyond the binary. Depathologization discourses are related to a postmodern/poststructuralist deconstruction of dichotomous models, a questioning of medicalization and psychiatrization processes in Western society, postcolonial discourses, and discussion of health care models based on participation, social determinants of health, and human rights perspectives. Finally, it is important to note that trans depathologization discourses do not conceive depathologization as only a trans-specific issue. The questioning of cis/heteronormativity and gender binarism, as well as the demand of a broader social recognition of gender/body diversity, is considered an important issue for all people. The current pathologization of gender transition processes is perceived as part of the structural violence inherent to the social gender order. Therefore, the depathologization perspective opens up potential alliances with other critical theoretical reflections and social movements, among them intersex, body diversity, and antipsychiatry discourses and activisms. Amets Suess is a sociologist and trans activist who works as a researcher and teacher at the Andalusian School of Public Health, Granada, Spain. He is a collaborating author in the anthology El genero desordenado: Cri ticas en torno a la patologizacion de la transexualidad ґ ґ ґ (2010) among other publications. Karine Espineira holds a PhD in information and communication sciences from the University of Nice Sophia Antipolis. He is a contributing author of La Transyclopedie (2012) and Trans Bodies, Trans Selves (2014).

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While shifting should not be prevalent for the duration of the lunar sortie stay allergy testing kalamazoo mi best quibron-t 400 mg, crews will be required to shift while they are conducting critical mission tasks (S Gibson allergy symptoms after running buy quibron-t 400mg low cost, personal communication austin allergy forecast yesterday effective quibron-t 400mg, 2008) allergy shots eyes cheap 400mg quibron-t with mastercard. In addition allergy testing portland maine purchase quibron-t 400 mg, the day-night cues on the surface of the moon will be different than the day-night cues on Earth allergy medicine quercetin quibron-t 400 mg discount. The elevated portions on the rim of Shackleton crater, which is a proposed landing site that is near the South Pole of the moon, may be exposed to light as much as 90% of the time (flight surgeon R Scheuring, personal communication, 2007). Anecdotal reports of individuals conducting 2- to 3-week exploration missions in the Arctic, where light exposure is, as it is on the moon, close to continuous, indicates that exposure to constant light may result in an individual being unable to detect a need for sleep and/or rest (flight surgeon R Scheuring, personal communication, 2007). If the landing site is not at the lunar poles, however, but is at more equatorial locations, the day-night cycle on the moon involves 2 weeks of light exposure and 2 weeks of darkness. Either way, the natural lighting conditions will not be the same as those experienced on Earth due to the 24-hour clock. This means that astronauts will not be able to depend on natural lighting cues to help with their circadian rhythms. Additional factors that are associated with sleep and circadian issues in the current space flight environment ­. Subsequently, performance errors remain a plausible risk during the short-duration missions to the moon and could occur during the lunar sortie mission scenario. During these missions, both ground and flight crews will experience high-tempo operations and shift work. As was noted above, unfamiliar day-night cues could affect the circadian system and the subjective need to sleep. As a result, for long-duration lunar missions, it is estimated that human performance errors due to sleep loss, fatigue, extended work shifts, circadian desynchronization, and work overload could occur. Mars For a Mars mission, this risk remains relevant and important, although certain aspects of the risk may vary for the different mission phases. On the surface of Mars, work activities may consume a large part of crew time; the slam shifting that can lead to circadian desynchronization should be absent from a Mars scenario as the crews will, of necessity, manage their own timelines. It is suspected, however, that daylight is not bright on the surface Mars; the sunlight on Mars is about one-half of the brightness of that seen on Earth, and the martian sky does not appear blue but pink due to suspended dust, which means that the surface of Mars is, in fact, darker than what is experienced on Earth (Murphy, 1997). This difference in light exposure may complicate the entrainment of circadian rhythms, since the circadian system is most sensitive to blue wavelengths (Brainard et al. Additionally, Mars has a day-night cycle (lasting 24 hours 39 minutes) that differs from that on Earth, which, as evidenced by recent ground studies, may pose challenges to performance. Reduced levels of concentration and energy were also reported by most of the participants. The degree to which the physiological challenge of living on the Mars sol can threaten the success of a mission is described further in the appendix of the DeRoshia et al. Subjects who were living on a laboratory-simulated Mars sol schedule experienced sleep disruption and decrements in alertness and performance (Wright et al. Most humans cannot adapt to this non-24-hour day without adequate countermeasures (Gronfier et al. As a result, for Mars missions, it is estimated that human performance errors that are due to sleep loss, fatigue, extended work shifts, circadian desynchronization, and work overload could occur. Cognitive decrements that are caused by fatigue, inadequate light exposure, circadian dynamics, and work-sleep schedules, will more profoundly affect crews who are on a long-term lunar or Mars mission, where fewer resources will be available to mitigate these factors. The risk factors may become compounded by the fact that lunar and Mars missions bring additional restrictions. For example, returning to Earth from a lunar mission is not a readily available option, and returning to Earth during a Mars mission is not an option at all. The current standards, however, do not provide specific limits for performance thresholds. In mission analogs, astronauts can establish individual and group baselines as well as normative data for an environment that can be compared with space flight. Flight designers and flight surgeons are concerned that crew members, and especially ground control personnel, may not be obtaining the minimum recommended rest periods: actual work-sleep time is not the same as the time that is planned. During critical mission phases, schedule shifting and workload demands are strenuous for both ground and flight teams. If crews are shifted or have to perform during this allotted sleep time, recovery time needs to be allowed and individualized countermeasures need to be readily available. Conclusion Ground evidence clearly demonstrates the risk of performance errors due to sleep loss, fatigue, circadian desynchronization, and work overload. Reviews in the aviation and medical industry have consistently attributed accidents, injuries, and even death to performance errors arising from sleep and circadian issues. Space flight evidence shows that astronauts are regularly subject to shifting their sleep/wake schedules, long work hours, complex tasks, and sleep loss. The ground teams that support flight crews and robotic missions endure similar issues. The space flight environment is reported to be noisy, poorly lit, and, for some, uncomfortable. Shifting schedules and heavy workloads, particularly for the shuttle astronauts, can pose additional challenges. Adequately assessing the environment and making recommendations to improve on it, as well as understanding individual vulnerabilities to sleep loss, is an essential part of preparing for future missions to the moon and Mars. Astronauts have proven to be resourceful in mitigating sleep loss, circadian desynchronization, fatigue, extended work shifts, and work overload. Lighting, medication, good sleep hygiene, and improved scheduling serve as effective countermeasures for space flight crews. Much remains unknown concerning the best ways in which to implement these countermeasures, however, particularly over time. Some medications, for instance, are suspected to work differently in space than they do on Earth. Non-sleep medications may be required in flight, and the potential interactions between these and the sleep medications that are prescribed in space flight have yet to be determined. Similarly, additional research will aid in the use of artificial lighting as a countermeasure for increasing acute alertness as well as facilitating the alignment of circadian rhythms. The long-term safety and efficacy of light as a non-pharmaceutical aid for alertness, circadian shifting, and sleep will inform requirements for the lunar and Mars crew habitats as well as recommendations to the crews, flight controllers, and flight medical operations. Continued research efforts are necessary to address the psychological and physiological health of individuals during and following space flight missions. Similarly, countermeasures that are developed to aid the sleep and circadian system can also serve to enhance other aspects of health; as an example, research indicates that bright light can serve as an effective treatment for Seasonal Affective Disorder (Glickman et al. Risk of Performance Errors Due to Sleep Loss, Circadian Desynchronization, Fatigue, and Work Overload 109 Chapter 3 Human Health and Performance Risks of Space Exploration Missions Cajochen C, Munch M, Kobialka S, Krauchi K, Steiner R, Oelhafen P, Orgul S, Wirz-Justice A. Are individual differences in fatigue vulnerability related to baseline differences in cortical activation? Bright light induction of strong (type 0) resetting of the human circadian pacemaker. Risk of Performance Errors Due to Sleep Loss, Circadian Desynchronization, Fatigue, and Work Overload 111 Chapter 3 Human Health and Performance Risks of Space Exploration Missions Korth D, Leveton L, Dinges D. Safety considerations for the use of blue-light blocking glasses in shift-workers. Straif K, Baan R, GrosseY, Secretan B, Ghissassi F, Bouvard V, Altieri A, Benbrahim-Tallaa L, Cogliano V (2007) Carcinogenicity of shift-work, painting, and fire-fighting. Systematic interindividual differences in neurobehavioral impairment from sleep loss: evidence of trait-like differential vulnerability. Such knowledge will enable the space agency to meet these future challenges and succeed. In contrast, on Mar 31, 2005, Node 1 was down to only one lamp burning, with an illuminance of 0. The dim illumination in Node 1 presented a safety issue that was addressed, initially, by moving lamps from another area. Finally, in an airlock that has all four of its fluorescent lamps working, the illuminance is 17. The above illuminances were determined by the radiance illuminance model of the Lawrence Berkeley National Laboratory, Berkeley, Calif. Required illuminances for various tasks include: maintenance, 25 fc; transcribing, 50 fc; repair, 30 fc; reading, 50 fc; and night lighting, 2 fc. Foot-candles can be converted to the international unit of lux by multiplying by 10. The model core makes predictions of neurobehavioral performance capability that are based on sleep and sleep loss (acute and chronic), naps, circadian rhythms, and light exposure, which means that the model also incorporates predictions that are based on countermeasures. These predictions allow for the evaluation of risk and safety of sleep/wake/work schedules during both the planning and the execution of space missions. Prospective studies on the accuracy of these model predictions that simulate the conditions of many of the sleep loss and circadian provocations that occur in space flight remain to be done on Earth. Such studies are essential, and may indicate the need for additional model parameters and changes in model structure. The Circadian, Neurobehavioral Performance, and Subjective Alertness Model approach has been directed towards increasing the accuracy of predictions and adding operationally relevant features. For example, melatonin is now incorporated as a circadian marker rhythm to accurately predict the phase and amplitude of the circadian pacemaker. This model has recently been amended to allow the determination of an optimal light countermeasure regime for a given shift in sleep/wake or work schedule to improve performance at a desired time; this includes a schedule/countermeasure design prototype program that allows a user to interactively design a schedule and automatically design a countermeasure regime. These data, which are accumulated from actual astronauts in flight, will be integrated into the Circadian, Neurobehavioral Performance, and Subjective Alertness Model. This risk may be influenced by other space flight factors including microgravity and environmental contaminants. A Mars mission will not be feasible unless improved shielding is developed or transit time is decreased. Pictured is the Crab Nebula, a 6-light-year-wide expanding remnant of the supernova explosion of a star; the colors indicate the different expelled elements. Astronauts in space are exposed to protons and high-energy and charge ions that are released by events such as supernovae, along with secondary radiation, including neutrons and recoil nuclei that are produced by nuclear reactions in spacecraft and tissue. Ground studies and system biology models of cancer risk reduce uncertainties in risk projection models and pave the way for biological countermeasure development to protect astronauts on future Exploration missions. The evidence of cancer risk from ionizing radiation is extensive for radiation doses that are above about 50 mSv. Ongoing studies are providing new evidence of radiation cancer risks in populations that were accidentally exposed to radiation. These studies provide strong evidence for cancer morbidity and mortality risks at more than 12 tissue sites, with the largest cancer risks for adults found for leukemia and tumors of the lung, breast, stomach, colon, bladder, and liver. Genetic and environmental factors that contribute to radiation carcinogenesis are also being explored to support the identification of individuals with higher or reduced risk. Whole body doses of 1 to 2 mSv/day accumulate in interplanetary space, and approximately half of this value accumulates on planetary surfaces (Cucinotta et al. Therefore, with the exception of solar proton events, which are effectively absorbed by shielding, current shielding approaches cannot be considered a solution for the space radiation problem (Cucinotta et al. Epidemiological data, which are largely derived from the atomic-bomb survivors in Japan (Preston et al. Projections to predict cancer risks in astronauts are currently made using the double detriment life-table for an average population such as is found in the U. The model that is used for the radiation cancer mortality rate is based on epidemiological studies of atomic-bomb survivors, which are assumed to be scalable to other populations, dose-rates, and radiation types. The scaling of mortality rates for space radiation risks to astronauts to the atomic-bomb survivors introduces many uncertainties into risk estimates (Cucinotta et al. Debate continues on what level is acceptable for space radiation cancer risks for the exploration of the moon or Mars. Although a historical perspective is summarized herein, we note that the strong possibility of non-cancer mortality and morbidity risks must also be considered for a Mars mission. Improvements in safety in other areas of space flight should place pressure on radiation protection to improve and lower the risks to astronauts from space radiation. Ground-based experimentation (Durante and Cucinotta, 2008) is key to solving the problem of space radiation cancer risk estimation because flight experiments are difficult, expensive, and poorly reproducible; the dose-rate is too low to get useful data in reasonable time; and, in the past, experiments have yielded no major findings (Kiefer and Pross, 1999; Schimmerling et al. Systems biology models of cancer risk that can be used to extrapolate radiation quality over the broad range of nuclear types and energies and fluence rates in space suggest that effective mitigation measures are a promising new approach to these problems. Introduction As noted by Durante and Cucinotta (2008), cancer risk that is caused by exposure to space radiation is now generally considered the main hindrance to interplanetary travel for the following reasons: large uncertainties are associated with the projected cancer risk estimates; no simple and effective countermeasures are available, and significant uncertainties prevent scientists from determining the effectiveness of countermeasures. Optimizing operational parameters such as the length of space missions, crew selection for age and gender, or applying mitigation measures such as radiation shielding or use of biological countermeasures can be used to reduce risk, but these procedures are clouded by uncertainties. The risks of cancer from X rays and gamma rays have been established at doses above 50 mSv (5 rem), although there are important uncertainties and ongoing scientific debate concerning cancer risk at lower doses and at low dose-rates (<50 mSv/hour). A description of uncertainty analysis using Monte Carlo techniques is provided below. Current estimates of levels of uncertainty, which are represented as fold changes of the upper 95% confidence interval (C. The contribution of microgravity effects on space radiation risk has not yet been estimated but it is expected to be small (Kiefer and Pross, 1999). Risk of Radiation Carcinogenesis 123 Chapter 4 Human Health and Performance Risks of Space Exploration Missions Figure 4-1. Estimates of fold uncertainties from several factors that contribute to cancer risk estimates from space radiation exposures. The uncertainties are larger for astronauts who are in space as compared to typical exposures on Earth, as illustrated. The uncertainties are larger for astronauts who are in space as compared to typical exposures on Earth, as illustrated here.

Values and Preferences: these recommendations are a compromise between the competing goals of providing early appropriate antibiotic coverage and avoiding superfluous treatment that may lead to adverse drug effects allergy shots duration generic quibron-t 400mg fast delivery, Clostridium difficile infections allergy shots vomiting buy 400 mg quibron-t visa, antibiotic resistance allergy testing eggs discount quibron-t 400 mg line, and increased cost allergy treatment xerosis order quibron-t 400mg visa. Considerations should include their rate of change allergy testing training generic quibron-t 400 mg with mastercard, resources allergy medicine companies cheap quibron-t 400mg without a prescription, and the amount of data available for analysis. Options include: Piperacillin-tazobactam, cefepime, levofloxacin, imipenem, meropenem. The 20% threshold was chosen to balance the need for effective initial antibiotic therapy against the risks of excessive antibiotic use; hence, individual units can elect to adjust the threshold in accordance with local values and preferences. If patient has structural lung disease increasing the risk of gramnegative infection (ie, bronchiectasis or cystic fibrosis), 2 antipseudomonal agents are recommended. A high-quality Gram stain from a respiratory specimen with numerous and predominant gram-negative bacilli provides further support for the diagnosis of a gram-negative pneumonia, including fermenting and non-glucose-fermenting microorganisms. In the absence of other options, it is acceptable to use aztreonam as an adjunctive agent with another -lactam­based agent because it has different targets within the bacterial cell wall [137]. Remarks: the choice between vancomycin and linezolid may be guided by patient-specific factors such as blood cell counts, concurrent prescriptions for serotonin-reuptake inhibitors, renal function, and cost. Remarks: Routine antimicrobial susceptibility testing should include assessment of the sensitivity of the P. Remarks: High risk of death in the meta-regression analysis was defined as mortality risk >25%; low risk of death is defined as mortality risk <15%. For a patient whose septic shock resolves when antimicrobial sensitivities are known, continued combination therapy is not recommended. Values and Preferences: these recommendations place a relatively higher value on avoiding potential adverse effects due to the use of combination therapy with rifampicin and colistin, over achieving an increased microbial eradication rate, as eradication rate was not associated with improved clinical outcome. Values and Preferences: these recommendations place a high value on achieving clinical cure and survival; they place a lower value on burden and cost. Remarks: Inhaled colistin may have potential pharmacokinetic advantages compared to inhaled polymyxin B, and clinical evidence based on controlled studies has also shown that inhaled colistin may be associated with improved clinical outcomes. The clinical evidence for inhaled polymyxin B is mostly from anecdotal and uncontrolled studies; we are therefore not suggesting use of inhaled polymyxin B. Colistin for inhalation should be administered promptly after being mixed with sterile water. Remarks: De-escalation refers to changing an empiric broad-spectrum antibiotic regimen to a narrower antibiotic regimen by changing the antimicrobial agent or changing from combination therapy to monotherapy. Since 2005, new studies have provided additional insights into diagnosis and treatment of these conditions. Furthermore, in the 11 years since the publication of these guidelines, there have been advances in evidence-based guideline methodology. Patients with immunosuppression who are at risk for opportunistic pulmonary infection represent a special population that often requires an alternative approach to diagnosis and treatment. This document may also serve as the basis for development and implementation of locally adapted guidelines. We also considered the availability of more recent guidelines from other organizations to avoid needless redundancy. Pneumonia was defined in the 2005 document as the presence of "new lung infiltrate plus clinical evidence that the infiltrate is of an infectious origin, which include the new onset of fever, purulent sputum, leukocytosis, and decline in oxygenation. While the measurement of these events may be a useful concept for trending and benchmarking quality, these definitions were designed for the purposes of surveillance and quality improvement at the population level and not to aid in diagnosis and treatment decisions at the bedside. The panel therefore did not consider these definitions for the purposes of these guidelines. A total of 18 subject-matter experts comprised the full panel, which included specialists in infectious diseases, pulmonary medicine, critical care medicine, laboratory medicine, microbiology, and pharmacology as well as a guideline methodologist. An expert in guideline methodology, Dr Jan Brozek, oversaw all methodological aspects of the guidelines. The disclosures were used to categorize the panelists as cleared for full participation, allowed to participate with recusal from certain aspects of guideline development, or disqualified from participation. They therefore avoided any relationships with pharmaceutical or device companies that had products in development or being marketed for pneumonia. Furthermore, all panelists were precluded from participating in any marketing-related activities (ie, lectures or advisory boards directly funded by a pharmaceutical or device company with interests related to the subject of these guidelines) during the entire process. Clinical Questions and Evidence Review Searches were limited to studies performed in adults and those published in English or containing an English abstract. The initial literature searches were performed in 2012 and 2013, and then updated in July 2014. Studies published up to November 2015 were included if pertinent to these guidelines. To supplement the electronic searches, as needed, panelists contacted experts and hand-searched journals, conference proceedings, reference lists, and regulatory agency websites for relevant articles. The titles and abstracts of all identified citations were screened and all potentially relevant citations were subjected to a full-text review, using predefined inclusion and exclusion criteria. The results of the literature searches were thoroughly reviewed by the panelists followed by selection and evaluation of the relevant articles. Once the articles were selected, the panelists in conjunction with the co-chairs and the methodologist decided if a qualitative and/or a quantitative analysis was appropriate. Panelists were not required to update their recently performed meta-analyses with results of the last search unless there was likelihood that doing so would result in a change to the strength or direction of a recommendation. The summaries of evidence were discussed and reviewed by all committee members and edited as appropriate. Once the analyses were completed, the panelists presented their data and findings to the whole panel for deliberation and drafting of recommendations. Literature search strategies, evidence tables, evidence profiles, and additional data, including meta-analysis results, can be found in the supplementary materials [21]. After the committee prioritized the proposed topics via an online poll, the final set of clinical questions to be addressed was approved by the whole committee. All outcomes of interest were identified a priori and the guideline committee explicitly rated their importance for decision making. The words "we recommend" indicate strong recommendations and "we suggest" indicate weak recommendations. Table 1 provides the suggested interpretation of strong and weak recommendations for patients, clinicians, and healthcare policy makers. Although there is arguably ongoing need for research on virtually all of the topics considered in this guideline, "Research Needs" were noted for recommendations in which the need was believed by the panelists to be particularly acute. All members of the panel participated in the preparation of the guideline and approved the final recommendations. The findings do not lead to any specific recommendations, rather they provided guidance for the panelists for several of the treatment recommendations. Overall, 54 studies were identified in the literature search, and 39 were excluded because of duplicate publication (n = 1), lack of a comparator (n = 34), or nonclinical focus (n = 4). Potential risk factors that were not found to be consistently associated with resistant organisms in our analysis are listed in the supplementary materials [21]. This emphasizes the need for judicious selection of patients for antibiotic therapy. Sepsis may alter the response of cellular elements that comprise the innate immune system [34]. The study by Ewig et al comprehensively illustrates the pathogenesis and the rationale behind it [38]. First, it could be demonstrated that upper airway colonization was an independent predictor of subsequent tracheobronchial colonization. Second, colonization patterns in the upper and lower airways changed within the first 3­4 days from a community-like to a typical nosocomial pattern. Third, colonization with community-like patterns was associated with early-onset pneumonia, whereas nosocomial patterns were associated with a risk of late-onset pneumonia. Overall, 14 variables have resulted in potential predictive factors in 3 studies [41­43]. Based on the limited data, the panel agreed that the prior use of intravenous antibiotics was the most predictive risk e72 Seven variables were evaluated in 2 studies investigating the association between P. Direct comparison of available studies is difficult owing to the varied definitions used for multidrug resistance. While there are several potential risk factors, the published evidence is scarce and of low quality. Given the widespread acceptance of this tenet at the bedside and the likelihood that few data would be found to address this question, panel members decided that this issue would not be formally addressed in this document. Summary of the Evidence Our systematic review identified 5 relevant randomized trials [53­57]. In 3 of the trials, invasive sampling (bronchoscopy or blind bronchial sampling) with quantitative cultures was compared to noninvasive sampling (endotracheal aspiration) with semiquantitative cultures [53, 54, 57]; in the remaining 2 trials, invasive sampling with quantitative cultures was compared to noninvasive sampling with quantitative cultures [55, 56]. No trials were identified that compared noninvasive sampling with quantitative cultures to noninvasive sampling with semiquantitative cultures. Two of the trials that compared invasive sampling with quantitative cultures to noninvasive sampling with semiquantitative cultures measured antibiotic days: one demonstrated more antibiotic-free days in the invasive sampling group (5. Therefore, they were able to use monotherapy and there was less opportunity to deescalate antibiotics, potentially biasing the results toward no effect [53]. There was no difference in the emergence of antibiotic resistance in the only study that looked at this outcome [54]; no other information regarding adverse events was reported in any of the trials. Taken together, the evidence suggests that outcomes are similar regardless of whether specimens are obtained invasively or noninvasively, and whether cultures are performed quantitatively or semiquantitatively. The evidence provides low confidence in the effects estimated by the trials due to risk of bias (lack of blinding in some trials, possible selection bias), indirectness (differing protocols), and imprecision (3 of the trials included small numbers of patients) [55­57]. The performance characteristics were estimated by pooling data from studies that used histopathology as the reference standard. Noninvasive sampling can be done more rapidly than invasive sampling, with fewer complications and resources. Semiquantitative cultures can be done more rapidly than quantitative cultures, with fewer laboratory resources and less expertise needed. For these reasons, noninvasive sampling with semiquantitative cultures is the microbiological sampling technique recommended by the panel. This outcome is important due to the risks of acquiring antibiotic resistance, the risk of side effects, and the costs of unnecessary or excessive antibiotic therapy; however, the estimated effects of invasive sampling with quantitative culture on antibiotic exposure are inconsistent and, therefore, insufficient to guide therapy at this time [53­55]. Research Needs at the time of culture, degree of clinical suspicion, signs of severe sepsis, and evidence of clinical improvement. Summary of the Evidence the panel agreed that the question of whether or not invasive sampling with quantitative cultures reduces antibiotic use, antibiotic resistance, direct costs, and indirect costs should be a priority area for future research. In addition, the panel agreed that such trials should measure adverse outcomes, as most trials to date have only evaluated beneficial outcomes. Values and Preferences: this recommendation places a high value on avoiding unnecessary harm and cost. We therefore decided to address the issue of the safety of antibiotic discontinuation when quantitative cultures are below the diagnostic threshold. We excluded 20 studies that either did not withhold antibiotics on the basis of the culture results or did not measure the utilization of antibiotics once the culture results were known [53, 55­57, 74­88]. This trial found that bronchoscopic sampling with quantitative cultures decreased 14-day mortality and antibiotic use. However, it did not compare outcomes among those whose antibiotics were withheld on the basis of the culture results to those whose antibiotics were continued. Because the randomized trial did not answer our question, we next evaluated the 5 observational studies [68, 70­73]. Only 2 of the studies compared outcomes among those whose antibiotics were withheld on the basis of the invasively obtained quantitative culture results to those whose antibiotics were continued despite the culture results. Patients whose antibiotics were discontinued on the basis of the quantitative cultures had a similar mortality and rate of new respiratory infection as those whose antibiotics were continued [71]. Similar to the other observational study, patients whose antibiotics were discontinued did not have a higher mortality or rate of new respiratory infection compared to patients whose antibiotics were continued. It decreases unnecessary antibiotic use, which should reduce antibiotic-related adverse events (eg, Clostridium difficile colitis and promotion of antibiotic resistance) and costs. While there is no evidence that this approach worsens clinical outcomes, in theory it could result in antibiotics being withdrawn from some patients who would benefit from antibiotic therapy because the quantitative culture results were misleadingly low due to sampling error or prior exposure to antibiotics. There was no difference among the 2 groups in either clinical cure at 28 days or hospital length of stay. There was lower 28-day mortality in the empirically treated group than the invasive group, but this was not statistically significant (10% vs 21. This evidence provided very low confidence in the estimated effects of microbiologic studies because there was very serious risk of bias (fewer patients in the invasive group received antibiotics than in the noninvasive group [76% vs 100%], lack of blinding, lack of concealment) and imprecision. Values and Preferences: the suggestion places a high value on the potential to accurately target antibiotic therapy and then deescalate antibiotic therapy based upon respiratory and blood culture results. The panel recognizes that for some patients in whom a respiratory sample cannot be obtained noninvasively, there may be factors which could prompt consideration of obtaining samples invasively. Having culture results means that the antibiotic regimen can be adjusted on the basis of those results if the patient does not respond to initial therapy. Furthermore, performing cultures of respiratory samples provides the opportunity to de-escalate antibiotic coverage based on the results, minimizing unnecessary antibiotic exposure. The panel acknowledges the potential for falsepositive results related to oral contamination when noninvasive samples are obtained, but judged that the risks of inadequate initial coverage and the potential benefit of allowing deescalation outweigh the negative impact of false-positive culture results. The panel further agreed that the respiratory specimens should be obtained noninvasively rather than invasively. The panel considered potential advantages of invasive sampling, which might include less risk of inadequate initial antibiotic coverage [90­92] and facilitation of antibiotic de-escalation. Furthermore, routine use of invasive sampling via bronchoscopy would be associated with increased cost and increased risks to the patient. The meta-analysis revealed inconsistency of the evidence (heterogeneity analysis I 2 = 87. However, the panel did not downgrade the quality of evidence due to the inconsistency because the performance characteristics were similar even after the heterogeneity was reduced by excluding certain studies.

Even traditional native cultures differ considerably regarding specifc beliefs about the causes of illness and how best to treat them allergy shots for ragweed discount quibron-t 400mg amex. As discussed further below allergy testing houston cost quibron-t 400mg fast delivery, most American Indians and Alaska Natives try to balance traditional and mainstream views of health and healing allergy shots duration cheap quibron-t 400 mg on line, and many will seek help from both mainstream providers and traditional healers allergy shots long term effects generic quibron-t 400 mg fast delivery. Certain basic principles apply to health and illness as they are understood by most allergy medicine for 7 year old buy quibron-t 400mg mastercard, if not all allergy symptoms puffy eyes discount quibron-t 400mg mastercard, American Indian and Alaska Native cultures: · · · Health is viewed holistically. One aspect of health is believed to affect the others; addressing a problem at one level may help heal problems at other levels. A holistic view also means that prevention and treatment are not divided but seen as part of the same process. The holistic view of health may also extend to the relationship between the individual and his or her community. This also means that healing the community can positively affect individual health and that the process of healing may need to occur at the community level to be effective for the individual. Illness occurs when an individual is out of harmony, and healing is a process of restoring balance. Another potential source of imbalance is cultural; American Indians and Alaska Natives may feel a loss of balance or harmony in trying to fnd equilibrium between the values of two cultures. This is one reason why healing may involve reconnecting with a traditional culture. Remember that your clinical training is infuenced by the culture and common practices of mainstream health care. These practices can confict with or be insensitive to American Indian and Alaska Native beliefs. Likewise, they may view discussing prognosis or consequences of a behavior or illness as a prediction or prophecy, believing that thought and language have the power to shape reality and the future. An illness may be purposeful, in the sense that it occurs because an individual or a relative has broken some cultural taboo or natural law, which creates a state of disharmony and hence a state of illness. These violations may have occurred recently, in the past, or in a previous generation. Because of this, in some American Indian and Alaska Native cultures, a person may be held at least in part responsible for developing an illness, and the individual who has the illness may see it as his or her responsibility to bear the symptoms. An illness may also be personifed in the sense that it has a spirit, and that spirit may need to be addressed as part of the healing process. Traditional medicine and healing the traditional view of medicine and healing is signifcantly different from that of the mainstream healthcare system. Even the word "medicine" has a different meaning in American Indian and Alaska Native tradition. Medicine, in native cultures, is the essence of being or spirit that exists in everything on Earth (Garrett, 1999). Therefore, caring for individuals who are transitioning may be perceived as sacred work. When counseling American Indian and Alaska Native clients with drinking problems, one provider suggests to clients that alcohol is medicine and that by taking it without proper knowledge, the drinker is practicing a form of witchcraft on himself or herself by consciously ingesting bad medicine (E. Traditional healing usually involves physical actions like participating in ceremonies or taking herbal remedies. Often, a whole family or community is involved in the healing process through group rituals. Traditional healing can beneft clients in a number of ways (see the "How Does Traditional Healing Work? Healers may have no specifc label for a problem but will focus on what may have caused the problem. In some American Indian and Alaska Native cultures, some illnesses or problems. Traditional practices often increase social support, thereby improving health outcomes. These stories represent themes and often serve to guide individuals on how to handle various problems. Traditional healing helps individuals transcend their experiences by identifying the meaning and purpose of those experiences within the context of the community, including the environment. Traditional healers will often only work with members of their own tribe, but some may be willing to work with other Native Americans or even with people of other races. Most traditional healers are spiritual guides and practice traditional native spirituality. Some American Indians and Alaska Natives may not want to work with traditional healers because of religious differences. Christian traditions such as those associated with the Native American Church and the Pentecostal Church also provide healing rituals to American Indians and Alaska Natives. Traditional healing practices and beliefs may be expressed within a Christian context. Generally, traditional healers do not charge fees for treatment but will accept gifts for services rendered and money for transportation, if needed. There is no offcial body that sanctions traditional healers, and there are fraudulent practitioners who claim to represent native traditions. As a provider, you should obtain recommendations of traditional healers from tribal members and leaders. Often, individuals have to travel far or go to the reservation to fnd healers with the same cultural traditions. Depending on tribal affliation, traditional healers from other tribes may be accepted or rejected. The healer does not have the same relationship to the client as a medical provider does, nor is healing something that just occurs in a specialized facility. A traditional healer will recognize that healing is not something that is done by one person to another, but involves participation by the individual, spiritual entities, family, and friends, as well as the healer. Most often, but not always, they are non-native individuals who steal, misrepresent, and exploit indigenous practices, native knowledge, and sacred ceremonies for monetary or other self-gratifying gains. Equally important, you should not facilitate traditional healing practices with native or non-native individuals unless you are an authentic native healer. Offering this practice to clients misrepresents and exploits native cultures and crosses many ethical boundaries, beginning with the failure to practice within your area of competence. Some American Indians and Alaska Natives may not feel comfortable with ceremonies that have overtly "supernatural" elements (Hartmann & Gone, 2012). Religious preferences may also affect whether a client fnds traditional healing practices acceptable; for example, an American Indian with a strong Christian identity may seek healing from his or her church and feel strongly about not wanting to participate in ceremonies that come from traditional spiritual practices. Many American Indians and Alaska Natives, especially those in urban settings, may be interested in traditional healing but not know much about it. These clients may want education about traditional healing practices before committing to them. Such education should be provided by individuals experienced in these healing traditions-either healers themselves or community elders with strong ties to their traditional cultures. Some traditional healing practices are common to more than one tribe, including: · · · · Performing a sweat lodge or spirit lodge, in which participants sit in an enclosed structure around a pit of hot rocks-a communal experience of purifcation, prayer, and healing that has been found to improve emotional and physical well-being. Performing tribal dances-community events, some of which may be physically strenuous. Chanting and singing in groups, which require intense participation and can go on for days. Engaging in other traditional ways, such as going to a winter fsh camp, carving, tanning hides, and the like. In the North section, you will read more about how to integrate American Indian and Alaska Native spiritual and healing practices into a behavioral health program. Nonetheless, as a provider, you need to remember that traditional healing practices do not separate mental disorders from physical and spiritual ones. They do, however, recognize problems that mainstream health care identifes as mental and substance use disorders, even if they are only symptomatic of other underlying problems. Traditional healers may look at someone who would be diagnosed with depression and view the same symptoms as problems stemming from breaking a taboo or from unbalanced relations with family or community. Whatever the cause, the symptoms would still call for treatment to restore balance and harmony. Participating in a talking circle, where an object is passed from one person to the next, and each participant is listened to , allowing everyone to express feelings and thoughts. Giving herbal medicines either to an individual or to members of a group as part of rituals or for their medicinal properties. This is one reason that many American Indians and Alaska Natives talk about their culture as a form of healing or prevention, particularly in relation to mental and substance use disorders. However, if clients in early recovery have used alcohol or drugs during community activities in the past, they may need to limit participation or acquire support before and during community activities as a relapse prevention step. The sections that follow will help you understand how such disorders affect American Indians and Alaska Natives and the reasons behind this increased risk. Alcohol and other substance use disorders American Indians and Alaska Natives generally start using alcohol and other substances at a younger age than do youth from other major racial/ ethnic groups. Poverty and unemployment, common problems for Native Americans, are themselves risk factors for alcohol and other substance use disorders, as are the disruption of families, trauma exposure, historical trauma, and continuing discrimination. The primary substance of abuse for American Indians and Alaska Natives, as it is for Americans in general, is alcohol. Although many Native Americans do not drink at all, binge drinking and alcohol use disorders occur at high rates relative to other populations. Binge drinking among American Indians and Alaska Natives largely refects the drinking patterns to which they were frst exposed when alcohol was introduced to their cultures through the drinking patterns of White American frontiersmen, fur traders, and others. Mexican drug cartels have been deliberately targeting rural reservations for the sale of meth and as distribution hubs. Native Americans now experience the highest meth usage rates of any ethnic group in the United States. However, given this new challenge, Tribal leaders have been at the forefront of new and creative solutions and approaches that many other communities may fnd helpful in their struggles" (National Congress of American Indians, 2006, p. Binge drinking, or consuming large amounts of alcohol in a short period, causes serious health risks despite the recovery periods between binges. When larger amounts of alcohol are consumed, the body is not able to keep up with the consumption. Higher blood alcohol concentrations occur, and the body and its organs are exposed to the higher concentrations for longer periods. Binge drinking is associated with higher death rates, injuries, heart attacks and other cardiac problems, liver damage, poor control of diabetes, and cancer. Mental and Substance Use Disorders Among American Indians and Alaska Natives You are already aware that American Indians and Alaska Natives are at increased risk for certain behavioral health conditions. The second most common substance of abuse for Native Americans is marijuana, and American Indians and Alaska Natives are more likely to develop cannabis use disorder than are members of many other racial groups. Both methamphetamine and prescription opioid abuse are growing problems for American Indians and Alaska Natives and are of major concern in a number of native communities. The effects of historical trauma and other traumas can negatively affect behavioral health and may increase the risk of developing substance use, mood, and anxiety disorders. Preferences and Barriers Regarding Behavioral Health Services Preferences Many providers believe the myth that American Indians and Alaska Natives do not seek treatment for mental and substance use disorders. In stark contrast to this stereotype, native people actively seek help from traditional healing, mainstream treatment, and mutual-help groups, or a combination of these interventions. American Indians and Alaska Natives who live in native communities and are more traditional prefer services provided in the community to those provided off the reservation or outside the community and traditional healers over mainstream behavioral health service providers. However, even on reservations, clients will use both mainstream and traditional healing. Although some individuals may prefer American Indian and Alaska Native providers, cultural competence and interpersonal qualities play a signifcant role when it comes to provider preference. Research suggests that American Indians and Alaska Natives are more likely than the general population to have psychological distress that interferes with daily functioning and to have higher suicidality. As with other populations, mental disorders in American Indians and Alaska Natives frequently co-occur with substance misuse and substance use disorders. Important differences exist among native cultures as to the types of symptoms they most often express or report to providers. For instance, American Indians and Alaska Natives are more likely to report somatic (physical) symptoms related to depression. Keep in mind that physical and psychological symptoms are not typically separated from each other. Depression is a common diagnosis associated with traumatic stress and is one psychological consequence of it. American Indians and Alaska Natives experience very high rates of trauma with the background of historical trauma. Individual 48 Some individuals may prefer to travel a considerable distance to seek services off the reservation if they are concerned about maintaining their anonymity in their local community. For instance, it is highly probable that clients will know people working at the treatment program if they seek services within their community. Your clients may also be reluctant to attend the program because it is located somewhere where it is diffcult to remain anonymous when entering the building or parking their cars. They are more likely to believe that people with mental disorders can get better without professional help and less likely to believe that therapy can teach people new ways of coping with problems. However, reluctance may result from well-grounded, historically based mistrust in outside institutions. This is a response to events such as the history of boarding school placement and unwarranted removal of native children to non-native foster and adoptive homes. Lack of child care and transportation Perception that treatment contradicts cultural values of noninterference and self-reliance Limited number of American Indian and Alaska Native providers Lack of culturally competent providers who fully understand things such as emotional expressions, the role of historical trauma in presenting symptoms, and the effects of the cumulative stress of violence and discrimination Failure to consistently conduct individual assessments on cultural identifcation and traditional healing practice preferences Limited funding or treatment options of tribal or community services Failure to establish cultural brokers, including tribal leaders or native mentors, to help in arranging traditional healing practices from authentic providers Inability to provide services in native languages Mistrust of government-funded social services Barriers to treatment services American Indians and Alaska Natives face many barriers to accessible health care, including behavioral health services.

Additional information:

• Benazepril
• Rosuvastatin
• Alendronate