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As the momentum behind molecular testing continues to increase icd-9-cm code for erectile dysfunction order sildalis with visa, pathology practices may find themselves unprepared for the new wave of molecular medicine erectile dysfunction qof buy cheap sildalis 120 mg online. This special article was developed from a Webinar for the College of American Pathologists targeting education for pathologists about the transformation of pathology practice in the new molecular and digital age erectile dysfunction help without pills buy discount sildalis 120mg online. Summary: Laboratory tests have long been used to help diagnose and classify disease muse erectile dysfunction medication reviews purchase sildalis 120 mg fast delivery. Increasingly erectile dysfunction icd 9 code 2013 buy discount sildalis online, these assays are used to predict disease in healthy individuals or to predict outcomes in response to a specific therapy (See Table 1) erectile dysfunction treatment pills purchase sildalis 120mg free shipping. The recent introduction of array technology has added another layer of complexity involving massive parallel analysis of multiple genes, transcripts, or proteins. Consensus recommendations are proposed to improve report format and content, and areas of controversy are discussed. Resources are cited that promote use of proper gene nomenclature and that describe methods for reporting mutations, translocations, microsatellite instability, and other genetic alterations related to inherited disease, cancer, identity testing, microbiology, and pharmacogenetics. However, current rules do not yet cover all types of mutations, nor do they cover more complex mutations. This document lists the existing recommendations and summarizes suggestions for the description of additional, more complex changes. Mutation nomenclature extensions and suggestions to describe complex mutations: a discussion. Summary: Consistent gene mutation nomenclature is essential for efficient and accurate reporting, testing, and curation of the growing number of disease mutations and useful polymorphisms being discovered in the human genome. In this article, suggestions are presented for reporting just such complex mutations. Summary: Guidelines for human gene nomenclature were first published in 1979 [1], when the Human Gene Nomenclature Committee was first given the authority to approve and implement human gene names and symbols. Caughron received his medical degree from Creighton University School of Medicine in Omaha, Nebraska; he also completed his residency training in Anatomic and Clinical Pathology there. After residency, he completed a fellowship in Molecular Genetic Pathology at Vanderbilt University Medical Center in Nashville, Tennessee. He is board certified in Anatomic and Clinical Pathology, as well as Molecular Genetic Pathology. Adoption of molecular testing requires practicing in an area where things can change rapidly, where the basis for decisions will not be as established an area that is uncomfortable for many pathologists. If you are going to get into molecular testing, even if you are not performing all of the testing, you have to stay current so that you know the possibilities for your patients. Even the largest "do it all" to adopt reference labs send specimens for some molecular tests to other reference labs. Pick a focus pathology testing for your lab based on your patient mix, requests from other specialties, or target areas for growth. But if there are tests being sent out to other labs, find out what the testing it being used for and what its real value is to the patient. Do not allow yourself to be taken out of the loop for lab testing on your patients. But we are the only specialty with the training to properly evaluate, implement, and interpret the testing. The offerings to Association of Molecular Pathology has a support molecular tremendous number of resources available pathology to help understand and implement molecular testing. Section 2 7 Invest in this is a challenging, and rapidly changing understanding the area. However, the final success of your coverage, coding lab will probably depend on being able to and make it financially viable. Coding is how reimbursement for you describe to payers what you did in molecular testing your lab. Adopting molecular testing testing you offer today will yield fruit down the road, but only if it fits with the delivery of healthcare in your area. Bringing valuable testing online may not immediately generate a revenue stream, but may be compelling for its cost savings in other areas of care. Section 2 10 Think like a doctor As pathologists, we can get caught up in our analyses and lose sight of what the information we provide really means to the care and life of the patient. Molecular pathology is an opportunity for pathologists to claim a new and vital role in helping to take care of patients, by providing critical new kinds of information. When adopting or performing a test, keep asking: What is the clinical value to a test being performedfi Take a few minutes to become familiar with optimizing searching on PubMed and Google. Kiechle is board certified in Clinical and Anatomic Pathology and he has been practicing Clinical Pathology for over 30 years. Kiechle has initiated two molecular diagnostics laboratories: William Beaumont Hospital, Royal Oak, Michigan in 1991 and Memorial Healthcare System, Hollywood, Florida in 2006. The Michigan lab offered 33 billable procedures by August 2005 in human genetics, hematopathology and infectious diseases. This current narrow focus addresses the clinical needs expressed by the infectious disease practitioners who need a turnaround time of less than 24 hours for many of the microbe and/or viral assays they order for their patients. Delay may result in increased disease severity with resultant increased morbidity and/or mortality. Section 2 5 Organize the the manufacturers of random-access introduction of molecular devices either product very new assays to large or very small devices. Marketing the Outreach (inreach) molecular lab will increase utilization, program will have reduce unit cost per test and increase on the molecular margin. However, expenses, changes in reimbursement policies reimbursement (stacking codes to no stacking codes) may and margin every alter this financial picture. In: Molecular Diagnostics: Techniques and applications for the clinical laboratory. Summary: Illustrates the positive effect the increased test volume from successful outreach program had on the growth of a hospitalbased molecular diagnostics lab in Michigan. These applications would benefit from the development of a point-of-care device for nucleic acid extraction, amplification, and detection. The ideal device would have a low cost per test, use a disposable unit use device for all steps in the assay, be portable, and provide a result that requires no interpretation. The creation of such a device requires miniaturization of current technologies and the use of microfluidics, microarrays, and small-diameter capillary tubes to reduce reagent volumes and simplify heat conduction by convection during nucleic acid amplification. This ideal device may be available in 3 to 5 years and will revolutionize and expand the global availability of molecular diagnostic assays. In: Molecular Diagnostics: Techniques and Applications for the Clinical Laboratory. Hicks earned his medical degree from the University of Rochester School of Medicine and Dentistry. Hicks has co-authored over 140 peer reviewed articles that have appeared in a variety of journals, including Clinical Cancer Research, the American Journal of Pathology, Cancer and the American Journal of Surgical Pathology. He also serves on the editorial boards of the Archives of Pathology and Laboratory Medicine, Biotechnic and Histochemistry and Applied Immunohistochemistry and Molecular Morphology. In doing so, molecular analysis you will be better equipped to discuss the and breast cancer benefits and limitations of molecular care testing in the clinical setting. As molecular analysis of tissue samples becomes increasingly applicable to clinical care, the accuracy, reliability and relevance of this approach, and the tissue requirements for testing need to be addressed. Section 2 3 Provide clear, Develop a firm understanding of how your concise, and reports are used to make clinical decisions comprehensive and make sure the information is reports presented in a clear, concise and understandable manner. Be available as a diagnostic multidisciplinary consultant and actively participate in these care team discussions and share information on how molecular testing can be used to inform clinical diagnosis and treatment decisions. There is strong evidence in the literature that the histopathologic features of a breast cancer tumor correlate with its molecular profile. Section 2 tumor, the case should be thoroughly investigated by the pathologist in collaboration with medical oncology before decisions on adjuvant treatment are made. Summary: Clinicians caring for breast cancer patients have known for years that this disease shows significant heterogeneity, encompassing a number of distinct biologic entities with widely varied pathologic features and clinical behavior. This poses a major challenge for clinician caring for patients as they try and determine the risk of recurrence and the most appropriate adjuvant treatment regimen. A number of different strategies have been used to try and stratify patients into subset of disease to better understand this diversity. These important prognostic parameters are valuable and have been extensively validated in numerous clinical studies over many years of clinical practice. Section 2 Advances in biotechnology have brought us to the point where we can now analyze global genomic changes in clinical tissue samples from patients with breast cancer. These technical advances have shown great promise for the development of clinically relevant tumor classification, better assessment of prognosis and better prediction of response to therapy. In this webinar we will review some of these new approaches to profiling breast cancer patients as they rapid find their way into clinical practice. Molecular subtypes of breast cancer are closely correlated with conventional histologic and immunophenotypes of breast cancer, which will be reviewed. With this technical revolution, the pathology community has an unprecedented opportunity to help interpret molecular information into the morphologic and clinical context for each patient and in doing so can become a valuable member of the multidisciplinary breast cancer treatment team and directly impact decision on appropriate treatments and patient outcomes. The role of the indispensable surgical pathologist in treatment planning for breast cancer. Summary: the treatment of breast cancer has become increasingly specialized with rapidly changing new therapies and therapeutic guidelines. The pace at which these changes have taken place has proven to be a challenge for the field of pathology but also represents an opportunity for knowledgeable surgical pathologists to assume a greater role in this increasingly complex and specialized environment of breast cancer care. Section 2 pathology community can become active consultants and participating members of the multidisciplinary care team. The application of this technology to clinical samples in numerous studies has confirmed that breast cancer is not a single disease but rather, a group of molecularly distinct neoplastic disorders. The results of these studies have revealed molecular profiles with prognostic and therapeutic implications that could influence clinical care. Interestingly, there is little overlap between the different gene-signatures developed. Also, the different genes appear to map to critical pathways that underlie breast cancer biology, suggesting that each of these signatures track biologic characteristics that impact clinical behavior and outcomes in breast cancer. Genes associated with tumor differentiation and cell cycle drive the prognostic power of the intrinsic molecular classifications and other gene expression signatures. Each of these approaches is similar in their ability to stratify patients into high risk and low risk groups. Both morphology and the underlying gene expression patterns appear to track fundamental biologic characteristics which impact breast cancer. Summary: this article provides an excellent summary on the current state of knowledge of the molecular pathology of breast cancer, with recommendations for practicing pathologists in the new personalized health care era. A basic understanding of this knowledge is key to enabling pathologists to serve as clinical consultants. However, the results of these tests can be severely compromised by the presence of non-invasive tumor cells (inflammatory cells, in situ tumor cells and normal breast tissue). Summary: In a study reported by Yildiz-Aktas et al, breast resection specimens were subjected to variable cold ischemic times within the refrigerator and at room temperature. The result is reported as a recurrence score ranging from 0 to 100, divided into low-risk (<18), intermediate-risk (18-30), and high-risk (fi31) categories. Our pilot study showed that recurrence score can be predicted by an equation incorporating standard morphoimmunohistologic variables (referred to as original Magee equation). Using a data set of 817 cases, we formulated three additional equations (referred to as new Magee equations 1, 2, and 3) to predict the recurrence score category for an independent set of 255 cases. Any of the four equations can be used to estimate the recurrence score depending on available data. She serves as the Quality Assurance Officer for the Duke Anatomic Pathology Practice and is also a member of the College Shannon J. McCall received Bachelor of Science degrees in Chemical Engineering and Biochemistry from North Carolina State University in Raleigh, North Carolina and her medical degree from Duke University in Durham, North Carolina.

Syndromes

• Meat or poultry may come into contact with bacteria from the intestines of an animal being processed
• Apert syndrome
• Is there a history of cerebral palsy or muscular dystrophy?
• Hole (perforation) in the wall of the womb
• Pain in the entire limb
• When did hoarseness start?
• Occurs only on one side
• Loss of smell or taste does not always improve following treatment with medicine or surgery.
• Colon or breast cancer
• Tell your doctor if you have been drinking a lot of alcohol, more than 1 or 2 drinks a day.

All key staff responsible for care of the woman during pregnancy and afterwards should be informed of P events impotence tumblr generic sildalis 120 mg online. All key staff groups must be informed to ensure cancellation of existing appointments and continuity of follow-up erectile dysfunction videos safe sildalis 120mg. This includes the community midwives erectile dysfunction young age purchase 120 mg sildalis, health visitor erectile dysfunction causes agent orange sildalis 120mg generic, antenatal class coordinator and general practitioner impotence help generic sildalis 120 mg otc. Other existing carers such as psychiatrists erectile dysfunction juice drink cheap sildalis 120 mg free shipping, secondary care specialists and drug workers should also be contacted. It should also include voluntary groups who distribute free items to new mothers, but specific details should not be released to maintain confidentiality. Appointments for antenatal clinics (hospital and community), ultrasound scans and preoperative assessment should be cancelled. Carers must be alert to the fact that mothers, partners and children are all at risk of prolonged severe B psychological reactions including post-traumatic stress disorder but that their reactions might be very different. Perinatal death is associated with increased rates of admission owing to postnatal depression. Men demonstrate less guilt, Evidence anxiety and depression than women themselves, but they can also develop post-traumatic stress level 2+ disorder. Carers should be aware of and responsive to possible variations in individual and cultural approaches D to death. A Other family members, especially existing children and grandparents, should also be considered for D counselling. Debriefing services must not care for women with symptoms of psychiatric disease in isolation. This appears to be much Evidence more likely if professional support is not given,146 but there is a paucity of evidence from randomised level 147 1+/1++ trials that address the benefits and pitfalls of psychological interventions after perinatal death. A 10-year study of 843 parents who experienced a stillbirth, newborn death or sudden unexpected death in infancy included extended family members; primarily grandparents, but also existing children. The most Evidence common response of grandparents was a profound need to protect their own child. Some parents wish to have guidance on how to explain the death to siblings and how to help them mourn. There was no evidence of benefit in six studies and possible evidence of harm in a seventh. Evidence the authors emphasised the essential need to differentiate between parents who perceive their level 1+ experience of childbirth as emotionally traumatic and those who develop symptoms of depression or post-traumatic stress disorder (for whom specific psychiatric treatment might be required). In an observational study of 23 women who attended pregnancy loss groups, Evidence interviews showed that the primary focus for women was the need to seek recognition and level 3 acceptance of their grief. Carers should avoid persuading parents to have contact with their stillborn baby, but should strongly C support such desires when expressed. Parents who are considering naming their baby should be advised that after registration a name cannot P be entered at a later date, nor can it be changed. P Parents should be offered, but not persuaded, to retain artefacts of remembrance. Verbal consent should be sought from the parents and information governance regulations should be P complied with for clinical photography. If the parents do not wish to have mementos, staff should offer to store them securely in the maternal P case record for future access. Women who had held their stillborn baby were more Evidence depressed than those who only saw the baby, while those who did not see the baby were least level 2+ likely to be depressed (39% versus 21% versus 6%, P=0. Either option is allowable in law, but once the stillbirth has been registered, names cannot be added or changed (Births and Deaths Registration Act 1953; amended by the Still-Birth (Definition) Act 1992). This interpretation is also accepted by the General Register Office for Scotland and the General Register Office for Northern Ireland. The doctor or midwife attending the stillbirth is required to issue a Medical Certificate of Stillbirth that enables the birth to be registered. The mother (or father if the couple were married at the time of birth) is responsible for registering the stillbirth, normally within 42 days (21 days in Scotland) but with a final limit of 3 months for exceptional circumstances. This responsibility can be delegated to health professionals, including a midwife or doctor present at the birth or a bereavement support officer. The birth is entered onto the Stillbirth Register, which is separate from the standard Register of Births. The parents are then issued with a Certificate of Stillbirth and the documentation for burial or cremation. If information about the father is not recorded initially, it is possible for the birth to be re-registered to include his details later. There are no fees for registration, but additional certificates do carry a charge (fi3. If there is suspicion of actions taken deliberately to cause a stillbirth, the police service should be contacted. Maternity units should have arrangements with elders of all common faiths and nonreligious spiritual P organisations as a source of guidance and support for parents. P Maternity units should provide a book of remembrance for parents, relatives and friends. P Carers should offer parents the option of leaving toys, pictures and messages in the coffin. Funeral options including burial and cremation should be discussed with parents, taking into account religious and cultural considerations. Practical issues should be discussed with the parents, at a time and to an extent that suits them. If the parents request cremation they have to complete Cremation Form 3 (application for cremation of remains of a stillborn child). Information about fertility and contraception should be offered to mothers before returning home. C Mothers are vulnerable to psychological disorders when conception occurs soon after the loss. The wishes of the woman and her partner should be considered when arranging follow-up. P Before the visit, it is essential to ensure that all available results are readily to hand. P There is no evidence to support home visits over clinic follow-up, or to indicate the optimum timing and frequency of such appointments, but it is recognised that some parents find it very distressing to return to the unit where their baby was stillborn. Office consultation has the potential advantages over clinic follow-up of preventing waits and allowing flexible duration. Six to eight weeks is common practice for the timing of the appointment, when the placental and the postmortem histology results usually become available, but a flexible approach is appropriate according to the needs of the parents and the range of tests performed. Women should be offered general prepregnancy advice, including support for smoking cessation. C Women should be advised to avoid weight gain if they are already overweight (body mass index over B 25) and to consider weight loss. An offer should be made to discuss the potential benefit of delaying conception until severe C psychological issues have been resolved. Carers should be aware that while mothers tend to experience greater anxiety when conception occurs A soon after a fetal loss, partners are more likely to suffer anxiety if conception is delayed. Parents can be advised that the absolute chance of adverse events with a pregnancy interval less than B 6 months remains low and is unlikely to be significantly increased compared with conceiving later. The meeting should be documented for the parents in a letter that includes an agreed outline plan for P future pregnancy. Some women/couples might wish to use this to help set the agenda themselves at the start of the meeting. The discussion should cover general preparation for pregnancy: lifestyle, folic acid supplementation and rubella vaccination. Parents often desire an open, honest discussion with an opportunity to make comments and the chance to raise any concerns they might have. If care has been suboptimal, parents might want this to be acknowledged, lessons to be learned and care in the future to be improved. Vulnerability to depression and anxiety in the next pregnancy is related to time since stillbirth, with more recently bereaved women at significantly greater risk than controls. Women who stop Evidence smoking have equivalent stillbirth rates to women who have never smoked. The history of stillbirth should be clearly marked in the case record and carers should ensure they read P all the notes thoroughly before seeing the woman. For women in whom a normally formed stillborn baby had shown evidence of being small for gestational P age, serial assessment of growth by ultrasound biometry should be recommended in subsequent pregnancies. C the birth of a healthy baby does not compensate for a previous loss and can trigger a resurgence of grief; women might feel happy one moment and sad the next. P National Health Service Litigation Authority risk management maternity standards include expectations for care specific to intrauterine death and stillbirth. Standardised checklists can be used to ensure that all appropriate care options are offered and that the P response to each is recorded. Consent for perinatal postmortem examination should be documented using the nationally P recommended form. All stillbirths should be reviewed in a multiprofessional meeting using a standardised approach to P analysis for substandard care and means of future prevention. P Occupational Health should be contacted for advice if there are particular concerns about fitness to P work. Nearly one in ten obstetricians reported they had considered giving up obstetric Evidence practice because of the emotional difficulty in caring for a woman with a stillbirth. Talking level 2+ informally with colleagues (87%) or friends/family (56%) had been the most common strategies used by doctors to cope. Improved bereavement training can help staff care for grieving families but can also help staff cope with their own emotions. Royal College of Obstetricians and Gynaecologists and Royal anti-D immunoglobulin. A new system for grading B19 and herpes simplex viruses in cases of intrauterine fetal recommendations in evidence based guidelines. Tolfvenstam T, Papadogiannakis N, Norbeck O, Petersson K, after stillbirth: a cohort study. Identifying the causes of stillbirth: a comparison of four falciparum infections are endemic. Tolockiene E, Morsing E, Holst E, Herbst A, Ljungh A, Classification of stillbirth by relevant condition at death Svenningsen N,et al. Intrahepatic cholestasis of An evaluation of classification systems for stillbirth. Howard H, Martlew V, McFadyen I, Clarke C, Duguid J, of five cases of fetomaternal haemorrhages. Cervicovaginal infections during pregnancy: to reduce mortality and serious morbidity associated with epidemiological and microbiological aspects. Maternal and fetal inflammatory responses in Analysis of diagnoses and diagnostic categories in the first unexplained fetal death. Male sex between gestational cocaine use and pregnancy outcome: a and pre-existing diabetes are independent risk factors for meta-analysis. Derom C, Vlietinck R, Derom R, Boklage C, Thiery M, Van den unexplained third trimester intrauterine fetal death. Furukawa K, Nakajima T, Kogure T, Yazaki K, Yoshida M, Fukaishi hybridization on uncultured amniocytes yielding results within T, et al. Histologic evaluation of fetal induction of labour to terminate pregnancy in the second and organs; an autopsy study of 150 stillborns. A comparison of intravaginal misoprostol Gonzalez C, Rodriguez de Alba M, Ayuso C,et al. British Medical Association and Royal Pharmaceutical Society anomalies in spontaneous abortion.

While participants praised good services erectile dysfunction kidney transplant order sildalis 120 mg with amex, they also noted where professionals were not responsive to their needs erectile dysfunction pills supplements cheap sildalis amex. A survivor of cervical cancer was unaware of the impact of having both ovaries removed and would have opted to keep one if she had known it would put her into early menopause erectile dysfunction systems generic sildalis 120 mg fast delivery. In one case erectile dysfunction protocol free ebook order sildalis toronto, the correct diagnosis was made when the survivor sought a second opinion erectile dysfunction normal testosterone purchase sildalis with a visa. Three survivors described feelings of anger that the misdiagnosis had occurred and were traumatised by the experience impotence spell discount 120 mg sildalis otc. Participants who worked in the health sector noted that it would be difficult for Maori who were not assertive or proactive to receive the level of care they required. One of these health workers had been unaware of the fact that she could have had a reconstruction at the same time she had a mastectomy operation. One participant spoke of the value of nurses who were caring, understanding, and positive because they provided the reassurance that patients needed. An oncology nurse who visited a participant at home provided a copy of all her notes on request. By contrast, the information from the hospital on her chemotherapy was one illegible photocopied page. Another participant noted that the hospice staff provided a lot of information during home visits. In health professionals, participants valued competence, compassion, warmth, honesty, respect, and professionals who offered support and took an interest in them, meeting them halfway in terms of cultural needs. Participants preferred finding out about their cancer from a person they could trust and feel at ease with, preferably someone with whom they had an established relationship. The participants indicated that, for the majority of patients and whanau, the ethnicity of health professionals was less important than the qualities they demonstrated. The importance of whanau Whanau involvement in the cancer journey as well as the support whanau gave were seen as highly significant. Whanau need knowledge of the entire cancer journey as a participant explained: whanau need to know about the illness, what course it can take, what symptoms can appear, about different medications, why they are taking it, how it can help them, and about the side effects. They need to know that there is somebody they can contact if they should have any difficulties. The responsibility to care for whanau and the cost of this to whanau was also highlighted. Another participant, while delighted that her children wanted to care for her, was also concerned that they continue their paid employment. Holistic aspects of health As well as the medical treatment they received, most participants also sought emotional and spiritual support from within their own culture. Holistic approaches included mirimiri (massage), the application of kawakawa leaves, metallic healing, reiki, and reflexology. Discussion the present study examined the experience of Maori cancer patients, survivors and their whanau by providing them with opportunities to discuss their cancer journey in their own words. In terms of health system factors, participants in this research identified Maori health providers and Ozanam House as examples of services that work for Maori. Maori providers with a Maori worldview, provide practical support to Maori experiencing cancer and are a conduit between the patient and the cancer control system. This research suggests that the work of Maori providers should be extended and further resourced because of its importance in ensuring quality cancer control services for Maori. It is a mainstream organisation that successfully accommodates the needs of Maori, providing a place where Maori experiencing cancer can be Maori. At the healthcare process level participants across the four sites reported varying quality. People working in the health system were reported as unable at times to 8 establish rapport, a key issue discussed by Cram et al. This research demonstrates the need for significantly improved cultural competence training and ongoing assessment of cultural competence of all health professionals, including important gatekeepers such as receptionists and administration staff. Indeed, people to assist Maori in navigating the health system will be a valuable addition. Anecdotal evidence from Canterbury District Health Board suggests that the employment of a Maori navigator in the cancer control arena results in improved service delivery for Maori (personal communication, Kaitiaki Oncology, 2006). At the patient level, the research underscores the importance of whanau involvement in the cancer journey and taking a holistic approach to health. This view implies different priorities, and different ways of working from the concept that sees the continuum in terms of the cancer control workforce. But their involvement should not replace appropriate support from cancer control services that have an obligation to deliver services fairly to all. This support may need to come from outside the health sector and may require intersectoral action on the part of the health sector in areas such as education, employment and income. There is an expectation that the New Zealand health service is a level playing field. However, discrepancies in access to quality health services by Maori are beginning to 14,15 be documented. Too often, participants in this study expressed considerable gratitude for very limited care. Recent work on racism as a root cause of inequalities in health provides a further level 9,11 of analysis for this research. Applying this framework to the current research institutionalised racism is where Maori are being structurally excluded from equitable access to health services on the basis of ethnicity; personally mediated racism is where health workers make differential assumptions about Maori and treat Maori inadequately; and internalised racism is where Maori appear to expect differential lesser treatment (often based on past experiences) personally or within their whanau. Research on the experiences of Maori across the cancer control continuum and at health systems, healthcare processes, and patient levels is limited as is an analysis of the role of racism in driving health inequalities. Further research and action is urgently needed as a result if the gap between Maori and non-Maori in relation to cancer is to close. The present research provides valuable information on Maori experience of cancer from a Maori view. Author information: Tai Walker, Marie Russell, Kirstin Smiler are researchers at the Health Services Research Centre, Victoria University, Wellington; Louise Signal is a Director of the Health Promotion and Policy Research Unit, University of Otago, Wellington; and Rawiri Tuhiwai-Ruru is a health researcher based in Tairawhiti. Otaki Community Health Centre, The Wakahuia Hauora, The Aitanga a Hauiti Hauora, and Turanga Health are all Maori health providers. The research team would like to thank the participants who shared not only their experiences and insights but also their pain. Our thanks also go to Dr Kevin Dew and Donna Cormack (from the University of Otago) as well as two anonymous reviewers for their valuable comments on an earlier draft of this paper. This project was funded by a Grant-in-Aid from the National Scientific Committee of the Cancer Society of New Zealand (Inc). Tracking Disparity: Trends in Ethnic and Socioeconomic Inequalities in Mortality, 1981-2004. A Comparison of Maori and Non-Maori Patient Visits to Doctors: the National Primary Medical Care Survey (NatMedCa): 2001/02. Effects of self-reported racial discrimination and deprivation on Maori health and inequalities in New Zealand: cross-sectional study. Racism and health: of the relationship between experience of racial discrimination and health in New Zealand. Methods Patients with newly diagnosed thyroid malignancies seen at thyroid clinic, Christchurch Hospital between 1995 and 2006 were identified from the thyroid clinic database, and the histological diagnoses and clinical features were reviewed from hospital records. Results During the 12-year study period, 213 patients with thyroid malignancy were identified. Tumours of nonfollicular cell origin included 12 medullary thyroid cancers (6% of primary thyroid malignancies), and all were apparently sporadic, 7 primary thyroid lymphomas, and 2 thyroid metastases. The female-male ratio was fi2 in all patient groups with primary thyroid malignancies. Tumours of non-follicular cell origin were uncommon and included medullary cancers, lymphomas, and metastases. Short-term follow up (median 6 y) confirms that anaplastic thyroid cancer is highly malignant, and the only patients with differentiated thyroid cancer with early cancer deaths had presented with advanced disease and were > 55 years at diagnosis. In New Zealand, and in other developed countries the incidence of thyroid cancer is increasing and it is uncertain whether this is because of changed histological criteria, 2 better diagnostic procedures or environmental factors. The New Zealand thyroid cancer incidence rate has risen between 1971 and 1996 from 3. Thyroid cancer is one of the few cancers with female incidence greater than in males. Adverse indicators include age greater than 45 y, primary tumour greater than 4 cm in diameter, extrathyroidal 4 invasion, and distant metastases. A small proportion of thyroid malignancies are of nonfollicular cell origin and include 6,7 medullary thyroid cancers of C cell origin, and primary thyroid lymphomas. The Thyroid Clinic at Christchurch Hospital established a database of diagnoses from the beginning of 1995. In this report we document the number of newly diagnosed thyroid malignancies identified on the database from patients referred to our service over the last 12 years. Clinical data and histological classification are presented, and preliminary outcome data is also reported. The population is largely Caucasian, and in the Canterbury area currently some 8% are Maori and 6% Asian. Patients included those initially diagnosed at thyroid clinic, plus patients referred for further management from surgeons in the public and private sectors. A small proportion of patients were seen in the Oncology Department where they had been referred for management of anaplastic thyroid cancer or lymphoma. Initial investigations for the majority of patients included nuclear medicine scans or thyroid ultrasound, and fine needle aspiration cytology. Histological diagnosis was confirmed following tumour resection, or in inoperable cases by open biopsy. This study was confined to newly diagnosed thyroid malignancies, and patients diagnosed and treated elsewhere in New Zealand or overseas were excluded from analysis, and one patient treated in Christchurch but referred from Southland was also excluded. Results In the 12-year study period, 213 patients with newly diagnosed thyroid malignancy were identified from the thyroid database. The distribution of the histological types of thyroid malignancy is shown in Figure 1. Malignancies of nonfollicular cell origin included 12 medullary thyroid cancers of C cell origin (almost 6% of malignancies), 7 primary thyroid lymphomas (3%), and 2 thyroid metastases. The median age for both papillary and follicular cancer patients was 48 y, with Hurthle cell, anaplastic and lymphomas occurring in older patients. Only 3 paediatric (<16 y) patients were diagnosed; all 3 had papillary tumours and the youngest patient aged 7 years presented with cervical lymphadenopathy and lung metastases. Hurthle cell and medullary thyroid cancers have proved more malignant, and again early cancer deaths were associated with advanced disease. Anaplastic cancer had a high mortality, but currently 3 of the 9 patients survive beyond 12 months.

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Furthermore, few evaluations have been different training and different norms (including epiconducted of the cost-effectiveness of general investdemiology, clinical medicine, logistics, and disaster ment in health systems, infrastructure, and capacity response). However, an appropriately sized and trained building as a means to achieve pandemic preparedness health workforce (encompassing doctors, nurses, epi(Drake, Chalabi, and Coker 2012). Pandemics are rare events, and the risk the overall resiliency of the health system, an improveof occurrence is influenced by anthropogenic changes in ment that can be applied to any emergency that results the natural environment. Investments in these capacities are likely to not remain geographically contained, and damages can surge after pandemic or epidemic events and then abate be mitigated significantly through prompt intervention. Hence, stable investment to As a result, there are strong ethical and global health build sustained capacity is critical. Further developing these mechanisms Investments to improve pandemic preparedness will allow countries to offload portions of pandemic risk may have fewer immediate benefits, particularly relaand response that are beyond their immediate budgetary tive to other pressing health needs in countries with capacity. However, countries must have predefined contindemic preparedness are essential for prioritizing and gency and response plans as well as the absorptive capactargeting capacity-building efforts. Thinking about ity to use the emergency financing offered by such risks in terms of frequency and severity, notably using solutions. Broad and effective use of pandemic insurance 338 Disease Control Priorities: Improving Health and Reducing Poverty will require parallel investments in capacity building and 2. Improving the tracking of ing disease surveillance and for identifying and monitoring spending and aid flows specifically tied to pandemic pathogens that can be shared between animals and people. For more information, see the project website, clinical facilities, supplies, human resources, and. Influenza: Social and Institutional Responses to Pandemic Pandemics: Risks, Impacts, and Mitigation 339 Emergencies. Crisis Group Africa Report 232, International -sgovernment-global-emerging-infectious-disease Crisis Group, Brussels, October 28. World Disasters Report, Resilience: Saving Burden of the 2009 Pandemic H1N1 Influenza in Korea. Pushed to the Limit and Review of Pharmacoeconomics and Outcomes Research 9 (6): Beyond: A Year into the Largest Ever Ebola Outbreak. Pandemics: Risks, Impacts, and Mitigation 345 Chapter 1 the Loss from Pandemic Influenza Risk Victoria Y. Less noticed was the likelihood that a pandemic with characteristics similar to the 1918 influenza pandemic would have killed about 10 times as Value of Lives Lost and Illness Suffered many people in Liberia, Guinea, and Sierra Leone as did the second major dimension of loss from a pandemic Ebola. The global death total from such a pandemic lies in the intrinsic value of lives prematurely lost and of could be 2,500 times higher than the World Health illness suffered. Nevertheless, extensive empirical findings appear in the economics literature, particularly for losses from premature mortality (Hammitt and Economic Loss Robinson 2011; Lindhjem and others 2011; Viscusi In addition to the enormous loss in terms of human 2014). This chapter estimates the magnitude of these losses (Burns, Mensbrugghe, and Timmer 2008; this dimension of loss from pandemic influenza using Jonas 2013) and found that a pandemic of the severity of standard methods. McKibbin and Sidorenko (2006) examined expressed as the fraction of the world population that Corresponding author: Victoria Y. The estimated loss is relative We define severe pandemics as having mortality rates of to the counterfactual of no risk (r = 0). The historical record suggests that the 1918 influenza pandemic was an outlier, with unusual circumstances, including the co-occurrence of World War I. Fauci (2017) point to long-term morbidity and disability In 1918, 20 million deaths would constitute 1. It uses an expected value frameWe searched PubMed and Google Scholar for all work to estimate losses from an uncertain and studies on influenza epidemics and pandemics. We found three studies that examined loss in national income from influenza pandemics of varying Implications of All of the Available Evidence severity. This finding points to the need estimates of the magnitude of pandemic risk were for more attention to pandemic risk in public polfound in only two sources, both partially icy and to the value of enhanced understanding proprietary. Lowand middle-income countries Added Value of this Study would suffer more than high-income countries in this study provides the first assessment of the mortality losses. Further studies to investigate the expected value of losses from pandemic influenza potential losses from pandemics from other causes and, specifically, the value of intrinsic losses from are ongoing. The table includes pandemics dating from 1700 to 2000 for which severity could be ascertained from the literature. Morens and Fauci (2004) and Morens and Taubenberger (2011) identify 12 to 17 pandemics in the period from 1700 to 2000, but many of those resulted in lower mortality than those in this table (or had mortality levels that could not be ascertained). Although the world may be expected to experience rather to select plausible values from that literature to moderately severe to severe pandemics several times define reference cases. With Taubenberger and others each century, there is consensus among influenza experts (2007), we emphasize the uncertainty inherent both in that an event on the very severe scale of the 1918 panthe history and in projections drawn from it. In light of demic may be plausible but remains historically and this literature and its attendant uncertainty, we develop biologically unpredictable (Taubenberger, Morens, and and report results for two representative levels of severFauci 2007). First, information on missible and virulent viruses could lead to global death pandemic severity is used to generate increases in rates substantially higher than in 1918 (McKibbin and age-specific death rates for the world and for each of the Sidorenko 2006; Osterholm 2005). Second, In general, lower-income areas of the world suffered the literature on valuation of changes in mortality rates disproportionately in 1918; in particular, India suffered is used to generate estimates of the age-specific losses a major share of global pandemic mortality (Davis from mortality increase and, by extension, of total loss. Estimates of the age-specific excess mortality rate in 1918 was low, probably because of lower case ity rates of different populations from the 1918 fatality rates rather than lower incidence rates (Cheng pandemic are consistent in their form of a unique and Leung 2007). This finding points to the possibility of inverted U-shaped distribution, whereby adults ages heterogeneity between countries of comparable national 15 to 60 years experienced elevated rates compared to income levels in a modern pandemic. The average severity of a pandemic in a given severity range is the expected value of severity given that a pandemic did in fact occur in that range. Let s*(x) be the contribution of If we had access to a function r(s) showing exceedance probability as a function of severity, our analypandemic severity greater than x to expected pansis could proceed using the expected value of severity demic severity. For the first step in our tary cumulative distributions provides natural canassessment of expected severity, we use recent history didates for r(s), and we parameterize the hyperbolic as a straightforward guide to frequency and severity in terms of its expectation and the fatness of its tail box continues next page 350 Disease Control Priorities: Improving Health and Reducing Poverty Box 18. However, for s = 4 in the United the fatness of the tail (smaller values imply a fatter States (over 7 million deaths worldwide), the expotail). We estimates (Madhav and others 2018) of exceedance infer global severity from the severity in the United probability and pandemic risk that use methods States using the approach described in the main text. Substantially greater severities severity for the United States of such a pandemic of and likelihoods have been discussed by Madhav 8. The fatality rate among Using the age distributions of populations and the young adults, although high in the 1918 influenza panlife tables from the World Population Prospects of the demic, was relatively low in the 1957 and 1968 epidemUnited Nations Population Division (2015), we calculate ics (Simonsen and others 1998). We also use an excess deaths and the estimated reduction in life expecalternative and more typical distribution of excess tancy based on these age-specific mortality rates mortality, where young children and elderly persons (Preston, Heuveline, and Guillot 2000). Our expected of the two, assuming the same proportional increase in annual pandemic death total across both severities is mortality for all age groups. Relative severity indicates severity in each income group relative to the high-income group. Our specific calculations followed the methods used in Global Health 2035 (Jamison and others 2013). In calculating the income loss figures as expected annual values but uses value of change in mortality at age, we used as a reference different values for annual pandemic risk. This amount was adjusted up or down for loss for the world as a whole from the intrinsic loss from ages other than 35 years in proportion to the ratio of life pandemic risk to be -0. The dominant position in the literature is that lower-income countries should have lower values for v (Hammitt and Robinson 2011). The literature provides weak quantitative guidance on how v should vary with y, if at all, and the numbers we have chosen should be viewed as reasonable assumptions within the spirit of the literature. Very substantial uncertainty adheres to these cost estimates (see note a, table 18. For any given value of s, our calculation of the value of intrinsic loss from a pandemic depends on the age distribution of deaths from the pandemic, and the calculations reported here use different age distributions for pandemics of different severities. In particular, for moderately severe pandemics, we assume an older age distribution of deaths, typical of such pandemics. For severe pandemics, we assume the younger age distribution of deaths that characterized the 1918 pandemic. In contrast to the modest nummates in the literature of the income loss from pandember of studies on potential pandemic loss, there are hunics of differing levels of severity (Burns, Mensbrugghe, dreds of studies on the cost of climate change and the and Timmer 2008; Jonas 2013; McDonald and others social cost of carbon (Pizer and others 2014; Tol 2013). Though our severGlobal carbon dioxide emissions were on the order of ity categories differ from theirs, the values of 1 percent of 36,000 million tons in 2013, containing 6,200 million global income from a moderately severe pandemic and tons of carbon (Global Carbon Project 2015). Estimates 4 percent from a severe pandemic are consistent with estiof the social cost of carbon vary widely, but if it were mates in the literature. The synthesis of the 2014 report of the which 95 percent is from severe pandemics. In comparison, our expected annual Expected annual pandemic losses appear substantial. Modest reductions in Sensitivity to Assumptions cold-related mortality and morbidity will be offset by the magnitude and severity of the increased risks. However, the gradual nature of often an ineffective substitute for dimensions of human warming allows time for costly adaptations that could well-being. In practice, however, these estimates are be expected to reduce the mortality consequences. A obtained from ex post observations of the labor market recent paper points to potentially important mortality and reflect the way people differentially value and trade off reductions in the United States resulting from efforts to very small fatality risks for income. These benefits at a given age in the United States and in the way the valappear to flow almost entirely from reduced pollution uation (v) should vary across ages and countries (Hammitt rather than slower atmospheric warming. Our losses from climate change are then likely to be calculations to test the sensitivity of our results to this included in the income losses from adaptation rather alternative assumption found a change of only about than included separately. Another useful comparator for pandemic risk lies in Hammitt and Robinson (2011) have assembled the deaths from selected alternative causes. One might Health 2035 did not include this potential effect in its reasonably add 300,000 deaths per year from seasonal calculations (Jamison and others 2013). As we have noted Comparable to Expected Deaths from Pandemic throughout, the estimates we use for pandemic risk, r, and Influenza, 2015 severity, s, remain subject to substantial inherent uncerCause of death Magnitude of deaths tainty. In contrast to estimates that the likely cost of global warming falls in the the robustness of our conclusions with respect to how range 0. Increased global temperature social sciences generally fail to pay adequate attention to may reduce the case fatality rates of influenza, but it may potentially catastrophic events, although literature is also increase the transmissibility of the virus. Populationemerging (Barro and Jin 2011; Pike and others 2014; level immunity against a particular influenza strain likely Pindyck and Wang 2013). Concluding that the academic varies by region and by age distribution, although the and policy attention provided to pandemic risk falls well extent of that variation is not known. In 1918, a few short of a sensibly estimated comparison of that risk with countries did not experience the typical inverted its consequences is reasonable. However, recent trends U-shaped distribution of excess age-specific mortality are encouraging.

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