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Jadwiga A. Wedzicha

Professor of Respiratory Medicine
Royal Free and University College Medical
School
University College
London, UK

Underlying causes for intensification could include demographic expansion medications and grapefruit interactions 500mg keppra visa, cumulative technological advance medicine 101 cheap 250mg keppra overnight delivery, and social and cognitive changes conventional medicine buy keppra 500mg visa, but attempts to identify a single cause will certainly fail medications prescribed for ptsd order keppra 250 mg with mastercard. Traits can be investigated independently, and should not be approached on the assumption that they are linked by some pre-existing common connection. There is also a need to examine how traits traditionally linked with the Ubaid were transmitted, both through time and across space. The issue of cultural transmission is at the heart of social and cultural replication and change, and there is much scope for theoretical work on ethnogenesis versus phylogenesis, symbolism, ideology, identity, and the transmission of meaning. The goal would be to establish which of those features traditionally associated with the Ubaid were genuinely transmitted together as a package, and which as independent variables. To that extent, we must not be blinded by style: as pollock demonstrates, a detailed examination of ceramic assemblages allows us to investigate the extent to which material from different sites or regions was implicated in similar or different social practices, regardless of general cultural assignations. The elaboration of ceramic decoration on pottery, and the association between pottery and food consumption, itself a key arena for the creation and negotiation of social relationships, is in itself not surprising. To develop our earlier discussion regarding the connection between material culture and fields of action, it is likely that what has traditionally been seen as the dissolution of the Ubaid reflects varying local responses to a range of new possibilities, including both new resources and continually developing social, economic, and organizational structures. This introduction has been more deconstructive than constructive, as we have sought to remove the conceptual debris that we see as obstructing research on the later prehistoric societies of the region: reconstruction begins with the ensuing papers. We hope that a new and more powerful understanding of middle eastern prehistory, and prehistoric interactions in general, arise from these contributions. This broadened geographical focus in Ubaid research compels us to reformulate many of our long-held views about this period and culture. We are confronted with a wide range of variability in assemblages that we can more or less group together as having some kind of Ubaid character. But what we do not understand is how or whether this material culture complex spread beyond southern mesopotamia, how the different local groups who used these assemblages were organized, how the stylistically Ubaid assemblages in northern mesopotamia and other regions differ from parallel assemblages in central and southern mesopotamia, what social processes linked the different regions, and what these linkages mean in terms of the identities of the people who made and used those items. These questions are fundamentally important for any understanding of the development of complex societies in the ancient near east. To understand this complex set of interacting regions, it is not enough to simply examine their shared Ubaid characteristics. The distinctively local character of each region is critically important to a broader understanding of this period. We can see this variation in social complexity, political organization, subsistence and craft economies, exchange activities, and ritual organization. By isolating these domains of variation, we can better understand how and why these diverse local entities chose to interact with one another through participation in a broader overarching framework within which they selectively appropriated and shared specific classes of Ubaid material culture and organizational forms. This is a risky thing to do, since it homogenizes variation between regions and can lead to the reconstruction of a societal type that may never have actually existed in the past. The hamrin differs from the southern Ubaid area in having not only a significantly different environmental setting (with concomitant implications for economic variation), but also through the apparent absence of temples, even at sites such as Tell abada, where over 80 percent of the settlement has been exposed. These contrasts are important because they suggest that the economic infrastructure and at least some aspects of community organization of the hamrin and the Ur/eridu regions might have differed in significant ways. When we consider the public ritual architecture associated with these Ubaid centers, we see further evidence for regional variation (fig. These major contrasts in scale, style, organization, and public access to ritual architecture collectively imply significant inter-regional variation in these two contemporaneous, neighboring religious systems. The clear differences in rainfall, hydrology, raw materials, and geomorphology lead us to expect significant differences, not only between northern and southern mesopotamia, but also within the south itself. But, as i note later, the role of irrigation in the south has become more problematical. We currently have only limited published evidence for animal economies, but these too show marked regional variation that has important implications for the organization of small-scale polities across the Ubaid horizon. By contrast, sheep and goats predominate in the Ubaid-related mehmeh-phase deposits at the drier site of Tepe sabz on the deh luran plain (flannery and cornwall 1969). The late Ubaid occupation at Tell arpachiyah also yielded at least one copper ax (mallowan and rose 1935: 104, pl. The technology of stamp-seal use, whether as a marker of personal ownership or as part of an administrative record-keeping system, originated in the north and characterized both north syria and the Taurus-zagros arc in the fifth millennium (fig. The stone for the celts, mace-heads, and palettes found at gawra, yarim Tepe iii, the Ubaid sites in the hamrin, and those in the south were also probably imported (most, presumably, from highland iran). The volume of trade in exotic stones seems to have reached a peak in the late Ubaid (gawra stratum Xiii; Tobler 1950: 192, 202). This conceptualization of social identity provides an extremely useful way to approach the similarities between greater mesopotamian regions and more importantly, the spread of Ubaid styles of material culture from south to north in the fifth millennium b. What statements about social identity were being made by the people at northern sites such as Tepe gawra who chose to give up using halaf house forms and ceramics in order to use Ubaid forms insteadfi This distinctive ceramic style would have signalled membership of a group sharing identity through the medium of some kind of kinship, social, or religious ideology (Berman 1994: 29; matthews 2003: 103; Thuesen 1992: 16). The ceramic and mortuary evidence points to significant changes in social identity. They are rare or absent at most halaf sites, and only appear at the latter locations in Ubaid levels. The widespread distribution of labrets and ear spools across these diverse regions within the Ubaid horizon, combined with their appearance in tandem with the spread of other Ubaid styles in the later fifth millennium, may indicate that these were significant and easily recognized markers of Ubaid personal identity. The available evidence suggests that some form of pan-regional Ubaid identity did emerge in the fifth millennium. We do not know the basis of this Ubaid identity, or even if it was expressed in the same way, with the same cultural meanings, in the different regions that comprised the Ubaid horizon. Ubaid heartland forces us to re-examine critically the question of whether the southern part of this region would have had sufficient amounts of arable land available to generate systematic large-scale food surpluses though irrigation agriculture. This now seems to have been an oversimplification of a far more variable situation. We need to systematically re-examine the relationship between environmental parameters, economic structures, and sociopolitical organization in this region.

All efforts should be made to ensure that the social circumstances of vulnerable children 5 medications that affect heart rate purchase keppra 250 mg online. If fi 1 antiretroviral is missing from the medicine regimen treatment action campaign buy genuine keppra, treatment should be stopped until they are all available again treatment 4 pimples buy keppra in india. Adherence problems need to be nd rd addressed thoroughly before switching to a 2 or 3 line regimen medicine for yeast infection buy cheapest keppra and keppra. Do not use in patients with significant psychiatric co-morbidity, renal compromise 2 (creatinine clearance < 50 mL/min/1. Children < 6 weeks or < 3 kg, who Consult a person experienced in initiating are positive at birth. Assess adherence and record (ask mother, self-assessment, record correct number of pills remain, watch body language). Web annexes: Chapter 7 Clinical guidance across the continuum of care: antiretroviral therapy guidelines; section 7. Web annexes: Chapter 7 Clinical guidance across the continuum of care: antiretroviral therapy guidelines;Section 7. Abacavir use and cardiovascular disease events: a meta-analysis of published and unpublished data. Isoniazid plus antiretroviral therapy to prevent tuberculosis: a randomised double-blind placebo-controlled trial. The prevention and treatment of isoniazid toxicity in the therapy of pulmonary tuberculosis. Healthcare utilization of patients accessing an African national treatment program. Screening for cryptococcalantigenemia in patients accessing an antiretroviral treatment program in South Africa. Systematic review of antiretroviral-associated lipodystrophy: lipoatrophy, but not central fat gain, is an antiretroviral adverse drug reaction. Lopinavir exposure is insufficient in children given double doses of lopinavir/ritonavir during rifampicin-based treatment for tuberculosis. This allows for the treatment of one or more conditions that often occur at the same time and has been accepted as the management of choice. It is important to take a good sexual history and undertake a thorough ano-genital examination in order to perform a proper clinical assessment. The history should include questions concerning symptoms, recent sexual history, sexual orientation, type of sexual activity (oral, vaginal, anal sex), the possibility of pregnancy (females), use of contraceptives including condoms, recent antibiotic history, antibiotic allergy and recent overseas travel. Penicillin allergic pregnant or breastfeeding women, refer for penicillin desensitisation. It is usually self-limiting but can be progressive in an advanced stage of immunodeficiency. In most cases, warts resolve without treatment after 2 years in nonimmunosuppressed patients. The bites cause intense itching, which often results in scratching with bacterial superinfection. Remarkable increase in central Japan in 2001-2002 of Neisseria gonorrhoeaeisolates with decreased susceptibility to penicillin, tetracycline, oral cephalosporins, and fluoroquinolones. A remarkable reduction in the susceptibility of Neisseria gonorrhoeae isolates to cephems and the selection of antibiotic regimens for the single-dose treatment of gonococcal infection in Japan. Treatment of uncomplicated gonococcal urethritis by double-dosing of 200 mg cefixime at a 6-h interval. Phenotypic and genetic characterization of the first two cases of extended-spectrum-cephalosporin-resistant Neisseria gonorrhoeae infection in South Africa and association with cefixime treatment failure. The role of core groups in the emergence and dissemination ofantimicrobial-resistant N gonorrhoeae. Azithromycin versus doxycycline for genital chlamydial infections: a meta-analysis of randomized clinical trials. Azithromycin for empirical treatment of the nongonococcal urethritis syndrome in men. Comparison of azithromycin and doxycycline in the treatment of non-gonococcal urethritis in men. Re-evaluating the treatment of nongonococcal urethritis: emphasizing emerging pathogens-a randomized clinical trial. Standard treatment regimens for nongonococcal urethritis have similar but declining cure rates: a randomized controlled trial. Single-dose azithromycin versus penicillin G benzathine for the treatment of early syphilis. A randomized, comparative pilot study of azithromycin versus benzathine penicillin G for treatment of early syphilis. The emergence of Neisseria gonorrhoeae with decreased susceptibility to Azithromycin in Kansas City, Missouri, 1999 to 2000. Plasmid-mediated penicillin and tetracycline resistance among Neisseria gonorrhoeae isolates in South Africa: prevalence, detection and typing using a novel molecular assay. Gonococcal resistance: evolving from penicillin, tetracycline to the quinolones in South Africa implications for treatment guidelines. A randomized comparison of azithromycin and doxycycline for the treatment of Mycoplasma genitalium-positive urethritis in men. Population pharmacokinetics of azithromycin in whole blood, peripheral blood mononuclear cells, and polymorphonuclear cells in healthy adults. Single-dose azithromycin versus erythromycin or amoxicillin for Chlamydia trachomatis infection during pregnancy: a meta-analysis of randomised controlled trials. Comparing ceftriaxone plus azithromycin or doxycycline for pelvic inflammatory disease: a randomized controlled trial. Global action plan to control the spread and impact of antimicrobial resistance in Neisseria gonorrhoeae. The prevalence of Chlamydia trachomatis infection in Australia: a systematic reviewand meta-analysis. These should be given according to the catch-up schedule which is shown in the table on page 4. Do not immunise a sick child if the mother seriously objects, but encourage her to bring the child for immunisation on recovery. Protects against diphtheria, tetanus, pertussis, poliomyelitis, hepatitis B infection and invasive infections caused by Haemophilus influenza type b. Hib conjugate vaccine is presented as a white, homogenous powder while the acellular component of pertussis vaccine is combined with diphtheria and tetanus toxoids and injectable polio vaccine is in a form of whitish turbid suspension for injection. Two dose schedule (6 months apart) currently offered as part of the Integrated School Health programme to Grade 4 girls (fi 9 years of age) in public schools. All personnel working in a health care facility (including support staff) fi Hepatitis B, 3 adult doses of 1 mL. May be an early manifestation of degenerative joint conditions (osteoarthrosis) or local and systemic diseases. Suspect rheumatic fever in children, especially if arthralgia affects several joints in succession. Note: Haemophiliacs may present with an acute arthritis similar to septic arthritis.

Further research is to be developing a National Adaptation Strategy needed to investigate the effectiveness of these or equivalent treatment for vertigo buy 250mg keppra with amex. It is commonly promoted through these initiatives have successfully reduced the forNational Forest Acts or equivalents medications qid cheap keppra 250mg on-line. These defcits probably sponse to climate treatment centers 500 mg keppra visa, and may occur in the absence refect the diffculties in introducing adaptation of knowledge about longer-term climate change treatment tendonitis trusted keppra 500 mg. The degradation of traditional landscapes in a successful adaptive forest governance. Enhancing sustainable livelihoods in drought for strengthening local and indigenous commuprone areas of Mudzi (Makaha Ward) and Gwanda (Gwanda nity adaptation to climate change should be recWard 19). Economic aspects uitable collaborative efforts between the holders of adaptation to climate change. Traditional forest knowledge and tional ecological knowledge as adaptive management. Genetically Modifed Forests: as Indicated in United Nations Framework Convention on from Stone Age to Modern Biotechnology. Investment and fnancial fows to address climate mentation of related international commitments. Vulnerability and adaptive capacity in Strategies: Growing acacia albida in Burkina Faso. Database on Local Coping Global climate change adaptations: examples from Russian Strategies: Reforestation/Afforestation to prevent soil boreal forests. Grenada: Macro-socio-economic assessment of the watershed management in upper north-west Himalayas damages caused by Hurricane Ivan September 7th, 2004. Human impacts on the tundra-taiga zone transformation throughout the developing world. Country Adaptation Bangladesh Cultivation of drought-tolerant fruit trees to diversify household income sources, ensure food security and provide shade and fuelwood (Selvaraju et al. The Monpas, a Bhutanese ethnic group, harvest wild vegetables, fruits and tubers from the forest during times of food scarcity due to erratic rainfall. The fruit are vitamin-rich and the trees are able to produce even during drought years, and provide an additional income when traditional crops fail due to poor weather (Boven and Morohashi 2002). Brazil Erosion-prone areas near Rio de Janeiro are being reforested in order to control erosion and reduce the associated land-slide and food risks to the city, particularly the vulnerable squatter settlements (favelas) (Lobo 1998). Canada Indigenous ecological knowledge has been documented and communicated in Canada with the aim of informing public policy and environmental decision-making in the Hudson Bay bioregion (Boven and Morohashi 2002). China, Loess HighReforestation using indigenous species adapted to the local conditions to control lands erosion and fooding problems. Fruit trees and medicinal herbs are also increasingly cultivated to increase farmersfi incomes (Wu Bin 2005). El Salvador Addressing drought problems by reforesting areas with fruit trees (among other measures), to protect soil from erosion caused by water and wind while augmenting the local food supply (Vega 2003). Grenada Growing appropriate tree species on cultivated land to reduce vulnerability to hurricanes and to provide various other benefts, including reversal of the deforestation trend 132 (World Agroforestry Centre 2007). Jamaica Alley cropping (the practice of planting trees in rows with food or cash crops between them) is used to reduce the vulnerability of the population and their environment to hurricanes and hurricane-related devastations (Thomas-Hope and Spence 2002, Spence 2005). Mali Farmers grow Jatropha plant for fuel and protection from damage from wind and water (Henning 2002). Senegal Cultivation of moringa trees that are very drought-resistant and tolerate a wide variety of soil types. They can be used to combat malnutrition by providing enriched food and by treating drinking water (Boven and Morohashi 2002). Sri Lanka Agro-forestry practices have been implemented in response to drought and the declining per capita availability of agricultural land (Ranasinghe 2004). Sweden Forestry workers have adapted to changes in climate (notably warmer temperatures) by road building and road sanding to combat early thawing (Keskitalo 2008). Tanzania In the Shinyanga region in the north of Tanzania, traditional practices of conservation have been revived by a government initiative. Thailand Five-year Action Plan for Mangrove Management in the Gulf of Thailand preserves mangrove forests and promotes sustainable use of mangrove resources. Mangroves provide protection against disasters such as storm surges and are an important coastal protection resource. Zimbabwe Deep-rooted trees are used in agro-forestry operation in order to tap more moisture from a lower depth during the dry season, in order to increase the overall productivity of land. Different crop canopies use light effciently, and the agro-forestry systems return large amounts of nutrients to the soil, as well as provide shelter against wind erosion (Agobia 1999). Joyce, Seppo Kellomaki, Bastiaan Louman, Aynslie Ogden, John Parrotta and Ian Thompson Contributing authors: Matthew Ayres, Chin Ong, Heru Santoso, Brent Sohngen and Anita Wreford Abstract: this chapter develops a framework to explore examples of adaptation options that could be used to ensure that the ecosystem services provided by forests are maintained under future climates. The services are divided into broad areas within which managers can identify specifc management goals for individual forests or landscapes. Adaptation options exist for the major forest regions of the world but the scientifc basis for these adaptation options and their potential effectiveness varies across regions. Because of the great variation in local conditions, no recommendations can be made that are applicable to an entire domain. The choice of management option will depend on the likely changes occurring in the forest, the management objectives of that forest, its past management history and a range of other factors. Local managers must have suffcient fexibility to choose the most appropriate suite of management options for their conditions. The current failure to implement fully the multi-faceted components of sustainable forest management is likely to limit the ability of forest management to adapt to climate change. Forest managers will need to plan at multiple spatial and temporal scales and will need to adopt adaptive collaborative management as their primary form of management. Careful monitoring and evaluation will be required, with a change in focus from outputs to outcomes. Keywords: climate change, forest management, forest planning, adaptation, boreal forests, temperate forests, subtropical forests, tropical forests, deforestation, forest degradation, carbon emissions, carbon sinks 6. There are many different possibilities, with orest management has a long history of develsome changes (such as changes in the frequency and Fopment through scientifc research and through severity of forest disturbances) affecting multiple management experience. In relation to the thematic areas of sustainpractice continue to evolve as new stresses and threats able forest management developed by the United Naaffect forest dynamics. Numerous possibilities exist to meet the chalHealth: increased mortality due to climate stresses; lenges presented above. In forest management, decreased health and vitality of forest ecosystems these include both reducing the effects of potential due to the cumulative impacts of multiple stresimpacts and developing new management practices sors; deteriorating health of forest-dependent and strategies to take advantage of new opportunities peoples. The adjustments will be infuenced by the erosion due to increased precipitation and meltadaptive capacity of the forest ecosystem, and by ing of permafrost; more/earlier snow melt resultthe socio-economic communities and the political ing in changes in the timing of peak fow and setting of the forest. Adaptive management provides a mechanism in the incidence of conficts between humans to move forward when faced with such uncertainty. Within the context of climate change, forest management aims at moderating or offsetting From the above, it is evident that one particular imthe potential damage or taking advantages of opporpact could be affecting a number of the thematic artunities created by a given climate change. Consequently, many adaptation the consequent functioning of the forest ecosystem options focus on reducing the potential impact of to resist harmful impacts of climate change, and to major disturbances. It is important to emphasize here utilize the opportunities created by climate change. Adaptive management involves a process of obFor example, in some areas, the magnitude and/or servation, analysis, planning, action, monitoring, refrequency of disturbances may actually decrease. A key part of the However, under all climate scenario clusters (see process is to ensure that there is adequate monitoring Chapter 3), the magnitude and frequency of forest of the effectiveness of management actions: are they 136 Figure 6. However, in the tropical forests, susto develop according to their own priorities.

Acknowledging that values play a role in every important patient care decision highlights our limited understanding of how to ensure that decisions are consistent with individual and symptoms 9dp5dt discount 500 mg keppra otc, where appropriate treatment ear infection order 500mg keppra, societal values medicine 8 soundcloud buy genuine keppra. Health economists have played a major role in developing the science of measuring patient preferences 5 medications related to the lymphatic system cheap 500 mg keppra free shipping. If patients truly understand the potential risks and benefits, their decisions will reflect their preferences. Nevertheless, many unanswered questions remain concerning how to elicit preferences and how to incorporate them in clinical encounters already subject to crushing time pressures. One of us, a secondary-care internist, developed a lesion on his lip shortly before an important presentation. He was concerned and, wondering whether he should take acyclovir, proceeded to spend the next 30 minutes searching for and evaluating the highest-quality evidence. After making the diagnosis, the clinician relies on experience and background knowledge to define the relevant management options. Having identified those options, the clinician can search for, evaluate, and apply the best evidence regarding treatment. In applying evidence, clinicians rely on their expertise to define features that affect the applicability of the results to the individual patient. Some patients are uncomfortable with an explicit discussion of benefits and risk and object to clinicians placing what they perceive as excessive responsibility for decision making on their shoulders. Fortunately, new resources to assist clinicians are available and the pace of innovation is rapid. One can consider a classification of information sources that comes with a mnemonic device, 4S: the individual study, the systematic review of all the available studies on a given problem, a synopsis of both individual studies and summaries, and systems of information. Evidence-based selection and summarization is becoming increasingly available at each level (see Chapter 4, Finding the Evidence). Progress in addressing this daunting question will require a major expenditure of time and intellectual energy from clinician researchers. This book deals primarily with decision making at the level of the individual patient. Evidence-based approaches can also inform health policy making,17 day-to-day decisions in public health, and systems-level decisions such as those facing hospital managers. In the policy arena, dealing with differing values poses even more challenges than in the arena of individual patient care. Should we restrict ourselves to alternative resource allocation within a fixed pool of health care resources, or should we be trading off health care services against, for instance, lower tax rates for individuals or corporationsfi How should we deal with the tension between what may be best for a person and what may be optimal for the society of which that person is a memberfi The debate about such issues is at the heart of evidence-based health policy making, but, inevitably, it has implications for decision making at the individual patient level. Transferring evidence from research into practice, 1: the role of clinical care research evidence in clinical decisions. The n-of-1 randomized controlled trial: clinical usefulness: our three-year experience. Randomized trials versus observational studies in adolescent pregnancy prevention. Decision aids for patients facing health treatment or screening decisions: systematic review. Cancer patients: their desire for information and participation in treatment decisions. These questions address normal human physiology and the pathophysiology associated with a medical condition. Traditional medical textbooks that describe underlying physiology, pathology, epidemiology, and general treatment approaches provide an excellent resource for addressing these background questions. The sorts of questions that seasoned clinicians usually ask require different resources. Traditionally, clinicians address this question by subscribing to a number of target medical journals in which articles relevant to their practice appear. They keep up to date by skimming the table of contents and reading relevant articles. This traditional approach to what we might call the browsing mode of using the medical literature has major limitations of inefficiency and resulting frustration. We describe such secondary journals in more detail in Chapter 4, Finding the Evidence. Some specialties (primary care, mental health) and subspecialties (cardiology, gastroenterology) already have their own devoted secondary journals; others do not. The New York Academy of Medicine keeps a current list of available secondary journals in many health care disciplines. If you are not yet fortunate enough to have your own, you can apply your own relevance and methodologic screen to articles in your target specialty or subspecialty journals. When you have learned the skills, you will be surprised at the small proportion of studies to which you need attend and at the efficiency with which you can identify them. Problem Solving Experienced clinicians confronting a patient with diabetes mellitus will ask questions such as, In patients with new-onset type 2 diabetes mellitus, which clinical features or test results predict the development of diabetic complicationsfi In patients with type 2 diabetes mellitus requiring drug therapy, does starting with metformin treatment yield improved diabetes control and reduce long-term complications better than other initial treatmentsfi Here, clinicians are defining specific questions raised in caring for patients and then consulting the literature to resolve these questions. Background and Foreground Questions One can think of the first set of questions, those of the medical student, as background questions and of the browsing and problemsolving sets as foreground questions. In most situations, you need to understand the background thoroughly before it makes sense to address foreground issues. This book explores how clinicians can use the medical literature to solve their foreground questions. Dissecting the question into its component parts to facilitate finding the best evidence is a fundamental skill. The interventions or exposures (diagnostic tests, foods, drugs, surgical procedures, time, risk factors, etc). What are the management strategies we are interested in comparing or the potentially harmful exposures about which we are concernedfi For issues of therapy, prevention, or harm, there will always be both an experimental intervention or putative harmful exposure and a control, alternative, or comparison intervention or state to which it is compared. What are the patient-relevant consequences of the exposures in which we are interestedfi We may also be interested in the consequences to society, including cost or resource use. Therapy: determining the effect of interventions on patientimportant outcomes (symptoms, function, morbidity, mortality, costs) 2. Harm: ascertaining the effects of potentially harmful agents (including therapies from the first type of question) on patient-important outcomes 3.

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