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Reuter order zithromax 500 mg with visa bacterial biofilm, ‘Drug War Heresies: Learning from Other Vices buy zithromax 100mg fast delivery antimicrobial keyboard and mouse, Times, & Places’, Cambridge University Press, 2001 12 Five models for regulating drug supply 13 1 2 3 Introduction Five models for regulating drug supply The practical detail of regulation 4 5 6 Making a regulated system happen Regulated drug markets in practice Appendices 2. These can be broadly seen as existing on a continuum between the poles of completely unregulated free markets, and harshly enforced punitive prohibition. Decriminalisation of personal possession and use can operate within a prohibitionist framework. Regulated markets A range of regulatory controls are deployed covering drug production and trade, product, gatekeepers of supply, and user. Free market legalisation, or ‘supermarket model’ Drugs are legal and available for essentially unrestricted sale in the ‘free market’, like other consumer goods. While these prohibitions are absolute in nature for all non-medical use, the detail of penalties and enforcement regimes are not specifed and vary widely between states. The only legal production and supply models for drugs covered by the conventions are those permitted for medical and scientifc purposes, such as opiates for maintenance 3 prescribing for dependent users. Some exemptions also operate in a legal grey area for traditional and religious uses (see: 5. Such models are consequently limited to a tiny proportion of the total using population. Within the overarching global prohibition framework, individual states have considerable fexibility to determine enforcement regimes and punitive responses for prohibited activities. Indeed, responses to identical offences in different countries vary from de facto decriminali- sation through to long prison sentences or, at the extremes, the death penalty. While many countries’ drug policies have become increasingly draco- 4 nian and punitive, there has been, throughout much of the developed world and in the newly industrialising countries of South America, a clear trend towards grudging tolerance and decriminalisation of drug 5 possession and use. It is also important to note that, while exploration of these less puni- tive approaches to personal possession and use is allowed within the international legal framework, no form of legal production and supply of any drug prohibited under the conventions, or domestic law, can be explored for non-medical use in any way. The medical prescrip- tion model is the only real quasi-exception to this rigid rule; as such, it exists as an island of regulated production and supply, albeit within very narrow parameters. Beyond this there is zero fexibility for any 3 The conventions also control the medical uses of listed drugs, such as opiates for pain control. Furthermore, this absolute legal barrier creates genuine political obstacles to even discussing or proffering such policy alterna- tives. Defenders of the status quo often adopt dogmatic and entrenched moral positions, portraying regulatory legal alternatives as immoral, 6 extreme, ‘pro-drug’, radical, or even heretical. The clear implication is that debating such alternatives is a political ‘no-go’ zone. Until relatively recently, the climate of fear thus created had pushed the law reform position to the margins of mainstream political discourse. To the rational public health or social policy pragmatist, exploring and seeking out policy options that will deliver the best policy outcomes—an optimum point along this drug policy continuum—the idea that such an arbitrary barrier to policy research and development exists is diffcult to justify. This is especially true given that the vast majority of markets for goods and services, particularly ones that involve risk or poten- tial harm (including many hundreds of medical and non-medical psychoactive drugs), are both legally available and regulated by governments. Legal regulation of potentially risky A wide range of evidence based regulatory mecha- goods and activities is nisms and related enforcement/oversight agencies demonstrably not only are deployed to control and manage producers, the norm; it is one of suppliers, environments, products and consumers. For even the exploration of any such regulatory options to be forbidden in one, relatively narrow, feld of human behaviour does not sit well with the wider commitment of the United Nations to ‘promote social progress and better standards of life 7 in larger freedom’. Activities that take place beyond the parame- ters of a given regulatory framework remain prohibited and subject to legal sanctions. With the possible exception of some very low risk products such as coffee or coca tea, such models are not appropriate for drugs, because they forgo the potential for most forms of responsible state intervention in market regulation and control. In this, they are handing control of drug markets to exploit- ative profteers just as surely as prohibition. Legal commercial actors—whose primary concern is proft maximisation—would be free to aggressively promote consumption through marketing and advertising. The potential for such an approach to create unacceptable public health costs has been all too clearly demonstrated with the example of the free markets for tobacco in much of the developed world during the frst 60 years of the 20th century, and to a greater extent in large parts of the developing world today (see: 5. Nadelmann ‘Thinking Seriously About Alternatives to Drug Prohibition’, Daedalus, 1992, 121: pages 87–132. We describe them below, starting with the most restrictive and moving to the most open. Variants on these models already exist and function across the world, supporting the entirely legal distribution of a range of medical, quasi-medical and non-medical psychoactive drugs. Of course, the precise nature of the respective regulatory frameworks and enforcement infrastructure varies from country to country. This leads to a certain amount of generalisation, but also helps emphasise that such models will inevitably operate differently in different locations. We have also made some basic suggestions as to how to adapt these basic models to cater for the challenges of non-medical drug supply in the future. Under this model, drugs are prescribed to a named user by a qualified and licensed medical practitioner. They are dispensed by a licensed practitioner or pharmacist from a licensed pharmacy or other designated outlet. These guide, oversee and police the prescribing doctors and dispensing pharmacists. They also help determine which drugs are available, in what form, where, and under what criteria. It is limited to medical necessity, which restricts its actual or poten- tial use to the problematic/chronic dependent end of the drug use 9 spectrum. Most commonly, it supports maintenance prescribing as part of a treatment regimen or harm reduction programme. As such it will only ever involve a small fraction of the total drug using population, although it should be noted that this user group is disproportionately associated with the greatest personal and 10 societal harms (especially under prohibition ). Prescribed injectable heroin (diamorphine) also has a long history, and established evidence 11 base. Less common, although not unknown, is the prescription of stimulants, including amphetamines and cocaine. They provide a useful, if limited, demonstration of how legal regulation of drugs can help people become prescribed, rather than street, users; a clear example of the benefts of decriminalisation of drug use and regularisation of their supply route. It is hard to know how such services would develop if managed with the latitude afforded to other, less controversial areas of patient care such as, for example, diabetes or mental health. Witton, ‘Thematic review—heroin prescribing’, Drug and Alcohol Findings, 2003, issue 9, page 16. These include requirements for consumption to be supervised in a specifc venue, for very specifc qualifying criteria to be met, or for the prescribing doctor to obtain a special licence. Prescribing is often time limited, administered in progressively reduced dosage, or made conditional on the patient meeting specifc rehabilitation milestones. It raises some diffcult questions for practitioners, as it exposes the grey areas between medical, quasi-medical and non-medical use. There are ongoing controversies and conficts between the clear need to reduce harms associated with problematic illicit drug use and a reluctance to dispense drugs that are being used in any way non-medically. From a medical point of view, these are particularly helpful to those injecting, who are at high risk of contracting blood borne diseases. These benefts are sometimes undermined if practitioners are accused of supporting drug use for pleasure or recreation, while simultaneously ‘failing to treat’—or even ‘endorsing’—dependence.

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A first step toward assessing the utility of psychosocial treatments for specific phobias is to tease apart the relative contributions of treatment and non-specific factors cheap zithromax on line antibiotic joint replacement dental. There is considerable variance in the effect sizes of psychosocial treatments relative to placebo and no-treatment controls generic 100mg zithromax with amex antibiotics make acne worse before better. Because exposure treatments represent the most widely studied treatment of specific phobia, a sufficient number of studies were available to separately examine their efficacy relative to (a) no treatment; (b) a placebo control; and (c) psychotherapies that do not include an exposure component. Moreover, several studies manipulated parameters of exposure treatment to evaluate ways to enhance its efficacy. The decision to test these comparisons was based entirely on the availability of studies. Several studies of truly non-exposure psychosocial treatments were located, which allowed us to estimate their efficacy relative to no treatment. However, there were too few studies to compare non-exposure treatments to placebo. Effect size moderators The available studies were markedly heterogeneous on a number of dimensions, such as specific phobia subtype, treatment dose, and level of therapist involvement. For those comparisons showing statistically significant hetero- geneity, we examined whether these factors significantly influenced estimates of treatment efficacy. Unlike many other disorders, specific phobias can display significant symptom reduction in doses as low as a single session (e. An understanding of the dose– response relationship can be useful for both treatment planning and for a theoretical understanding of fear reduction. None of the studies meeting inclusion criteria investigated treatment efficacy across more than one specific phobia subtype. However, these conclusions were qualitative and were based on a very small number of studies. Consequently, we included phobia type as a putative moderator of treatment outcome. However, because of the public health significance associated with self-administered treatment delivery, we examined this exposure parameter as a putative moderator of treatment efficacy. Based on past research suggesting that date of publication may influence effect sizes of randomized treatment studies (Abramowitz, 1997), we examined whether date of publication moderated the effect sizes for the comparisons of interest. Selection of studies We began by searching all published reports of randomized treatment studies of psychosocial interventions for specific phobia. These searches were limited to peer-reviewed, English language journals, with only adult participants. We then examined the abstracts of these 988 articles, and identified 46 articles that provided descriptions consistent with the study inclusion criteria (see below). Next, we examined the reference sections of the 46 articles and selected an additional 14 articles that appeared to qualify for inclusion. Of the 37 remaining studies, eight studies did not report statistics that would allow for the calculation of effect sizes. After attempting to contact the authors, we were successful in obtaining the necessary data for 2 four of the eight studies. The remaining four studies were excluded, thus leaving a total of 33 published studies. Exposure treatments Treatments were classified as exposure treatments if they included direct or indirect confrontation with the feared stimulus. Although some authors labeled their treatments as something other than exposure, we considered these treatments exposure if they included any exposure component. Non-exposure treatments These were defined as any treatment presumed to be active (i. Classification of outcome measures Outcome measures were classified into one of the following three domains: Behavioral, physiological, and questionnaire. These included self-reported fear ratings while participants approached the phobic target and level of behavioral approach (e. Measures assessing psychophysiological responding were classified as physiological measures. They included: heart rate, heart rate reactivity, skin conductance, systolic and diastolic blood pressure. Questionnaire measures varied greatly and depended on the particular phobic target under study. However, questionnaires were only included if they directly measured fear or avoidance of the phobic target (e. Effect sizes for each measure were calculated for the 11 treatment comparisons of interest. Effect sizes for each comparison were categorized as falling into one of three outcome domains described 5 above (i. Multiple measures in a given domain were averaged to form one composite effect size for that domain. When studies included multiple groups that were suitable for comparison, multiple effect sizes were obtained. For example, a study comparing three types of exposure therapy with a wait-list condition would generate three separate “exposure vs. For each comparison of interest, we obtained a separate effect size for each available outcome assessment domain: behavioral and/or questionnaire and/or physiological (though very few included physiological outcomes). For studies including more than one measure in a given domain, separate effect sizes were calculated for each measure and were then averaged to form a pooled behavioral or questionnaire effect size. Analyses for each comparison used only these pooled behavioral, questionnaire, and physiological outcomes. For example, a study assessing outcome using three questionnaire measures and two behavioral measures would yield two effect sizes — a composite questionnaire and a 6 composite behavioral effect size. For each comparison of interest, separate analyses were conducted 7 for each assessment domain, and an overall composite effect size was calculated by pooling the behavioral, questionnaire, and physiological effect sizes. Effect sizes for each outcome were weighted by sample size in the analysis of each comparison. Weighting of sample size was done in order to minimize the risk that a small, outlying sample would exert a disproportionate influence over the final effect size for a comparison (Rosenthal, 1991). For each comparison, we calculated the statistical significance (p-value) of the effect size, the within- 3 Participants were provided with the rationale that these events (e. These statistics, reported in Table 2, provide information on the stability, significance, and range of the true effect size. Characteristics of the final sample of studies This final sample of 33 studies were published from 1977–2004 and included 90 treatments administered to 1193 participants. The average length of follow-up was 168 days, with follow-up assessment periods ranging from 2 weeks to 14 months. Table 1 shows the studies included in the meta- analysis for each of the 11 a priori comparisons. Efficacy of active treatments relative to no treatment Twenty studies compared one or more active treatments to a wait-list or no-treatment control condition. Not surprisingly, this comparison revealed that phobic participants receiving active treatment showed marked benefit relative to untreated participants.

Prac- complexityin middle-aged andolder adultswith ety 2012 Beers Criteria Update Expert Panel quality 250mg zithromax antibiotic use in livestock. American Geriatrics Society updated Beers Cri- individualized nutrition approaches for older Med Care 2010 proven zithromax 100mg antibiotic yeast infection prevention;48:327–334 teria for potentially inappropriate medication adults in health care communities. Update on diabetes in the elderly and in ment of the American Diabetes Association. Brussels,Belgium,Interna- relates of quality of life in older adults with di- care. J Pain Symptom Manage 2006;32:275–286 tional Diabetes Federation, 2013 abetes: the Diabetes & Aging Study. An ap- Care 2011;34:1749–1753 of diabetes during the last days of life: attitudes proach to diabetes mellitus in hospice and pal- 32. Atten- tion to family dynamics, developmental stages, and physiological differences re- lated to sexual maturity are all essential in developing and implementing an optimal diabetes treatment plan (4). Due to the paucity of clinical research in children, the recommendations for children and adolescents are less likely to be based on clinical trial evidence. A multidisciplinary team of specialists trained in pediatric diabetes management and sensitive to the challenges of children and adolescents with type 1 diabetes and their families should provide care for this population. The appropriate balance between adult supervision and independent self-care should be defined at the first interaction and reeval- uated at subsequent visits. The balance between adult supervision and inde- pendent self-care will evolve as the adolescent gradually becomes an emerging young adult. Diabetes Self-management Education and Support Recommendation c Youth with type 1 diabetes and parents/caregivers (for patients aged ,18 years) should receive culturally sensitive and developmentally appropriate individual- ized diabetes self-management education and support according to national standards at diagnosis and routinely thereafter. B No matter how sound the medical regimen, it can only be effective if the family and/or affected individuals are able to implement it. Family involvement is a vital component of optimal diabetes management throughout childhood and adolescence. In Standards of capable of evaluatingtheeducational, behavioral, emotional,and psychosocial factors Medical Care in Diabetesd2017. DiabetesCare that impact implementation of a treatment plan and must work with the individual 2017;40(Suppl. More infor- the educational needs and skills of day care providers, school nurses, or other school mation is available at http://www. S106 Children and Adolescents Diabetes Care Volume 40, Supplement 1, January 2017 School and Child Care adulthood. Diabetes management during Screening As a large portion of a child’s day is spent childhood and adolescence places sub- Screening for psychosocial distress and in school, close communication with and stantial burdens on the youth and family, mental health problems is an important the cooperation of school or day care necessitating ongoing assessment of psy- component of ongoing care. It is important personnel are essential for optimal dia- chosocial status anddiabetes distress dur- to consider the impact of diabetes on qual- betes management, safety, and maximal ing routine diabetes visits (10–12). Consider assessing youth for diabetes tes management require ongoing pa- distress, generally starting at 7 or 8 years of Psychosocial Issues rental involvement in care throughout age (13). Consider screening for depres- Recommendations childhood with developmentally appro- sion and disordered eating behaviors us- c At diagnosis and during routine priate family teamwork between the ing available screening tools (10,23). With follow-up care, assess psychoso- growing child/teen and parent in order respect to disordered eating, it is impor- cial issues and family stresses to maintain adherence and to prevent de- tant to recognize the unique and dan- that could impact adherence to di- terioration in glycemic control (14,15). As gerous disordered eating behavior of abetes management and provide diabetes-specific family conflict is related insulin omission for weight control in appropriate referrals to trained to poorer adherence and glycemic con- type 1 diabetes (24). The presence of a mental health professionals, pref- trol, it is appropriate to inquire about mental health professional on pediatric erably experienced in childhood such conflict during visits and to either multidisciplinary teams highlights the diabetes. E help to negotiate a plan for resolution or importance of attending to the psycho- c Mental health professionals should refertoanappropriatementalhealth social issues of diabetes. Monitoring of social ad- social factors are significantly related to the pediatric diabetes multidisci- justment (peer relationships) and school nonadherence, suboptimal glycemic plinary team. E performance can facilitate both well- control, reduced quality of life, and c Encourage developmentally appro- being and academic achievement. Sub- higher rates of acute and chronic diabe- priate family involvement in diabe- optimal glycemic control is a risk factor tes complications. Although and adolescents’ diabetes distress, cognitive abilities vary, the ethical position Current standards for diabetes manage- social adjustment (peer relation- often adopted is the “mature minor rule,” ment reflect the need to lower glucose as ships), and school performance to whereby children after age 12 or 13 years safely as possible. This should be done determine whether further inter- whoappeartobe“mature” have the right with stepwise goals. B to consent or withhold consent to general individualized glycemic targets, special c In youth and families with behav- medical treatment, except in cases in consideration should be given to the ioral self-care difficulties, repeated which refusal would significantly endanger risk of hypoglycemia in young children hospitalizations for diabetic keto- health (19). E should receive education about the risks with adverse effects on cognition during c Adolescents should have time by of malformations associated with un- childhood and adolescence. Factors that themselves with their care pro- planned pregnancies and poor metabolic contribute to adverse effects on brain vider(s) starting at age 12 years. E control and the use of effective contra- development and function include c Starting at puberty, preconception ception to prevent unplanned pregnancy. A enables adolescent girls to make well- However, meticulous use of new therapeu- informed decisions (20). Preconception tic modalities, such as rapid- and long-acting Rapid and dynamic cognitive, develop- counseling resources tailored for adoles- insulin analogs, technological advances mental, and emotional changes occur dur- cents are available at no cost through the (e. Nevertheless, the other autoimmune conditions, such as roid function tests should be performed increased use of basal-bolus regimens, in- Addison disease (primary adrenal insuf- soon after a period of metabolic stability sulin pumps, frequent blood glucose mon- ficiency), autoimmune hepatitis, auto- and good glycemic control. Subclinical itoring, goal setting, and improved patient immune gastritis, dermatomyositis, and hypothyroidism may be associated with education in youth from infancy through myasthenia gravis, occur more com- increased risk of symptomatic hypogly- adolescence have been associated with monly in the population with type 1 di- cemia (39) and reduced linear growth more children reaching the blood glu- abetes than in the general pediatric rate. Furthermore, studies documenting Recommendations c Consider testing individuals with neurocognitive imaging differences re- c Consider screening individuals with type 1 diabetes for antithyroid per- lated to hyperglycemia in children pro- type 1 diabetes for celiac disease oxidase and antithyroglobulin anti- vide another motivation for lowering by measuring either tissue transglu- bodies soon after the diagnosis. E and after glucose control has been of hypoglycemia and the developmental c Consider screening individuals established. If normal, consider re- burdens of intensive regimens in children who have a first-degree relative checking every 1–2 years or sooner and youth. In addition, achieving lower with celiac disease, growth failure, if the patient develops symptoms A1C levels is more likely to be related to weight loss, failure to gain weight, suggestive of thyroid dysfunction, setting lower A1C targets (33,34). A1C diarrhea, flatulence, abdominal thyromegaly, an abnormal growth goals are presented in Table 12. E plained hypoglycemia or deterio- Autoimmune Conditions ration in glycemic control. E Autoimmune thyroid disease is the Recommendation c Individuals with biopsy-confirmed most common autoimmune disorder c Assess for the presence of auto- celiac disease should be placed associated with diabetes, occurring in immune conditions associated on a gluten-free diet and have 17–30% of patients with type 1 di- with type 1 diabetes soon after a consultation with a dietitian ex- abetes (35). At the time of diagnosis, the diagnosis and if symptoms periencedinmanagingbothdia- about 25% of children with type 1 di- develop. S108 Children and Adolescents Diabetes Care Volume 40, Supplement 1, January 2017 Celiac disease is an immune-mediated Management of Cardiovascular Risk Normal blood pressure levels for age, sex, disorder that occurs with increased Factors and height and appropriate methods for frequency in patients with type 1 dia- Hypertension measurement are available online at betes (1. Screening for celiac disease c Blood pressure should be measured Dyslipidemia includes measuring serum levels of at each routine visit. Children found Recommendations IgA and anti–tissue transglutaminase to have high-normal blood pressure (systolic blood pressure or diastolic Testing antibodies, or, with IgA deficiency, blood pressure $90th percentile for c Obtain a fasting lipid profile in screening can include measuring IgG age,sex,andheight)orhypertension children $10 years of age soon af- tissue transglutaminase antibodies (systolic blood pressure or diastolic ter the diagnosis (after glucose or IgG deamidated gliadin peptide blood pressure $95th percentile control has been established).