This guide accompanies the following article: 'Isn't Every Crime a Hate Crime? The Case for Hate Crime Laws', Sociology Compass 5/4 (2011): 244–255, 10.1111/j.1751‐9020.2011.00364.x.Author's introductionHave you ever heard someone say, 'Isn't every crime a "hate crime"?' The process to create hate crime laws in the United States has wrestled with the core issues of freedom of speech and greater harm to society. It is important to look at the evolution of bias crime laws, culminating with President Obama's signing of the Matthew Shepard and James Byrd, Jr. Hate Crimes Prevention Act in 2009. The constitutionality of the laws is still a subject of debate. Four elements of hate crime laws are criminality, intent, perception, and protected statuses. The logic of hate crime laws is based on the argument that hate crimes are a form of terrorism, designed to intimidate large groups of people. Police are often the ones who are responsible for making this determination. Once hate crimes have been defined, how should social scientists study them?Author recommendsIn the last 15 years, sociologists and criminologists have done a lot of work to understand the causes of hate crimes as well as issues associated with hate crime laws. The classic in the field is Hate Crimes: The Rising Tide of Bigotry and Bloodshed by Jack Levin and Jack McDevitt (Westview Press, 2001). It provides a great overview of the types of hate crimes, the role hate groups play, and how police respond to such acts.Several recent books to a wonderful job of explaining why people commit hate crimes and how these crimes impact their victims. In the Name of Hate: Understanding Hate Crimes by Barbara Perry (Routledge, 2001) should be at the top of the required reading list. Why We Hate by Jack Levin and Gordana Rabrenovic (Prometheus Books, 2005) also is very enlightening. Home‐Grown Hate: Gender and Organized Racism is a collection of readings by Abby L. Ferber (Routledge, 2003) that explores the role gender plays in hate crimes and hate groups.For those who are interested in the more personal stories of those involved in the world of hate, Autobiography of a Recovering Skinhead: The Frank Meeink Story as Told to Jody M. Roy, Ph.D. (Hawthorne Books, 2010) is riveting reading. Meeink was one of the most notorious Nazi skinheads on the east coast in the 1990s. Katleen Blee interviewed female members of the white supremacist world for her book, Inside Organized Racism: Women in the Hate Movement (University of California Press, 2002). Raphael S. Ezekiel interviewed leaders of the racist movement for his book, The Racist Mind (Penguin, 1996). Each of these three books gives you a chance to read hate mongers own accounts of why they believe what they believe.If you are interested in the anatomy of a hate crime, Elinor Langer's A Hundred Little Hitlers: The Death of a Black Man, the Trial of a White Racist, and the Rise of the Neo‐Nazi Movement in America (Picador, 2004) is the gripping exploration of a brutal murder in Portland, Oregon by skinheads.Finally, if you are interested in the legal debates surrounding hate crimes, pick up a copy of Brian Levin's recent edited volume, Understanding and Defining Hate Crimes (Preager, 2009). Levin is the attorney who argued the constitutionality of hate crime laws before the Supreme Court.Online materialsThere are a number of online sources for students interested in hate crimes and the debate about hate crime laws. The first source is the FBI's Uniform Crime Report (discussed in the article). Here you can get the latest data about hate crimes that have been reported to and by the police. The FBI's crime data website is at: http://www.fbi.gov/about‐us/cjis/ucr/ucr.Another well‐know website belongs to the Southern Poverty Law Center (SPLC). The SPLC is a civil rights group that has helped track hate groups. It's website has a 'hate group map', so you can see which hate groups are active in your state. The SPLC has also helped to raise the awareness of the importance of hate crime laws and the limitation of the data that is reported to the FBI. Their web address is: http://splcenter.org/.The Anti‐Defamation League (ADL) is the Jewish civil rights group who helped create the first hate crime legislation in the 1980s. Their website has a handy map for finding the specific hate crime laws (and what they cover) for each state. The ADL website also has a database for hate symbols and what they mean, useful for police, teachers, and students. The ADL website is at: http://adl.org/combating_hate/.Finally, the Center for the Study of Hate & Extremism has a website that serves as a wonderful portal to other online resources, including academic research and community based anti‐hate groups. The Center is headed by Dr Brian Levin, one of the leading experts on the legal aspects of hate crime laws. Their web address is: http://hatemonitor.csusb.edu/.Sample syllabusThere are now numerous college courses taught on the topic of hate crimes (as well as courses for law enforcement on the subject). Here is an outline of my 10‐week hate crime course at Portland State University. The class explores the origins of hate crime laws, hate groups, and the philosophy of hate itself. It also challenges students to explore their own biases.
A major requirement both of national and international ethical codes for human experimentation, and of national legislation in many cases, is that new substances or devices should not be used for the first time on human beings unless previous tests on animals have provided a reasonable presumption of their safety. That is so called: Good Clinical Praxis (GCP). There are two international ethical codes intended principally for the guidance of countries or institutions that have not yet formulated their own ethical requirements for human experimentation:The Declaration of Helsinkiof the World Medical Association andThe Proposed International Guidelines for Biomedical Research Involving Human Subjectsof the Council for International Organizations of Medical Sciences and the World Health Organization[1]. Animal experimentation is fundamental to the biomedical sciences, not only for the advancement of specific vital processes, but also for the improvement of methods of prevention, diagnosis, and treatment of disease both in man and in animals. The use of animals is also indispensable for testing the potency and safety of biological substances used in human and veterinary medicine, as well as for determining the toxicity of the rapidly growing number of molecules that never existed before in nature and which may represent a hazard to health. This extensive exploitation by man of animals implies philosophical and moral problems that are not peculiar to their use for scientific purposes, and there are no objective ethical criteria by which to judge claims and counterclaims in such matters[2]. However, there is a consensus that "deliberate cruelty is repugnant". While many countries have general laws or regulations imposing penalties for ill-treatment of animals, relatively few make specific provision for their use for scientific purposes. Because of differing legal systems and cultural backgrounds there are varying approaches to the use of animals for research, testing, or training in different countries. In the few that have done so, the measures adopted vary widely: on the one hand, legally enforceable detailed regulations with licensing of experimenters and their premises together with an official inspectorate; on the other, entirely voluntary self-regulation by the biomedical community, with lay participation. Many variations are possible between these extremes, one intermediate situation being a legal requirement that experiments or other procedures involving the use of animals should be subject to the approval of ethical committees of specified composition. The International Guiding Principles are the product of the collaboration of a representative sample of the international biomedical community, including experts of the World Health Organization, and of consultations with responsible animal welfare groups. The International Guiding Principles have already gained a considerable measure of acceptance internationally. European Medical Research Councils (EMRC), an international association that includes all the West European medical research councils, fully endorsed the Guiding Principles in 1984. Here we bring the basic bioethical principles for using animals in biomedical research[3]: Methods such as mathematical models, computer simulation andin vitrobiological systems should be used wherever appropriate, Animal experiments should be undertaken only after due consideration of their relevance for human or animal health and the advancement of biological knowledge, The animals selected for an experiment should be of an appropriate species and quality, and the minimum number required to obtain scientifically valid results, Investigators and other personnel should never fail to treat animals as sentient, and should regard their proper care and use and the avoidance or minimization of discomfort, distress, or pain as ethical imperatives, Procedures with animals that may cause more than momentary or minimal pain or distress should be performed with appropriate sedation, analgesia, or anesthesia in accordance with accepted veterinary practice. Surgical or other painful procedures should not be performed on unanesthetized animals paralyzed by chemical agents, Where waivers are required in relation to the provisions of article V, the decisions should not rest solely with the investigators directly concerned but should be made, with due regard to the provisions of articles IV, and V, by a suitably constituted review body. Such waivers should not be made solely for the purposes of teaching or demonstration, At the end of, or, when appropriate, during an experiment, animals that would otherwise suffer severe or chronic pain, distress, discomfort, or disablement that cannot be relieved should be painlessly killed, The best possible living conditions should be maintained for animals kept for biomedical purposes. Normally the care of animals should be under the supervision of veterinarians having experience in laboratory animal science. In any case, veterinary care should be available as required, It is the responsibility of the director of an institute or department using animals to ensure that investigators and personnel have appropriate qualifications or experience for conducting procedures on animals. Adequate opportunities shall be provided for in-service training, including the proper and humane concern for the animals under their care. Also seeDraft CIOMS Guiding Principles 2011to be used by the international scientific community to guide the responsible use of vertebrate animals in scientific and/or educational activities[4]. Go to: Alternatives for animal in biomedical research There remain many areas in biomedical research which, at least for the foreseeable future, will require animal experimentation. An intact live animal is more than the sum of the responses of isolated cells, tissues or organs; there are complex interactions in the whole animal that cannot be reproduced by biological or non-biological "alternative" methods. The term "alternative" has come to be used by some to refer to a replacement of the use of living animals by other procedures, as well as methods which lead to a reduction in the numbers of animals required or to the refinement of experimental procedures. The experimental procedures that are considered to be "alternatives" include biological and non-biological methods. The biological methods include the use of micro-organisms,in vitropreparations (subcellular fractions, short-term cellular systems, whole organ perfusion, and cell and organ culture) and under some circumstances, invertebrates and vertebrate embryos. The non-biological methods include mathematical modeling of structure-activity relationships based on the physico-chemical properties of drugs and other chemicals, and computer modeling of other biological processes. In addition to experimental procedures, retrospective and prospective epidemiological investigations on human and animal populations represent other approaches of major importance. There no need specialy underline that the adoption of "alternative" approaches is viewed as being complementary to the use of intact animals and their development and use should be actively encouraged for both scientific and humane reasons.
This thesis contributes to the literature on the endogenous relationship between the health status of a population and the economic development of a nation. We focus on a wide phenomenon touching many low-income countries: malaria. Firstly, we propose to rethink the economic analysis of malaria by combining economic epidemiology tools with the poverty trap literature. The endogeneity of malaria with respect to households and individuals socioeconomic characteristics and choices remains a particularly relevant and unresolved issue. In spite of massive efforts to generalize efficient prevention (such as ITNs), malaria remains prevalent in many countries. We design a theoretical model of rational preventive behaviors in response to the disease, which includes endogenous externalities and disease characteristics. Two important conclusions emerge from the model. First, agents increase their preventive behaviors when the degree of prevalence of malaria in a society is more severe. This result is consistent with the literature on "prevalenceelastic behavior". Second, we find that multiple equilibria are theoretically possible and so is the existence of malaria traps, defined as any self-reinforcing mechanism, which causes malaria to persist. Two implications discussed in this chapter concern malaria exogeneity for trapped communities and possible mechanisms to get out of the trap (through public policies). For the communities trapped and if the disease affects negatively some economic variables, it is plausible to assume that the disease itself generates the socio-economic obstacles to its control. Secondly, we try to understand the socioeconomic effects of malaria. If malaria deaths and illness occur mostly in young African children, the economic literature on the subject primarily focused on its effects on adult productivity or on private health and public expenditure accumulation related to the disease. The last three chapters of this thesis tackle the question of the economic effects of malaria under a new angle: the effects of the disease on children human capital accumulation, which can potentially have heavy consequences on future generations. A small but growing number of medical studies are drawing an alarming report of the impact of malaria on creative and intellectual development of children. Given the frightening distribution of falciparum malaria, any effect of malaria on cognitive function or educational achievement is likely to result in a massive macroeconomic loss. Our macroeconomic results show that performance of educational systems in countries with intensive malaria is lower than in countries not affected by malaria, other things being equal. These results suggest that the macroeconomic effects of malaria on education are not negligible, taking into account the number of malaria clinical cases worldwide. These results are then confronted to two microeconomic analyses. We start with data from Demographic and Health Surveys. We next move to a longitudinal investigation we carried out in a village in a malaria endemic area in Mali in collaboration with the Malaria Research and Center training. From a methodological point of view, thanks to a multi-disciplinary approach, we improve the measure of malaria indicators generally used in economic studies. The main finding of this thesis relates to the effects of asymptomatic malaria. Asymptomatic malaria is defined as a malariapositive smear for P. falciparum parasitaemia associated with no clinical symptoms. Asymptomatic malaria affects significantly school performances of the children in endemic area. We also show that higher income offers little protection against the negative effects of asymptomatic malaria on education in the village. Our results can lead to change the social and psychological perception of the risks associated with malaria, thus opening promising prospects as regards to malaria eradication and control programs. ; Cette thèse contribue à la littérature sur la relation endogène entre l'état de santé d'une population et le développement économique d'une nation. Nous nous focalisons pour cela sur un phénomène de grande ampleur touchant de nombreux pays en développement: l'endémie palustre. Dans un premier temps, nous reformulons le cadre théorique dans lequel la relation bidirectionnelle entre paludisme et développement économique est généralement analysée. Nous utilisons un modèle d'épidémiologie économique qui place la maladie et les comportements préventifs au centre de l'analyse et débouche sur des comportements dits «prévalence-élastiques». Nous montrons que ce modèle conduit à de possibles équilibres multiples et, par conséquent, à des trappes de santé potentielles du fait des externalités engendrées par les décisions des agents. Une implication forte de ces trappes concerne le caractère exogène de la maladie pour les communautés piégées. Une autre implication importante concerne les politiques de contrôle de la maladie. Si les communautés sont piégées dans de telles trappes et que la maladie affecte négativement certaines variables économiques, il est possible que la maladie engendre, de par sa nature même, des obstacles socioéconomiques à son contrôle. Dans un deuxième temps, nous cherchons donc à mieux comprendre les effets socioéconomiques du paludisme. Si le paludisme touche principalement les enfants, les études économiques sur le sujet se sont essentiellement focalisées sur ses effets sur la productivité chez l'adulte ou l'accumulation des dépenses de santé privées et publiques liées à la maladie. Les trois derniers chapitres de cette thèse abordent la question des effets économiques du paludisme sous un angle nouveau: celui des conséquences de la maladie sur l'accumulation de capital humain chez l'enfant, pouvant avoir des conséquences lourdes sur les générations futures. Certaines études médicales font un constat alarmant de l'impact du paludisme sur les capacités de développement créatif et intellectuel chez l'enfant. Nos résultats montrent que les pays intensivement touchés par le paludisme ont des systèmes éducatifs moins performants par rapport aux pays non touchés. Ces résultats suggèrent des effets non négligeables du paludisme au niveau macroéconomique, compte tenu de l'ampleur de l'endémie palustre. Ils sont ensuite confirmés par deux analyses microéconomiques à partir de données DHS et d'une enquête longitudinale que nous avons réalisée dans un village en zone endémique au Mali en collaboration avec le Malaria Research and Training Center. D'un point de vue méthodologique, nous améliorons la mesure des indicateurs de paludisme généralement utilisés dans les études économiques. L'une des principales découvertes de cette thèse concerne les effets du paludisme asymptomatique. Le paludisme asymptomatique à P. falciparum affecte significativement les performances scolaires des enfants en zone endémique. Nous montrons également qu'un niveau de richesse plus élevé ne protège pas des effets négatifs de la parasitémie sur l'éducation. Nos résultats peuvent déboucher sur une modification de la perception sociale et psychologique des risques associés à la maladie, ouvrant ainsi des perspectives prometteuses en matière de politique de lutte.
• Tobacco control in Arizona flourished from 1997-2007, thanks to public support at the ballot box and the hard work of Arizonan tobacco control activists. • Arizona's state-run Tobacco Education and Prevention Program (TEPP), created by Proposition 200 in 1994 from 23% of a 40 cent tobacco tax increase, provided a key component in Arizona tobacco control, spending between $15 and $36 million annually. • Tobacco control advocacy between 1997 and 2007 resulted in more than tripling tobacco excise taxes from 58 cents to $2.00, enacting comprehensive local clean indoor air ordinances, defeating tobacco industry counter-initiatives, and passing Smoke-Free Arizona, Arizona's statewide comprehensive clean indoor air law. • Arizona tobacco control advocates instituted 18 local clean indoor air ordinances between 1997 and 2007. The tobacco industry has never won at the ballot box in Arizona, locally or statewide. • On November 7, 2006, Arizona became the 16th state to pass a comprehensive clean indoor air act. The law went into effect on May 1, 2007. The Arizona Department of Health Services enforces the law with revenues from a 2 cent tobacco excise tax included in the Smoke-Free Arizona initiative. Any tax funds not used to enforce clean indoor air go to Arizona's tobacco control program TEPP. • Tobacco taxes were raised to 58 cents per pack by Arizona voters in 1994. In 2002, voters raised tobacco taxes 60 cents to $1.18 per pack, with the revenue going to the Arizona Health Care Cost Containment System (AHCCCS). Tobacco taxes were raised again by voters in 2006 to $2.00 per pack with 80 cents paying for early childhood care. • Deciding how to spend Master Settlement Agreement (MSA) money was contentious and politically difficult, as illustrated by an unwillingness to compromise among the Legislature, Governor, and County Health Departments. Ultimately voters decided in November 2000 to allocate all of the MSA funds to AHCCCS to expand Arizona's medicare program to 100% the federal poverty level. No MSA money goes to tobacco control. • The Tempe smokefree ordinance, passed by initiative in May 2002, became Arizona's first 100% clean indoor air act including bars. Dr. Leland Fairbanks led the Arizona tobacco control organization Arizonans Concerned About Smoking (ACAS) to spearhead the successful effort and defended Tempe's smokefree ordinance against the ensuing legal challenges and attempted referendum by pro-tobacco groups. • Local efforts to pass other clean indoor air ordinances in Arizona often led to compromises that routinely exempted bars. Also, elected officials in Phoenix resisted adopting a smokefree ordinance despite tobacco control leaders' concerted efforts. Tempe's successful comprehensive clean indoor air act in 2002, however, paved the way with Guadalupe (2002) for Prescott (2003), Coconino County (2003), Flagstaff (2005), and Sedona (2006), to successfully pass comprehensive clean indoor air acts of their own. • In FY2002 Governor Jane Hull and the Legislature, looking for available funds during a recession period, diverted $60 million from the Health Education and Research Accounts, which fund TEPP and research on tobacco-related disease. These funds were never recovered. • To prevent further seizures of TEPP funds, in November 2002 voters passed the referendum Proposition 303 which increased the tobacco tax 60 cents (two per cent of which went to tobacco control) and re-enacted the original 1994 Proposition 200 tobacco control measure bringing TEPP under voter protection, preventing it from further legislative tampering. Voluntary health organizations now turned their attention from protecting TEPP funds to translating their electoral success into a comprehensive statewide smokefree campaign. • While TEPP expenditures exceeded the Centers for Disease Control (CDC) minimum recommended levels for state tobacco control expenditures (at the time, $27.8 million) from FY1999 through FY2001, in October 2007 the CDC increased its Best Practices estimate for Arizona to $68.1 million annually, a figure Arizona has not yet approached in its tobacco control spending. • In 2004, prompted by citizens (but not the ALA, AHA, or ACS), Arizona Legislator Linda Lopez (D-Tucson) introduced a statewide clean indoor air bill including bars into the Republican-controlled House. The bill, however, was assigned to three committees, denied a hearing, and died in the Commerce Committee. • In Arizona, the tobacco industry spent a total of $16,201 in direct campaign contributions between 1997 and 2006 on legislators, constitutional officers, and political parties. Tobacco industry lobbyists spent $25,367 on legislators during this period. Republicans received more than 5 times the tobacco companies' contributions as Democrats. • In the 2006 election cycle RJ Reynolds mounted an $8.8 million counter-initiative (Proposition 206, the Non-Smoker Protection Act) in an attempt to confuse voters and preempt local tobacco control. The campaign concentrated much of its resources attacking Proposition 201, the health group-driven Smoke-Free Arizona initiative. Despite Reynolds' superior resources and negative campaigning, 57.3% of voters rejected Reynolds' initiative, while 54.8% of voters approved Smoke-Free Arizona. • TEPP's media campaigns with Riester-Robb from 1996-2001 enjoyed commendations nationally. The TEPP-contracted ad agency sold over 2 million units of merchandise with the media campaign's tagline Tobacco: Tumor causing, teeth staining, smelly puking habit. In July 2001 the Arizona Department of Health Services (ADHS), which manages TEPP, did not renew the media contract with Riester-Robb, instead favoring the E.B. Lane agency. This rough transition from one agency to the next occurred just as the Legislature appropriated TEPP's funds, throwing TEPP into disarray, resulting in a dead year (approximately Fall 2001-Fall 2002) under the E.B. Lane contract when tobacco control media came to a virtual halt. E.B. Lane provided TEPP's lower intensity media campaigns from 2002 through 2005. From 2005 to 2007, TEPP did not coordinate media through a contracted ad agency, instead working on a more fragmented ad hoc basis. In late 2007, TEPP contracted again with the Riester firm, though with a smaller budget. • TEPP suffered from a lack of leadership since the program's inception, with a revolving-door Office Chief position, inconsistent directives from the ADHS, and overcautiousness concerning crossing the lobbying-advocacy/advocacy-education line. Between 2005 and 2007 every TEPP employee left, leaving the agency without many employees having any prior experience in tobacco control. As a result, many tobacco control advocates perceived TEPP as an ineffective program, not making best use of its resources. While TEPP leadership in 2007 painted an optimistic vision of TEPP's future, concrete programmatic action that reflects current best practices remains to be demonstrated.
Tobacco industry money has not been successful in recent years in buying support from lawmakers in Hawai'i. Since 2001, major legislation on clean indoor air, tobacco tax increases and a tobacco tax stamp measure have passed by comfortable margins. In 1994, the City Council of Honolulu passed smokefree workplaces ordinances that exempted bars and nightclubs. Mayor Jeremy Harris vetoed the bill because it covered restaurants. In 1997, Honolulu made all workplaces smokefree except restaurants and bars, which Mayor Harris signed because of the restaurant exemption. In December 2001, county government leaders of Honolulu, Kaua'i and Maui Counties announced they would be introducing legislation that would end restaurant smoking because of the state Legislature's inaction. Honolulu passed Hawai'i's first smokefree restaurant law in 2002. The State Department of Health media campaign that started June 1, 2001 focusing on the health impact of secondhand smoke on restaurant workers may have contributed to the polling data released in January, 2002 that showed strong support for a smokefree restaurant law. In the end, it was the persistence of the tobacco control advocates that carried the day. Honolulu's law set the stage for the Kaua'i and Maui ordinances that would follow shortly. During 2002 and 2003, each county in Hawai'i passed a smokefree restaurant or workplace law. By February 1, 2004, well over 80% of Hawai'i workplaces were smokefree and smoking was prohibited in virtually all restaurants. This status would set the tone for the passage of a sweeping statewide smokefree law. Polling data released in December, 2005 showed very strong public support for a statewide smokefree law. The statewide clean indoor air measure passed in 2006 with virtually no amendments from introduction to final passage, and with only three Nays in the Senate (out of 25) and three Nays in the House (out of 51). In 2007, a group of bar owners tried to undo the new statewide smokefree law in the Legislature and through a lawsuit claiming the law was unconstitutional. Tobacco control advocates prevailed in killing all of the bills that would have exempted some or all bars and restaurants with smoking rooms and the court dismissed the lawsuit. The Department of Health, however, as of July 1, 2008, had still failed to take any effective enforcement action against repeat violators of the smokefree law, to get local law enforcement agencies to act, or to issue the administrative rules required by the state law that went into effect November 16, 2006. There has been no sustained public education campaign about the public's power for enforcement. This failure made proactive implementation of the law all but impossible and created a situation that invites pro-tobacco forces to undermine the law's long-term effectiveness. Hawai'i has taken modest steps to control illegal sales of tobacco products to minors. Cigarette vending machines are restricted to venues in which minors under the age of 18 are not permitted, mobile food vendors (lunch wagons) are prohibited from selling or distributing cigarettes within 1,000 feet of any school, and the sale or distribution of single cigarettes or packs of cigarettes containing fewer than 20 cigarettes is prohibited. In 1998, the fines levied against individuals who sell or distribute tobacco products to minors were raised to $500 for the first offense and $2,000 for subsequent offenses. However, the law does not penalize the business owner for illegal sales to minors, which probably accounts for the large number of violations found in sting operations. In 1993, the tobacco industry was successful in replacing the Hawai'i ad valorem tax on cigarettes (40% of the wholesale price) with an excise tax, but this plan to reduce the size of the cigarette tax by switching to a per unit tax backfired. The per unit taxes established by state legislation between 1997 and 2007 exceeded the rates that cigarettes would have been taxed if the 40 percent ad valorem tax had remained in place. In 2006, the cigarette tax was increased by $.20 per pack per year over six years to $2.60. However, there were lost opportunities to add some of the new revenue from the increased cigarette taxes to tobacco control programs. In 2001, Hawai'i became one of the last states to require a tax stamp on cigarette packages to reduce smuggling and improve tax collections. The tax stamp was credited in a Department of Health report with reducing the number of smuggled cigarettes sold in Hawai'i and for increasing the tax revenues by $20 million annually. When the Legislature in 1999 split MSA funds into two accounts for tobacco control, one for the Department of Health and one in a Trust Fund, tobacco control advocates did achieve one goal of protecting funding from administrative diversion to programs other than tobacco control by putting the money in a nongovernmental organization. What they were not able to protect was the amount of funding that went into that Trust Fund, which was cut from 25% of MSA monies to 12.5% in 2002. Heavy lobbying by the University of Hawai'i to raid the MSA funds to build medical school facilities robbed tobacco control programs of vital resources. The 25% of the MSA funds that goes to the Department of Health is to be spent for a variety of health promotion and disease prevention programs, but the Department allocates relatively little to tobacco control. While Hawai'i has slowly improved its spending on tobacco control, it has never reached the 1999 CDC Best Practices recommendation of $10.8 to $23.4 million per year (reduced by CDC to $9.6 to $19.6 million per year in 2007. The closest it has come was 2006 when the Department of Health and the Trust Fund spent a total of $8.2 million on tobacco control. Despite these issues, there have been continuing declines in adult and youth smoking prevalence, though per capita cigarette consumption is not showing the steady decline we see nationally. When the Trust Fund was created from MSA monies, the legislation established an independent source of tobacco control funding, with its own Advisory Board, separate from the Department of Health which had its own MSA monies and its own tobacco control advisory group. Without any apparent statutory authority, the Department of Health has substantially interfered with that independence by effectively controlling how the Trust Fund spends its money on tobacco control by disapproving or requiring modifications of Trust Fund Advisory Board recommendations on funding, budgets and tobacco control programs.
This paper broadly evaluates the role and performance of non-governmental development organizations (NGDOs) in promoting social development before and since the 1995 World Summit for Social Development. Two kinds of analysis and recommendations are offered. The first concerns the practices of NGDOs and their relationships with other "partners in development". The second focuses on the deep-rooted pathologies of the aid system that condition the form and effectiveness of many development interventions not only by NGDOs but also by the larger universe of entities comprising civil society organizations (CSOs). This review concludes that, in the absence of thoroughgoing reform, the aid system will continue to hinder mobilization by the larger civil society with NGDOs to bring about genuine development in the Third World. The concept of civil society has altered development thinking and practice in the major donor countries. However, the Western image of civil society that donors employ does not necessarily apply to civil societies elsewhere. This has serious consequences for efforts to mobilize civil society organizations in developing countries. In practice, donors need to have a much deeper understanding of the configuration and capacity of civil society in the specific locations where they intend to intervene. Donors must also recognize that NGDO efforts, while useful, are limited, and that they cannot substitute for those of the wider civil society. The tasks NGDOs set for themselves, and the expectations of those that finance them, are complex and (probably too) demanding. They cover most facets of social development: reducing poverty and exclusion; improving access to basic services; conflict prevention; fostering democracy; influencing public policies, etc. NGDOs also function at multiple levels, from the individual, through households and intermediary institutions into the arena of international relations, conventions and commitments. In doing so, they may touch some 20 per cent of the world's poor. However, evidence suggests that the NGDO contribution to social change is less substantial and durable than imagined. NGDOs would like to do better and are doing something about it themselves. However, they are limited in this by the unfair, power-imbalanced and donor-serving framework of aid that they operate in. At the same time, NGDOs remain substantially aid-dependent and vulnerable, which can result in questionable motivations and behaviour. For NGDOs to improve their contributions in mobilizing for development, they must better learn to: understand and overcome the factors undermining their efforts; work differently with communities to ensure that change is sustained; develop an ability to cope with relative powerlessness within the "partnerships" that are possible in an unreformed aid system; improve relations between themselves; alter Northern NGDOs' roles vis-à-vis Southern partners and their own national constituencies, and work together with all kinds of NGDOs in coalitions and networks; broaden and bring enduring structure into interactions with wider civil society; interface more broadly with national and local government; operate in the international arena with downward accountability, while adopting advocacy strategies that do not undermine domestic governance or provoke a government "backlash". But structural features of the international aid system limit NGDOs' capacity for self-improvement. Under existing rules, most recipients of aid are relatively powerless and are kept that way. The distorted language of "partnership" is a current example of how rhetoric masks major disparities in power and the maintenance of dependency. And this power imbalance generates perverse incentives for aid recipients. It blocks their necessary ownership of and commitment to change. Six reforms are proposed to attenuate or remove the institutional dysfunctions of aid, and hence make feasible the possibilities for NGDOs to work with diverse CSOs on a larger scale. First, bring greater equity, co-responsibility and ownership into the aid process. Trust funds, or similar mechanisms, have often been proposed and should be implemented. These should create an appropriate distance between the giver and receiver of aid, set within a transparent governance framework. Second, recognize relationships other than "partnership". The aid community requires an array of relationships, named for what they are, each designed to serve different purposes. Different relationships require the open negotiation of different rights and obligations of the parties involved. Third, establish "honest brokers" along the lines of an Ombudsperson, as is now being considered by agencies working in humanitarian and emergency operations. Fourth, prevent "development mono-culture" by encouraging NGDOs to do what they should do best: work with local agents of change to understand and promote integrative, cross-cutting, thematic, participatory and innovative approaches to development, tailored to specific situations. This goes against the current trend of forcing NGDOs to conform to official standards and methods, often prescribed along technical, sectoral lines favoured by the donor. Fifth, improve social development practice by incorporating into interventions a deeper understanding of the interrelationships among social and economic change, the evolution of civic participation, the role and kinds of capacity building needed by CSOs, etc. The meaning of this is made clear by an example of a promising approach to capacity building. Finally, expand relations with civil society on the basis of dialogue and building effective relations between diverse actors at multiple levels. Institutional mapping is one way of identifying entry points for, and obtaining, this type of engagement. The aid system has not demonstrated an ability to reform its fundamental principles and structures. Should it continue this way, NGDOs' credibility when engaging with CSOs will be further compromised. It is not a question of not knowing what needs to be done. Necessary reforms are readily apparent. The problem is that failure to move as needed stems from a donor predisposition to prioritize domestic interests over those of recipients who remain in second place and second class. This may satisfy tax payers' need to see how they themselves benefit from their aid. Nevertheless, this stance is deficient when the same taxpayers ask what is actually being achieved on the ground. They want both home benefits and overseas results. Consequently, poor performance will eventually result in lost credibility at both ends of the aid chain. This must not be allowed to happen. People who are poor and marginalized, and in whose name the system operates, have a fundamental right that this not occur.
The tobacco industry is a major political and legal force in Florida through campaign contributions, public relations efforts, lobbying and litigation, which at least from the late 1970s, has had a centralized political organization in Florida that defends and promotes its political and economic interests at the local and state levels of government. Although the industry has operated in the open in some political campaigns, it has also operated quietly behind the scenes, often through front groups, in various other state and local political campaigns. In Dade County in 1979, GASP of Miami ran a clean indoor air initiative without the active support of the local affiliates of the American Cancer Society, American Lung Association, and American Heart Association. Despite being outspent by the tobacco industry 90 to 1, GASP only lost by 820 votes. Had the health groups provided public and political support, the initiative may well have won, substantially increasing the momentum for clean indoor air ordinances in Florida and elsewhere. Prior to 1985, there were numerous ongoing local efforts to pass and enact a wide variety of local clean indoor ordinances. These efforts subsided considerably after the passage of the preemption clause in the weak Florida Clean Indoor Air Act (FCIAA) of 1985 which, at first, was supported by the American Cancer Society, American Lung Association, and American Heart Association. Since the passage of FCIAA, the tobacco industry has been able to stop all efforts by the three health groups and sympathetic politicians to repeal the preemption clause. After the passage of campaign contribution limit laws in 1991 in Florida, tobacco industry campaign contributions have been redirected away from individual candidates and to the two major political parties. In the 1993-1994 election cycle, the industry gave the largest amount of contributions with $475,000 given to the parties compared to $95,856 to political candidates. The largest contribution to a political party came from Philip Morris, which gave $382,500 to the Republican Party. These contributions in conjunction with others has reinvigorated the two major parties as political power brokers who provide their candidates with advertising, technical assistance, and paid staff. During the 1997-1998 electoral cycle, the tobacco industry's total campaign contributions were $398,194, with $310,250 given to the two major political parties in comparison to $84,194 for legislators. The Republican Party received $227,250 compared to the Democratic Party which received $82,500. The largest contribution to a political party came from Philip Morris, which contributed $125,000 to the Republican Party. In August 1997, Florida and the industry settled a Medicaid fraud lawsuit. Under the terms of the settlement, the industry agreed to pay Florida $11.3 billion, end outdoor billboards, pay for public anti-tobacco campaigns, remove vending machines from places accessible to children, end tobacco advertising on buses and trains, complete an anti-tobacco youth campaign within two years of the settlement, and not name the industry in anti-tobacco ads. Due to further negotiations with the industry, on September 11, 1998, the amount paid to Florida was increased to $13 billion and restrictions on the two year time limit regarding the youth anti-smoking campaign and specifically naming the industry in anti-tobacco advertisements were lifted. After February 1998, Florida began an effort to establish a $200 million youth anti-smoking campaign called the Tobacco Pilot Program in an effort to meet the two year deadline. The Tobacco Pilot Program has engaged in an extensive media campaign known as the "Truth Campaign" which began in late April 1998 and included tough in-your-face print, billboard, and media advertisements which ran throughout Florida. The major theme of this campaign is that Florida youth should choose "Truth" rather than use tobacco and be targets of industry advertising manipulation in the use of tobacco. A report released on March 17, 1999 by the Florida Department of Health, Office of Tobacco Control regarding the progress of the Tobacco Pilot Program indicated that the Tobacco Pilot Program and its anti-tobacco media advertising campaign, in less than a year, had a substantial impact on influencing a significant number of Florida teens not to smoke. From February 1998 to 1999, the number of teens who were current smokers (smoked in the last 30 days) dropped from 23.3% to 20.9%. This represented 31,000 fewer Florida teenagers who were current smokers. These results represent the best results ever obtained in a large scale primary prevention program. Although new Republican Governor Jeb Bush publicly called for the continuation of the Tobacco Pilot Program and the Truth Campaign, the program's funding was reduced from $70.5 million to $45.2 million (-36%) for the 1999-2000 Fiscal Year due to legislative votes by Republican colleagues in the House and the Senate to substantially reduce the funding of the program. These cuts were made despite public opinion polls showing that 49% of the public supported the program without any cuts and 30% supported the program with the $8.5 million cut proposed by Governor Bush. Two projects of the Tobacco Pilot Program which are crucial to maintaining the viability of the program including the Truth Campaign and administrative support for the Students Working Against Tobacco (SWAT) also received large budgetary reductions. While the Tobacco Pilot Program received substantial funding cuts in the 1999 Legislative Session, funding for the American Heart Association's Youth Fitness Program of $3 million and $1 million for the Just The Facts program which was derived from the $45.2 million Tobacco Pilot Program budget, would have reduced the amount of funding for projects directly oriented towards tobacco control efforts to $41.2 million for 1999-2000. On May 27, 1999, Governor Bush vetoed these two diversionary projects, as well as the $2.5 million Sports for Life project which was related to tobacco control, further reducing the program's funding of projects directly related to tobacco control efforts from $70.5 million to $38.7 million (-45.1%). For the past twenty years, a consistent pattern has emerged with respect to the American Cancer Society, the American Heart Association, and the American Lung Association missing key political opportunities that would have significantly advanced anti-tobacco efforts and public health in Florida. These lost opportunities included failing to support GASP of Miami in its 1979 Dade County clean indoor air initiative, supporting the preemption clause in the Florida Clean Indoor Air Act of 1985 which essentially quashed a blossoming grassroots anti-tobacco movement, and failing to forcefully advocate for the Tobacco Pilot Program by holding specific legislators directly and publicly accountable for the substantial funding cuts that occurred in the 1999 Legislative Session.
[SPA] En zonas sísmicamente activas, la ocurrencia de terremotos ocasiona cuantiosos daños materiales y en algunos casos incluso la pérdida de vidas humanas. Es por ello que la comunidad científica y las administraciones competentes realizan esfuerzos para que la ocurrencia de un terremoto importante provoque el menor daño posible sobre la población. Sin embargo, en muchas ocasiones el rápido crecimiento urbanístico se lleva a cabo sin los adecuados criterios preventivos lo cual hace que estas nuevas zonas urbanas sean muy vulnerables ante un terremoto, incluso de magnitud moderada. El sureste de la península Ibérica aúna ambos ingredientes: a una rápida expansión urbanística se suma la ocurrencia de terremotos de magnitud moderada (y en algunos casos, según los registros históricos, de gran magnitud). La serie sísmica ocurrida en Lorca (localizada en el sureste de la Península Ibérica) en 2011 puso de manifiesto que estos terremotos de magnitud moderada pueden provocar grandes daños. El valor promedio de velocidad de cizalla en los primeros 30 metros de profundidad (VS30) del terreno es un parámetro fundamental en la dinámica de suelos y en ingeniería sísmica, siendo determinante para clasificar las condiciones de sitio reflejadas en los códigos sísmicos (p.e. NEHRP-94, Eurocode 8 (EC8), NCSE-02). El uso de técnicas de prospección sísmicas, basadas en el registro del ruido ambiental (pasivas) y/o con el uso de fuentes sísmicas (activas), se ha extendido en los últimos tiempos. Entre ellas, el método de análisis multicanal de ondas superficiales (MASW), refracción por microtremores (REMI) o autocorrelación espacial (SPAC) son técnicas que se caracterizan por una rápida adquisición de datos y una mínima afección al medio urbano. En este estudio se ha obtenido y analizado la estructura superficial del terreno en las ciudades del sureste de la Península Ibérica (Lorca, Adra y Almería) mediante los métodos sísmicos MASW y SPAC. Los valores de VS30 obtenidos con estos métodos sísmicos fueron utilizados para crear nuevos mapas de clasificación del suelo de las ciudades de estudio, los cuales son necesarios en los estudios de microzonificación sísmica. Con el fin de realizar mediciones en el área urbana de estas ciudades se ha desarrollado un sistema land streamer, el cual ha permitido obtener datos sísmicos con una alta productividad utilizando el método MASW. Finalmente, se ha utilizado el método del gradiente topográfico para estimar los valores de VS30 del terreno. Los resultados obtenidos con el método del gradiente topográfico, considerando las ciudades de estudio como regiones tectónicamente activas, muestran una buena correlación con los resultados obtenidos con los métodos sísmicos. Estos resultados ponen de manifiesto que, bajo determinadas condiciones y con un modelo digital del terreno (MDT) adecuado, el método de gradiente topográfico puede ser una alternativa para aquellas áreas del mundo donde no se tenga un acceso adecuado a las técnicas de prospección sísmica de mayor detalle y más costosas que se vienen aplicando en la actualidad. Los parámetros del movimiento sísmico del terreno se han calculado utilizando sismogramas sintéticos como movimiento de entrada. La severidad del movimiento del suelo se ha cuantificado a través de la estimación de los valores de aceleración pico máxima (PGA), velocidad pico máxima (PGV), intensidad de Arias (AI), periodo predominante (Tp), e intensidad instrumental. Todos estos parámetros se basan en la estructura de velocidad de ondas de cizalla obtenida con los métodos sísmicos. ; [ENG] In seismically active zones, the occurrence of earthquakes produces substantial economic losses and sometimes important human lives casualties. In light of this, the scientific community and governments devote significant efforts with the aim of minimizing the negative impact of major earthquakes related to local economies and population. However, the rapid growth of inhabited areas is not always followed with the appropriate development of prevention standards, making newly developed urban areas very vulnerable to earthquakes of even moderate magnitude. For instance, the south-eastern part of the Iberian Peninsula has these two ingredients: a rapid urban growth and the existence of moderate and (according to historic records) major seismic activity. Indeed, the seismic series that took place in Lorca (located in the SE of the Iberian Peninsula) in 2011 showed that even a moderate magnitude earthquake may cause very serious damages on buildings and human losses. Besides, the average values of the shear-wave velocity of the upper 30 m (VS30) of the soil is a critical parameter in soil dynamics and earthquake engineering which is determined to classify site conditions reflected in seismic codes (e.g. NEHRP-94, Eurocode 8 (EC 8), NCSE-02). The use of prospecting techniques has been extended in recent times, based on environmental noise measurements (passive) and seismic head-waves creation sources (active). Among them Multichannel Analysis of Surface Wave (MASW), Refraction Microtremor (ReMi), and Spatial Autocorrelation (SPAC) are seismic methods characterized by a rapid data acquisition and minimal impact on the urban environment. In this study we have obtained and assessed the subsurface structure of the cities of Lorca, Adra and Almería by means of seismic methods (MASW and SPAC). The VS30 values obtained from seismic method were used to create a new soil classification map of these cities which is suitable for microzoning purposes. In order to perform measurements in the urban area of these cities a towed land-streamer was developed to gather seismic data with high productivity using the MASW method. Also, it has been used the topographic slope method to estimate the value of VS30. The results obtained by the topographic slope estimation, considering as active tectonic region, show significant similarity to those obtained by the seismic methods. These results demonstrate that under certain conditions and with an adequate Digital Elevation Model (DEM) the topographic slope method can be a good alternative for those areas of the world with limited economic resources that cannot apply traditional seismic prospecting techniques. Finally, strong ground motion parameters have been calculated using synthetic seismograms as input motion. The severity of subsurface motion has been quantified through the estimation of peak ground acceleration (PGA), peak ground velocity (PGV), Arias intensity (AI), predominant period (Tp), and instrumental intensity values of the ground motion, all of them based on shear-wave velocity structures obtained from the seismic methods. ; Universidad Politécnica de Cartagena ; Programa de doctorado en Ingeniería del Agua y del Terreno
China's 12th five-year plan (2011-2015) aims to promote inclusive, equitable growth and development by placing an increased emphasis on human development. Good health is an important component of human development, not only because it makes people's lives better, but also because having a healthy and long life enhances their ability to learn, acquire skills, and contributes to society. Indeed, good health is a fundamental right of every human being. Good health among a population can also enhance economic performance by improving labor productivity and reducing economic losses that arise from illnesses. The findings and recommendations can inform and promote a broad dialogue toward the development of a multisectoral response to effectively address the growing burden of Non Communicable Diseases (NCDs), including a better alignment of the health system with the population's health needs. The report also advocates implementing 'health in all' policies and actions for a multisectoral response to NCDs in China to help achieve the ultimate goal of 'harmonious' development and growth.
In this era of startling developments in the medical field there remains a serious worry about the hazardous potential of various by products which if not properly addressed can lead to consequences of immense public concern. Hospitals and other health care facilities generate waste products which are evidently hazardous to all those exposed to its potentially harmful effects. Need for effective legislation ensuring its safe disposal is supposed to be an integral part of any country's health related policy. This issue is of special importance in developing countries like Pakistan which in spite of framing various regulations for safeguarding public health, seem to overlook its actual implementation. The result unfortunately is the price wehave to pay not only in terms of rampant spread of crippling infections but a significant spending of health budget on combating epidemics which could easily have been avoided through effective waste disposal measures in the first place. Waste classified under the heading 'bio-hazardous' includes any infectious or potentially infectious material which can be injurious or harmful to humans and other living organisms. Amongst the many potential sources are the hospitals or other health delivery centres which are ironically supposed to be the centres of infection control and treatment. Whilst working in these setups, health care workers such as doctors, nurses, paramedical staff and sanitation workers are actually the ones most exposed and vulnerable to these challenges. Biomedical waste may broadly be classified into Infectious and toxic waste. Infectious waste includes sharps, blood, body fluids and tissues etcwhile substances such as radioactive material and by-products of certain drugs qualify as toxic waste. Furthermore health institutions also have to cater for general municipal waste such as carton boxes, paper and plastics. The World Health Organisation has its own general classification of hospital waste divided into almost eight categories of which almost 15% (10% infectious and 5% toxic) is estimated to be of a hazardous nature while the remaining 85% is general non hazardous content.1A recent study from Faisalabad, Pakistan has estimated hospital waste generation around 1 to 1.5 kg / bed /day for public sector hospitals in the region,2while figures quoted from neighbouring India are approximately 0.5 to 2 KG / hospital bed /day.3 Elsewhere in the world variable daily hospital waste production has been observed ranging from as low as 0.14 to 0.49 kg /day in Korea4 and 0.26 to 0.89 kg/day in Greece5to as high as 2.1 to 3.83 kg/day in Turkey6 and 0.84 to 5.8 kg/day in Tanzania.7Ill effects of improper management of hospital waste can manifest as nosocomial infections or occupational hazards such as needle stick injuries. Pathogens or spores can be borne either through the oro-faecal or respiratory routes in addition to direct inoculation through contact with infected needles or sharps. Environmental pollution can result from improper burning of toxic material leading to emission of dioxins, particulate matter or furans into the air. The habitat can also be affected by illegal dumping and landfills or washing up of medical waste released into the sea or river. Potential organisms implicated in diseases secondary to mismanagement of hospital waste disposal include salmonella, cholera, shigella, helminths, strep pneumonia, measles, tuberculosis, herpesvirus, anthrax, meningitis, HIV, hepatitis and candida etc. These infections can cause a considerable strain on the overall health and finances of the community or individuals affected. The basic principal of Public health management i.e 'prevention is better than cure' cannot be more stressed in this scenario as compared to any other health challenge. Health facilities must have a clear policy on hazardous waste management. To ensure a safe environment hospitals need to adopt and implement international and local systems of waste disposal. Hospital waste management plan entails policy and procedures addressing waste generation, accumulation, handling, transportation, storage, treatment and disposal. Waste needs to be collected in marked containers usually colour coded and leak proof. Segregation at source is of vital importance. The standard practice in many countries is the Basic Three Bin System ie to segregate the waste into RED bags/ boxes for sharps, YELLOW bags for biological waste and BLUE or BLACK ones for general/ municipal waste. All hospital staff needs to be trained in the concept of putting the right waste in relevant containers/ bags. They need to know that more than anything else this practice is vital for their own safety. The message can be reinforced through appropriate labelling on the bins and having posters with simple delineations to avoid mixing of different waste types. Sharps essentially should be kept in rigid, leak and puncture-resistant containers which are tightly lidded and labelled. Regular training sessions for nurses and cleaning staff can be organised as they are the personnel who are more likely to deal with waste disposition at the level of their respective departments. Next of course is transportation of waste products to the storage or disposal. Sanitary staff and janitors must be aware of the basic concepts of waste handling and should wear protective clothing, masks and gloves etc, besides ensuring regular practice of disinfection and sterilization techniques.8Special trolleys or vehicles exclusively designed and reserved for biomedical waste and operated by trained individuals should be used for transportation to the dumping or treatment site. Biomedical waste treatment whether on site or off site is a specialised entity involving use of chemicals and equipment intended for curtailing the hazardous potential of the material at hand. Thermal treatment via incinerators, not only results in combustion of organic substances but the final product in the form of non-toxicash is only 10 to 15% of the original solid mass of waste material fed to the machine. Dedicated autoclaves and microwaves can also be used for the purpose of disinfection. Chemicals such as bleach, sodium hydroxides, chlorine dioxide and sodiumhypochlorite are also effective disinfectants having specialised indications. Countries around the world have their own regulations for waste management. United Kingdom practices strict observance of Environmental protection act 1990, Waste managementlicensing regulations 1994 and Hazardous waste regulations 2005 making it one of thesafest countries in terms of hazardous waste disposal. Similar regulations specific for each state have been adopted in United States following passage of the Medical Waste tracking act 1988. In Pakistan, every hospital must comply with the Waste Management Rules 2005 (Environment Protection Act 1997), though actual compliance is far from satisfactory. It is high time that the government and responsible community organisations shape up to seriously tackle the issue of bio hazardous waste management through enforcement of effective policies and standard operating procedures for safeguarding the health and lives of the public in general and health workers in particular. Outbreaks, defined as excess cases of a particular disease or illness which outweighs the response capabilities, have the capacity to overwhelm health care facilities and need timely response and attention to details in order to avoid potentially disastrous sequelae . In this day and age when improvement in public health practices have significantly curtailed outbreak of various diseases, certain viral illnesses continue to make headlines. One of the notable vector borne infectious disease affecting significant portions of south east Asia in the early part of twenty first century is 'Dengue fever'. Dreaded as it is by those suffering from the illness, a lot of the hysteria created is secondary to a lack of education and understanding of the nature of the disease and at times a result of disinformation campaign for vested interests by certain political and media sections.'Dengue' in fact is a Spanish word, assumed to have originated from the Swahili phrase -ka dinga peppo -which describes the disease as being caused by evil spirit. 1 Over the course of time it has been called 'breakbone fever', 'bilious vomiting fever', 'break heart fever', 'dandy fever', 'la dengue' and 'Phillipine, Thai and Singapore hemorrhagic fever' Whilst the first reported case referring to dengue fever as a water poison spread by flying insects, exists in the Chinese medical encyclopedia from Jin Dynasty (265-420 AD), the disease is believed to have disseminated from Africa with the spread of the primary vector, aedes egypti, in the 15th to 19th century as a result of globalisation of slave trade 45In 80% of the patients affected by this condition the presentation is rather insidious and at best characterized by mild fever. The classical 'Dengue fever' present in about 5% of the cases is characterized by high temperature, body aches, vomiting and at times a skin rash. The disease may regresses in two to seven days. However inrare instances (<5%) it may develop into more serious conditions such as Dengue hemorrhagic fever whereby the platelet count is significantly reduced leading to bleeding tendencies and may even culminate in a more life threatening presentation i.e Dengue shock syndrome.6To understand the actual dynamics of Dengue epidemic it is important to understand the mode of its spread in affected areas. Aedes mosquito (significantly Aedes Egypti) acts a vector for this disease. Early morning and evening times7 are favoured by these mosquitos to feed on their prey. There is some evidence that the disease may be transmitted via blood products and organ donation. 8 Moreover vertical transmission (mother to child) has also been reported 9Diagnostic investigations include blood antigen detection through NS-I or nucleic acid detection via PCR. IO Cell cultures and specific serology may also be used for confirming the underlying disease. Whilst sporadic and endemic cases are part of routine medical practice and may not raise any alarm bells, outbreaks certainly need mobilization of appropriate resources for effective control. Needless to say 'prevention is better than cure' and should be the primary target of the health authorities in devising strategies for disease control.The WHO recommended 'Integrated Vector control programme', lays stress on social mobilisation and strengthening of public health bodies, coherent response of health and related departments and effective capacity building of relevant personnel and organisations as well as the community at risk. For Aedes Egypti the primary control revolves around eliminating its habitats such as open sources of water. In a local perspective in our city Peshawar, venue of the recent dengue epidemic, it may be seen in the form of incidental reservoirs such as receptacles and tyres dumped in open areas such as roof tops with rain water accumulating in them and provtdjng excellent breeding habitats, Larvicidal and insecticides may be added to more permanent sources such as watertanks and farm lands. There is not much of a role for spraying with organophosphorous agents which is at times resorted to for public consumption. Public education is the key to any effective strategy which must highlight the need for wearing clothing that fully covers the skin, avoiding unnecessary early morning and evening exposure to vector agents, application of insect repellents and use of mosquito nets. It is also important not to panic if affliction with the disease is suspected as in a vast majority of instances it is a self limiting illness without any long term harmful effects and needs simple conservative management like antipyretics and analgesics.An important consideration for responsible authorities in a dengue epidemic is to ensure that maximum management facilities for simple cases are provided at the community level through primary and secondary health care facilities and that the tertiary care hospitals are not inundated with all sort of patients demanding consultation. These later facilities should be reserved for those patients who end up with any complications or more severe manifestation of the disease.Research is underway to develop an ideal vaccine for Dengue fever. In 2016, a vaccine by the name 'Dengvaxia' was marketed in Phillipines and Indonesia. However with development of new serotypes of the virus, its efficacy has been somewhat compromised.As for treatment , there are no specific antiviral drugs. Management is symptomatic revolving mainly around oral and intravenous hydration. Paracetamol (Acetaminophen) is used for fever as compared to NSAIDS such as Ibuprophen infusion as well as blood and platelet transfusion.Data to date shows that slightly more than twenty three thousand people have been diagnosed with dengue over the past three months ie August to October there is a lower risk of bleeding with the former. Those with more severe form of the disease may need Dextran 2017, in Peshawar, Pakistan with around fourteen thousand needing admission and about sixty nine recorded deaths. The mortality is well within the acceptable international standards of less than 1% for the disease. In the backdrop of all the debate surrounding the current epidemic, one can infer that such outbreaks are best addressed with effective planningwell ahead of the time before the disease threatens to spiral out of control. Simple measures such as covering water storage facilities, using larvicidals where practical, use of insect repellents, mosquito nets and avoiding unnecessary exposure can offerthe best protection. Public health messages via print and electronic media can help educate people in affected areas and allay any anxiety building up from a fear of developing life threatening complications. Health department must mobilise all its resources to ensure local management of diagnosed patients with simple dengue fever and facilitate hospital admission only for those suffering from more severe form of the disease. Moreover the media hype into such situations needs to be addressed through constant updates and discouraging any negative politicking on the issue. To sum up Dengue fever is not really an affliction to be dreaded provided it is viewed and managed in the right perspective.
In this era of startling developments in the medical field there remains a serious worry about the hazardous potential of various by products which if not properly addressed can lead to consequences of immense public concern. Hospitals and other health care facilities generate waste products which are evidently hazardous to all those exposed to its potentially harmful effects. Need for effective legislation ensuring its safe disposal is supposed to be an integral part of any country's health related policy. This issue is of special importance in developing countries like Pakistan which in spite of framing various regulations for safeguarding public health, seem to overlook its actual implementation. The result unfortunately is the price wehave to pay not only in terms of rampant spread of crippling infections but a significant spending of health budget on combating epidemics which could easily have been avoided through effective waste disposal measures in the first place. Waste classified under the heading 'bio-hazardous' includes any infectious or potentially infectious material which can be injurious or harmful to humans and other living organisms. Amongst the many potential sources are the hospitals or other health delivery centres which are ironically supposed to be the centres of infection control and treatment. Whilst working in these setups, health care workers such as doctors, nurses, paramedical staff and sanitation workers are actually the ones most exposed and vulnerable to these challenges. Biomedical waste may broadly be classified into Infectious and toxic waste. Infectious waste includes sharps, blood, body fluids and tissues etcwhile substances such as radioactive material and by-products of certain drugs qualify as toxic waste. Furthermore health institutions also have to cater for general municipal waste such as carton boxes, paper and plastics. The World Health Organisation has its own general classification of hospital waste divided into almost eight categories of which almost 15% (10% infectious and 5% toxic) is estimated to be of a hazardous nature while the remaining 85% is general non hazardous content.1A recent study from Faisalabad, Pakistan has estimated hospital waste generation around 1 to 1.5 kg / bed /day for public sector hospitals in the region,2while figures quoted from neighbouring India are approximately 0.5 to 2 KG / hospital bed /day.3 Elsewhere in the world variable daily hospital waste production has been observed ranging from as low as 0.14 to 0.49 kg /day in Korea4 and 0.26 to 0.89 kg/day in Greece5to as high as 2.1 to 3.83 kg/day in Turkey6 and 0.84 to 5.8 kg/day in Tanzania.7Ill effects of improper management of hospital waste can manifest as nosocomial infections or occupational hazards such as needle stick injuries. Pathogens or spores can be borne either through the oro-faecal or respiratory routes in addition to direct inoculation through contact with infected needles or sharps. Environmental pollution can result from improper burning of toxic material leading to emission of dioxins, particulate matter or furans into the air. The habitat can also be affected by illegal dumping and landfills or washing up of medical waste released into the sea or river. Potential organisms implicated in diseases secondary to mismanagement of hospital waste disposal include salmonella, cholera, shigella, helminths, strep pneumonia, measles, tuberculosis, herpesvirus, anthrax, meningitis, HIV, hepatitis and candida etc. These infections can cause a considerable strain on the overall health and finances of the community or individuals affected. The basic principal of Public health management i.e 'prevention is better than cure' cannot be more stressed in this scenario as compared to any other health challenge. Health facilities must have a clear policy on hazardous waste management. To ensure a safe environment hospitals need to adopt and implement international and local systems of waste disposal. Hospital waste management plan entails policy and procedures addressing waste generation, accumulation, handling, transportation, storage, treatment and disposal. Waste needs to be collected in marked containers usually colour coded and leak proof. Segregation at source is of vital importance. The standard practice in many countries is the Basic Three Bin System ie to segregate the waste into RED bags/ boxes for sharps, YELLOW bags for biological waste and BLUE or BLACK ones for general/ municipal waste. All hospital staff needs to be trained in the concept of putting the right waste in relevant containers/ bags. They need to know that more than anything else this practice is vital for their own safety. The message can be reinforced through appropriate labelling on the bins and having posters with simple delineations to avoid mixing of different waste types. Sharps essentially should be kept in rigid, leak and puncture-resistant containers which are tightly lidded and labelled. Regular training sessions for nurses and cleaning staff can be organised as they are the personnel who are more likely to deal with waste disposition at the level of their respective departments. Next of course is transportation of waste products to the storage or disposal. Sanitary staff and janitors must be aware of the basic concepts of waste handling and should wear protective clothing, masks and gloves etc, besides ensuring regular practice of disinfection and sterilization techniques.8Special trolleys or vehicles exclusively designed and reserved for biomedical waste and operated by trained individuals should be used for transportation to the dumping or treatment site. Biomedical waste treatment whether on site or off site is a specialised entity involving use of chemicals and equipment intended for curtailing the hazardous potential of the material at hand. Thermal treatment via incinerators, not only results in combustion of organic substances but the final product in the form of non-toxicash is only 10 to 15% of the original solid mass of waste material fed to the machine. Dedicated autoclaves and microwaves can also be used for the purpose of disinfection. Chemicals such as bleach, sodium hydroxides, chlorine dioxide and sodiumhypochlorite are also effective disinfectants having specialised indications. Countries around the world have their own regulations for waste management. United Kingdom practices strict observance of Environmental protection act 1990, Waste managementlicensing regulations 1994 and Hazardous waste regulations 2005 making it one of thesafest countries in terms of hazardous waste disposal. Similar regulations specific for each state have been adopted in United States following passage of the Medical Waste tracking act 1988. In Pakistan, every hospital must comply with the Waste Management Rules 2005 (Environment Protection Act 1997), though actual compliance is far from satisfactory. It is high time that the government and responsible community organisations shape up to seriously tackle the issue of bio hazardous waste management through enforcement of effective policies and standard operating procedures for safeguarding the health and lives of the public in general and health workers in particular. Outbreaks, defined as excess cases of a particular disease or illness which outweighs the response capabilities, have the capacity to overwhelm health care facilities and need timely response and attention to details in order to avoid potentially disastrous sequelae . In this day and age when improvement in public health practices have significantly curtailed outbreak of various diseases, certain viral illnesses continue to make headlines. One of the notable vector borne infectious disease affecting significant portions of south east Asia in the early part of twenty first century is 'Dengue fever'. Dreaded as it is by those suffering from the illness, a lot of the hysteria created is secondary to a lack of education and understanding of the nature of the disease and at times a result of disinformation campaign for vested interests by certain political and media sections.'Dengue' in fact is a Spanish word, assumed to have originated from the Swahili phrase -ka dinga peppo -which describes the disease as being caused by evil spirit. 1 Over the course of time it has been called 'breakbone fever', 'bilious vomiting fever', 'break heart fever', 'dandy fever', 'la dengue' and 'Phillipine, Thai and Singapore hemorrhagic fever' Whilst the first reported case referring to dengue fever as a water poison spread by flying insects, exists in the Chinese medical encyclopedia from Jin Dynasty (265-420 AD), the disease is believed to have disseminated from Africa with the spread of the primary vector, aedes egypti, in the 15th to 19th century as a result of globalisation of slave trade 45In 80% of the patients affected by this condition the presentation is rather insidious and at best characterized by mild fever. The classical 'Dengue fever' present in about 5% of the cases is characterized by high temperature, body aches, vomiting and at times a skin rash. The disease may regresses in two to seven days. However inrare instances (<5%) it may develop into more serious conditions such as Dengue hemorrhagic fever whereby the platelet count is significantly reduced leading to bleeding tendencies and may even culminate in a more life threatening presentation i.e Dengue shock syndrome.6To understand the actual dynamics of Dengue epidemic it is important to understand the mode of its spread in affected areas. Aedes mosquito (significantly Aedes Egypti) acts a vector for this disease. Early morning and evening times7 are favoured by these mosquitos to feed on their prey. There is some evidence that the disease may be transmitted via blood products and organ donation. 8 Moreover vertical transmission (mother to child) has also been reported 9Diagnostic investigations include blood antigen detection through NS-I or nucleic acid detection via PCR. IO Cell cultures and specific serology may also be used for confirming the underlying disease. Whilst sporadic and endemic cases are part of routine medical practice and may not raise any alarm bells, outbreaks certainly need mobilization of appropriate resources for effective control. Needless to say 'prevention is better than cure' and should be the primary target of the health authorities in devising strategies for disease control.The WHO recommended 'Integrated Vector control programme', lays stress on social mobilisation and strengthening of public health bodies, coherent response of health and related departments and effective capacity building of relevant personnel and organisations as well as the community at risk. For Aedes Egypti the primary control revolves around eliminating its habitats such as open sources of water. In a local perspective in our city Peshawar, venue of the recent dengue epidemic, it may be seen in the form of incidental reservoirs such as receptacles and tyres dumped in open areas such as roof tops with rain water accumulating in them and provtdjng excellent breeding habitats, Larvicidal and insecticides may be added to more permanent sources such as watertanks and farm lands. There is not much of a role for spraying with organophosphorous agents which is at times resorted to for public consumption. Public education is the key to any effective strategy which must highlight the need for wearing clothing that fully covers the skin, avoiding unnecessary early morning and evening exposure to vector agents, application of insect repellents and use of mosquito nets. It is also important not to panic if affliction with the disease is suspected as in a vast majority of instances it is a self limiting illness without any long term harmful effects and needs simple conservative management like antipyretics and analgesics.An important consideration for responsible authorities in a dengue epidemic is to ensure that maximum management facilities for simple cases are provided at the community level through primary and secondary health care facilities and that the tertiary care hospitals are not inundated with all sort of patients demanding consultation. These later facilities should be reserved for those patients who end up with any complications or more severe manifestation of the disease.Research is underway to develop an ideal vaccine for Dengue fever. In 2016, a vaccine by the name 'Dengvaxia' was marketed in Phillipines and Indonesia. However with development of new serotypes of the virus, its efficacy has been somewhat compromised.As for treatment , there are no specific antiviral drugs. Management is symptomatic revolving mainly around oral and intravenous hydration. Paracetamol (Acetaminophen) is used for fever as compared to NSAIDS such as Ibuprophen infusion as well as blood and platelet transfusion.Data to date shows that slightly more than twenty three thousand people have been diagnosed with dengue over the past three months ie August to October there is a lower risk of bleeding with the former. Those with more severe form of the disease may need Dextran 2017, in Peshawar, Pakistan with around fourteen thousand needing admission and about sixty nine recorded deaths. The mortality is well within the acceptable international standards of less than 1% for the disease. In the backdrop of all the debate surrounding the current epidemic, one can infer that such outbreaks are best addressed with effective planningwell ahead of the time before the disease threatens to spiral out of control. Simple measures such as covering water storage facilities, using larvicidals where practical, use of insect repellents, mosquito nets and avoiding unnecessary exposure can offerthe best protection. Public health messages via print and electronic media can help educate people in affected areas and allay any anxiety building up from a fear of developing life threatening complications. Health department must mobilise all its resources to ensure local management of diagnosed patients with simple dengue fever and facilitate hospital admission only for those suffering from more severe form of the disease. Moreover the media hype into such situations needs to be addressed through constant updates and discouraging any negative politicking on the issue. To sum up Dengue fever is not really an affliction to be dreaded provided it is viewed and managed in the right perspective.
Purpose: studying of life quality indicators at elderly patients with osteoarthritis using international EuroQol questionnaire for evaluate of efficiency of sanatorium treatment.Materials and methods. 72 patients have been included in study at the age from 60 till 78 years, mean age was 67,6±8,7 years. Patients have been divided by method of randomization on two groups. Patients of one of groups in addition passed rehabilitation in sanatorium conditions for 18–21 days. Assessment of life quality related to health was conducted with use of international questionnaire EuroQol-5D-European Quality of Life instrument (EQ-5D).Results. At all patients with osteoarthritis health problems of varying degree have been revealed. In 12 months according to the questionnaire, reliable positive dynamics of life quality was observed at patients passing sanatorium treatment at the expense of improvement of ability to movement, reduce pain and discomfort and increase daily activity.Conclusions. Having of sanatorium stage of rehabilitation in complex treatment of osteoarthritis allows affect quality of life and keep remission for a longer period in comparison with outpatient treatment.KEY WORDS: quality of life, sanatorium treatments, osteoarthritis.Osteoarthritis (OA) is one of the most common disorders of the muscle-skeletal system, especially in the elderly age group ( in every third elderly person, reaching 70% among those who have over 65 years). During the natural aging occurs involutional changes in the connective tissue, especially in the tendons, ligaments, cartilage, bone tissue, in the walls of blood vessels, muscles [2]. Thus aging of body contributes to the accumulation of diseases. During the examination in elderly and senile patients were diagnosed from three to five different diseases. Modern elderly person is - a unique clinical phenomenon from the point of view on availability and the combination of its diverse in character and course of diseases that are competing for their prognostic significance and impact on quality of life. OA attributed to diseases with high comorbidity, and founded that patients with OA have a significantly higher risk of comorbid conditions than patients who do not suffering from OA [4].Clinical experience and numerous publications data suggest that OA is often associated with subsequent somatic disorders: hypertension, coronary heart disease, obesity, diabetes, lung diseases (chronic obstructive pulmonary disease) and gastro- intestinal tract diseases. The greatest burden on society observed in cases of combination OA and osteodeficiency (osteopenia, osteoporosis (OP)), which significantly decreses the quality of life [5].Quality of life - integrated description of physical, psychological, emotional and social functioning of a person based on its subjective perception. Assessment of quality of life at modern stage have more increasing strong position in medicine, reflecting on the one hand, the presence of new medical technologies that do not affect the life expectancy, but significantly improve its quality, and from the other hand - expanding activity of the patient, increasing of its role in choice of methods of diagnostic and treatment [9].When selecting the questionnaires it is important to consider that to be used in a clinical studying suitable only those that give results of the evaluation quality of life in a form of a single summary score from 0 to 1.0. These includes a generic questionnaire EQ-5D (EuroQol) [8]. This general questionnaire is easy to fill , widely used in different countries and gives during the processing of collected data single score to measure the quality of life, represented by values between 0 and 1, which also provides the possibility of its using in clinical trials. This questionnaire is widely used in various clinical situations , including in assessing the quality of life patients with rheumatic diseases [7].The aging process is controversial, because on the background of regression processes - atrophy, degradation, etc., develops progressive trends of creating the new compensatory-adaptive mechanisms to maintain homeostasis in an aging body, which, however, does not fully offset the growing phenomena of degradation [2]. It should be noted that the adaptive capacity of the aging body is reduced, the possibility of development various diseases increases. In this context, particularly important in cases of illness in the elderly patient is the role of sanogenetic mechanisms, their stimulation and support. A special interest belongs to the sanatorium stage of rehabilitation, whose mission is the prevention of disease progression, stimulation of compensatory capacity of the muscle-skeletal system and the possible restoration of joint function.Spa treatment has a special place in the treatment and preventive care of elderly patients , as a stage in the system of rehabilitation of many chronic diseases. Multi-disciplinary nature of medical rehabilitation in spa conditions, a wide range of rehabilitation methods can embrace patients of all age groups with the most common diseases [1].Compared with medication treatment, natural and artificial physical factors, when they are properly used, characterized by the absence of allergies, lower incidence and severity of side effects, the ability of positively influencing on the number of pathological processes and the whole body, thus helping to improve the quality of life and are important in the prevention of premature aging [2]. In the resort conditions further rehabilitation is indicated for patients with initial stages of OA, disabled (groups I and II), patients with resistant synovitis and comorbidity with the possibility of self-servicing (including general contraindications for a spa treatment) [3].The aim of the study. To investigate the quality of life in elderly patients with osteoarthritis using international EuroQol questionnaire to evaluate the effectiveness of spa treatment.Materials and methods. In study were included 72 patients aged from 60 to 78 years, middle age was 67,6 ± 8,7 years. Among the patients predominates women - 88.4 %. I radiographic stage of osteoarthritis by J.H. Kellgren-Lawrence [ 6] was diagnosed in 23,3 % of patients , II stage - in 76,7 %. In the view of modern geriatric approaches applying of the physical factors in patients with OA who were in the spa rehabilitation stage in the appointment of balneotherapeutic procedures we gave preference to ultrasonic inhalation of mineral waters and baths , from physiotherapy usually prescribed magnetic-lazer therapy, interferential therapy, patients also performed massage and physical rehabilitation . In order to prevent climate-adaptational and reaclimate-adaptational reactions and optimization process of climate-adaptation were included into the treatment complex ( based on established risk factors) adaptogens and treatment procedures that have adaptogenic action ( phytoaeroionisation , singlet-oxygen therapy). In the process of rehabilitation treatment in sanatorium conditions , we have selected the most effective combination of different methods of rehabilitation , which caused the most significant treatment effectiveness : a combination of balneotherapy , physiotherapy and exercise therapy. To improve continuity during medical rehabilitation, at discharging from the sanatorium patients were given written (in the form of special attractions ) recommendatitons about further treatment, lifestyle, physical activity, diet etc.By the method of randomization, patients were divided into two groups. A marked difference for the main source of clinical and functional parameters between the groups were not observed. The control group consisted of 14 patients of the same age without joint pathology. Treatment regimens differed between the studying groups the presence in one of the groups sanatorium stage of rehabilitation. In the first group (n=34) patients received Structum 500 mg 2 times a day ( within 6 months of the year ) and courses of NSAID, including mainly patients treated with meloxicam ( at a dose of 7,5 mg/d) or nimesulide (in dose of 100-200 mg/d) for 7-10 days during worcening. The patients of the second group (n=38) during the 18-21 day were on spa treatment ( once a year ), in the scheme of rehabilitation were: sitting hydrogen sulfide baths, a concentration of 80 mg/L for 10 minutes at a temperature of 360C , the course of 8 procedures every other day or ultrasonic inhalation by hydrogen sulfide water, period of 5 minutes; blue clay applications every other day at 260C temperature; interferential therapy and magnet-lazer therapy on the affected joints to 8 treatments alternately every other day ; pneumomassage ; classes of physical rehabilitation therapy, aromatherapy , singlet -oxygen therapy . After the sanatorium stage of rehabilitation patients are taking drugs containing chondroitin sulfate (within 6 months of the year), at worcening of NSAIDs.Assessment quality of life related to health , was conducted using an international EuroQol-5D-European Quality of Life instrument (EQ-5D), which consists of two parts. At first part the patient self- assessed his condition by 5 parameters: mobility, self-care , usual activities, pain and discomfort , anxiety and depression. In each variant patients could give three possible answers : No problem - 1 , there is some problem - 2, much of the problem - 3. In the second part of the questionnaire , patients assessed their health on a scale from 0 to 100 on the VAS, the so-called thermometer , where 0 means the worst condition , 100 - the best state of health of the patient. This part of the questionnaire is a quantitative assessment of general health.Statistical analysis of the results was done in the department of statistical system research at SHEE "Ternopil State Medical University by I. Y. Gorbachevsky Ministry of Health of Ukraine" in the software package Statsoft STATISTIC. To determine the reliability of the differences in the change of certain indicators were used parametric and non-parametric methods: criterion Wilkoksona, two-sided Fisher's criterion. A significant differences were considered when the degree of probability of error-free prognosis is (p) 95% (p <0.05). Results and discussion. General description of the health status of patients studied with OA according to EQ-5D questionnaire is given in the table.In all patients with osteoarthritis were found health problems of different severity degrees. Mostly suffers ability to travel and daily activity . This data confirms that the OA in the elderly age reduces quality of life. After 12 months, according to questionnaire, health status was different in two groups . Reliable positive trend was in patients from the second group 57,9 % (p < 0,05), as a result of improving the ability to travel in space , reducing pain and discomfort and increasing of daily activity.According to the second part of the questionnaire EQ-5D, at baseline, most patients had reduced general health assessment : the first group to 51,91 ± 1,07 ( median for «thermometer» EQ 52 points ) in the second group to 50,65 ± 1,17 ( median 48,5 points) in comparison with the best state of possible health. 12 months after the sanatorium stage of rehabilitation of patients with repeated testing were produced the following results : The average index quality of life on the " thermometer " EQ-5D questionnaire in the first group of patients was 54,76 ± 1,23 ( median - 56 points), the second group was 69,28 ± 0,89 ( median - 70 points), reliability differences is high : p < 0,001.In the category quality of life most of all patients reacted on the presence of sanatorium stage of rehabilitation in the category " movement in space " ( GPA retesting 1,60 ± 0,08, p < 0,001), " daily activity " ( GPA retesting 1 68 ± 0,07, p < 0,001), " pain / discomfort " ( GPA retesting 1,92 ± 0,08, p < 0,001), " anxiety / depression ( GPA retesting 1 52 ± 0,08, p < 0,05).Thus, the data suggested that in elderly patients with OA who were once a year on a spa treatment and took over 6 months structure-modification drugs significantly upgraded quality of life during 12 months.Conclusions1. Based on the analysis were founded that elderly patients with OA who underwent rehabilitation treatment in sanatorium- health resorts have continued improving quality of life in comparison with patients who were treated only in outpatient conditions.2. Availability sanatorium stage of rehabilitation in the treatment of elderly patients with OA contributes more complex influence on the human organism.3. Multi-disciplinary nature of medical rehabilitation in spa conditions , a wide range of used restorative treatment methods can affect the quality of life and maintain remission for more longer period in comparison with outpatient treatment.4. Monitoring the quality of life can not only control the functional state of the organism in the elderly aged people at various stages of treatment , but also to properly evaluate the effectiveness of treatment , and, if necessary, to carry out the correction of rehabilitation activities .Perspectives for future research. Aimed at studying the impact of rehabilitative and preventive measures on the quality of life in elderly patients with osteoarthritis at other stages of rehabilitation. Further work in this direction is reasonable and economically justified.REFERENCES1. Golyachenko A.O., Martynyuk V.I., Bakalyuk T.G. Medical rehabilitation in the spa conditions // Journal of research. - 2007 . - № 4. - P. 8-9.2. Kazymyrko V.K., KovalenkoV.N., Flehontova V.V. Involutional osteoarthritis and osteoporosis. - Donetsk: Publisher Zaslavsky A.J., 2011. - 724 p.3. Kovalenko V.N., Bortkiewicz A.P. Osteoarthritis . Practical guidance . - K.: Moryon , 2005. - 592 p.4. Mendel O.I., Naumov A.V., Alekseeva L.I. et al Osteoarthritis as a factor of risk in cardio-vascular catastrophes // Ukrainian Journal of Rheumatology . - 2010 . - № 3. - P. 68-73.5. Povoroznyuk V.V. Osteoarthritis // Art of treatments. - 2004 . - № 3. - P.16 -23.6 . Altman R., Asch E., Bloch D. et al. The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the knee // Arthritis Rheum. - 1986 . - № 29. - P. 1039-1049 .7 . Harrison M.J., Davies L.M., Bansback N.J. et al. The comparative responsiveness of the EQ-5D and SF-6D to change in patients with inflammatory arthritis // Qual Life Res. - 2009 . - № 18. - P. 1195-1205.8 . Herdman M., Gudex C., Lloyd A., et al. Development and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L) // Qual Life Res. - 2011 . - № 20 . - P. 1727-1736.9 . Langley P., Muller-Schwefe G., Nicolaou A., Liedgens H., Pergolizzi J., Varrassi G. The societal impact of pain in the European Union: health-related quality of life and healthcare resource utilization // J. Med Econ. - 2010 . - № 1. - P. 571-581. ; Мета: вивчення показників якості життя у хворих похилого віку на остеоартроз з використанням міжнародного запитальника EuroQol для оцінки ефективності санаторно-курортного лікування.Матеріали і методи. У дослідження було включено 72 пацієнти віком від 60 до 78 років, середній вік склав 67,6±8,7 року. Методом рандомізації пацієнтів було розподілено на дві групи. Пацієнти однієї з груп додатково проходили реабілітацію в умовах санаторію протягом 18-21 дня. Оцінка якості життя, пов'язаного зі здоров'ям, проводилась з використанням міжнародного запитальника EuroQol-5D-European Quality of Life instrument (EQ-5D).Результати. У всіх хворих на остеоартроз виявлено проблеми зі здоров'ям різного ступеня. Через 12 місяців за даними запитальника достовірна позитивна динаміка якості життя спостерігалася у пацієнтів, що проходили санаторно-куротне лікування, за рахунок покращення здатності до пересування, зменшення болю і дискомфорту та збільшення повсякденної активності.Висновки. Наявність санаторно-курортного етапу реабілітації у комплексному лікуванні остеоартрозу дозволяє вплинути на якість життя та зберегти ремісію на більш тривалий термін порівняно з амбулаторним лікуванням.КЛЮЧОВІ СЛОВА: якість життя, санаторно-курортне лікування, остеоартроз.
Purpose: studying of life quality indicators at elderly patients with osteoarthritis using international EuroQol questionnaire for evaluate of efficiency of sanatorium treatment.Materials and methods. 72 patients have been included in study at the age from 60 till 78 years, mean age was 67,6±8,7 years. Patients have been divided by method of randomization on two groups. Patients of one of groups in addition passed rehabilitation in sanatorium conditions for 18–21 days. Assessment of life quality related to health was conducted with use of international questionnaire EuroQol-5D-European Quality of Life instrument (EQ-5D).Results. At all patients with osteoarthritis health problems of varying degree have been revealed. In 12 months according to the questionnaire, reliable positive dynamics of life quality was observed at patients passing sanatorium treatment at the expense of improvement of ability to movement, reduce pain and discomfort and increase daily activity.Conclusions. Having of sanatorium stage of rehabilitation in complex treatment of osteoarthritis allows affect quality of life and keep remission for a longer period in comparison with outpatient treatment.KEY WORDS: quality of life, sanatorium treatments, osteoarthritis.Osteoarthritis (OA) is one of the most common disorders of the muscle-skeletal system, especially in the elderly age group ( in every third elderly person, reaching 70% among those who have over 65 years). During the natural aging occurs involutional changes in the connective tissue, especially in the tendons, ligaments, cartilage, bone tissue, in the walls of blood vessels, muscles [2]. Thus aging of body contributes to the accumulation of diseases. During the examination in elderly and senile patients were diagnosed from three to five different diseases. Modern elderly person is - a unique clinical phenomenon from the point of view on availability and the combination of its diverse in character and course of diseases that are competing for their prognostic significance and impact on quality of life. OA attributed to diseases with high comorbidity, and founded that patients with OA have a significantly higher risk of comorbid conditions than patients who do not suffering from OA [4].Clinical experience and numerous publications data suggest that OA is often associated with subsequent somatic disorders: hypertension, coronary heart disease, obesity, diabetes, lung diseases (chronic obstructive pulmonary disease) and gastro- intestinal tract diseases. The greatest burden on society observed in cases of combination OA and osteodeficiency (osteopenia, osteoporosis (OP)), which significantly decreses the quality of life [5].Quality of life - integrated description of physical, psychological, emotional and social functioning of a person based on its subjective perception. Assessment of quality of life at modern stage have more increasing strong position in medicine, reflecting on the one hand, the presence of new medical technologies that do not affect the life expectancy, but significantly improve its quality, and from the other hand - expanding activity of the patient, increasing of its role in choice of methods of diagnostic and treatment [9].When selecting the questionnaires it is important to consider that to be used in a clinical studying suitable only those that give results of the evaluation quality of life in a form of a single summary score from 0 to 1.0. These includes a generic questionnaire EQ-5D (EuroQol) [8]. This general questionnaire is easy to fill , widely used in different countries and gives during the processing of collected data single score to measure the quality of life, represented by values between 0 and 1, which also provides the possibility of its using in clinical trials. This questionnaire is widely used in various clinical situations , including in assessing the quality of life patients with rheumatic diseases [7].The aging process is controversial, because on the background of regression processes - atrophy, degradation, etc., develops progressive trends of creating the new compensatory-adaptive mechanisms to maintain homeostasis in an aging body, which, however, does not fully offset the growing phenomena of degradation [2]. It should be noted that the adaptive capacity of the aging body is reduced, the possibility of development various diseases increases. In this context, particularly important in cases of illness in the elderly patient is the role of sanogenetic mechanisms, their stimulation and support. A special interest belongs to the sanatorium stage of rehabilitation, whose mission is the prevention of disease progression, stimulation of compensatory capacity of the muscle-skeletal system and the possible restoration of joint function.Spa treatment has a special place in the treatment and preventive care of elderly patients , as a stage in the system of rehabilitation of many chronic diseases. Multi-disciplinary nature of medical rehabilitation in spa conditions, a wide range of rehabilitation methods can embrace patients of all age groups with the most common diseases [1].Compared with medication treatment, natural and artificial physical factors, when they are properly used, characterized by the absence of allergies, lower incidence and severity of side effects, the ability of positively influencing on the number of pathological processes and the whole body, thus helping to improve the quality of life and are important in the prevention of premature aging [2]. In the resort conditions further rehabilitation is indicated for patients with initial stages of OA, disabled (groups I and II), patients with resistant synovitis and comorbidity with the possibility of self-servicing (including general contraindications for a spa treatment) [3].The aim of the study. To investigate the quality of life in elderly patients with osteoarthritis using international EuroQol questionnaire to evaluate the effectiveness of spa treatment.Materials and methods. In study were included 72 patients aged from 60 to 78 years, middle age was 67,6 ± 8,7 years. Among the patients predominates women - 88.4 %. I radiographic stage of osteoarthritis by J.H. Kellgren-Lawrence [ 6] was diagnosed in 23,3 % of patients , II stage - in 76,7 %. In the view of modern geriatric approaches applying of the physical factors in patients with OA who were in the spa rehabilitation stage in the appointment of balneotherapeutic procedures we gave preference to ultrasonic inhalation of mineral waters and baths , from physiotherapy usually prescribed magnetic-lazer therapy, interferential therapy, patients also performed massage and physical rehabilitation . In order to prevent climate-adaptational and reaclimate-adaptational reactions and optimization process of climate-adaptation were included into the treatment complex ( based on established risk factors) adaptogens and treatment procedures that have adaptogenic action ( phytoaeroionisation , singlet-oxygen therapy). In the process of rehabilitation treatment in sanatorium conditions , we have selected the most effective combination of different methods of rehabilitation , which caused the most significant treatment effectiveness : a combination of balneotherapy , physiotherapy and exercise therapy. To improve continuity during medical rehabilitation, at discharging from the sanatorium patients were given written (in the form of special attractions ) recommendatitons about further treatment, lifestyle, physical activity, diet etc.By the method of randomization, patients were divided into two groups. A marked difference for the main source of clinical and functional parameters between the groups were not observed. The control group consisted of 14 patients of the same age without joint pathology. Treatment regimens differed between the studying groups the presence in one of the groups sanatorium stage of rehabilitation. In the first group (n=34) patients received Structum 500 mg 2 times a day ( within 6 months of the year ) and courses of NSAID, including mainly patients treated with meloxicam ( at a dose of 7,5 mg/d) or nimesulide (in dose of 100-200 mg/d) for 7-10 days during worcening. The patients of the second group (n=38) during the 18-21 day were on spa treatment ( once a year ), in the scheme of rehabilitation were: sitting hydrogen sulfide baths, a concentration of 80 mg/L for 10 minutes at a temperature of 360C , the course of 8 procedures every other day or ultrasonic inhalation by hydrogen sulfide water, period of 5 minutes; blue clay applications every other day at 260C temperature; interferential therapy and magnet-lazer therapy on the affected joints to 8 treatments alternately every other day ; pneumomassage ; classes of physical rehabilitation therapy, aromatherapy , singlet -oxygen therapy . After the sanatorium stage of rehabilitation patients are taking drugs containing chondroitin sulfate (within 6 months of the year), at worcening of NSAIDs.Assessment quality of life related to health , was conducted using an international EuroQol-5D-European Quality of Life instrument (EQ-5D), which consists of two parts. At first part the patient self- assessed his condition by 5 parameters: mobility, self-care , usual activities, pain and discomfort , anxiety and depression. In each variant patients could give three possible answers : No problem - 1 , there is some problem - 2, much of the problem - 3. In the second part of the questionnaire , patients assessed their health on a scale from 0 to 100 on the VAS, the so-called thermometer , where 0 means the worst condition , 100 - the best state of health of the patient. This part of the questionnaire is a quantitative assessment of general health.Statistical analysis of the results was done in the department of statistical system research at SHEE "Ternopil State Medical University by I. Y. Gorbachevsky Ministry of Health of Ukraine" in the software package Statsoft STATISTIC. To determine the reliability of the differences in the change of certain indicators were used parametric and non-parametric methods: criterion Wilkoksona, two-sided Fisher's criterion. A significant differences were considered when the degree of probability of error-free prognosis is (p) 95% (p <0.05). Results and discussion. General description of the health status of patients studied with OA according to EQ-5D questionnaire is given in the table.In all patients with osteoarthritis were found health problems of different severity degrees. Mostly suffers ability to travel and daily activity . This data confirms that the OA in the elderly age reduces quality of life. After 12 months, according to questionnaire, health status was different in two groups . Reliable positive trend was in patients from the second group 57,9 % (p < 0,05), as a result of improving the ability to travel in space , reducing pain and discomfort and increasing of daily activity.According to the second part of the questionnaire EQ-5D, at baseline, most patients had reduced general health assessment : the first group to 51,91 ± 1,07 ( median for «thermometer» EQ 52 points ) in the second group to 50,65 ± 1,17 ( median 48,5 points) in comparison with the best state of possible health. 12 months after the sanatorium stage of rehabilitation of patients with repeated testing were produced the following results : The average index quality of life on the " thermometer " EQ-5D questionnaire in the first group of patients was 54,76 ± 1,23 ( median - 56 points), the second group was 69,28 ± 0,89 ( median - 70 points), reliability differences is high : p < 0,001.In the category quality of life most of all patients reacted on the presence of sanatorium stage of rehabilitation in the category " movement in space " ( GPA retesting 1,60 ± 0,08, p < 0,001), " daily activity " ( GPA retesting 1 68 ± 0,07, p < 0,001), " pain / discomfort " ( GPA retesting 1,92 ± 0,08, p < 0,001), " anxiety / depression ( GPA retesting 1 52 ± 0,08, p < 0,05).Thus, the data suggested that in elderly patients with OA who were once a year on a spa treatment and took over 6 months structure-modification drugs significantly upgraded quality of life during 12 months.Conclusions1. Based on the analysis were founded that elderly patients with OA who underwent rehabilitation treatment in sanatorium- health resorts have continued improving quality of life in comparison with patients who were treated only in outpatient conditions.2. Availability sanatorium stage of rehabilitation in the treatment of elderly patients with OA contributes more complex influence on the human organism.3. Multi-disciplinary nature of medical rehabilitation in spa conditions , a wide range of used restorative treatment methods can affect the quality of life and maintain remission for more longer period in comparison with outpatient treatment.4. Monitoring the quality of life can not only control the functional state of the organism in the elderly aged people at various stages of treatment , but also to properly evaluate the effectiveness of treatment , and, if necessary, to carry out the correction of rehabilitation activities .Perspectives for future research. Aimed at studying the impact of rehabilitative and preventive measures on the quality of life in elderly patients with osteoarthritis at other stages of rehabilitation. Further work in this direction is reasonable and economically justified.REFERENCES1. Golyachenko A.O., Martynyuk V.I., Bakalyuk T.G. Medical rehabilitation in the spa conditions // Journal of research. - 2007 . - № 4. - P. 8-9.2. Kazymyrko V.K., KovalenkoV.N., Flehontova V.V. Involutional osteoarthritis and osteoporosis. - Donetsk: Publisher Zaslavsky A.J., 2011. - 724 p.3. Kovalenko V.N., Bortkiewicz A.P. Osteoarthritis . Practical guidance . - K.: Moryon , 2005. - 592 p.4. Mendel O.I., Naumov A.V., Alekseeva L.I. et al Osteoarthritis as a factor of risk in cardio-vascular catastrophes // Ukrainian Journal of Rheumatology . - 2010 . - № 3. - P. 68-73.5. Povoroznyuk V.V. Osteoarthritis // Art of treatments. - 2004 . - № 3. - P.16 -23.6 . Altman R., Asch E., Bloch D. et al. The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the knee // Arthritis Rheum. - 1986 . - № 29. - P. 1039-1049 .7 . Harrison M.J., Davies L.M., Bansback N.J. et al. The comparative responsiveness of the EQ-5D and SF-6D to change in patients with inflammatory arthritis // Qual Life Res. - 2009 . - № 18. - P. 1195-1205.8 . Herdman M., Gudex C., Lloyd A., et al. Development and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L) // Qual Life Res. - 2011 . - № 20 . - P. 1727-1736.9 . Langley P., Muller-Schwefe G., Nicolaou A., Liedgens H., Pergolizzi J., Varrassi G. The societal impact of pain in the European Union: health-related quality of life and healthcare resource utilization // J. Med Econ. - 2010 . - № 1. - P. 571-581. ; Мета: вивчення показників якості життя у хворих похилого віку на остеоартроз з використанням міжнародного запитальника EuroQol для оцінки ефективності санаторно-курортного лікування.Матеріали і методи. У дослідження було включено 72 пацієнти віком від 60 до 78 років, середній вік склав 67,6±8,7 року. Методом рандомізації пацієнтів було розподілено на дві групи. Пацієнти однієї з груп додатково проходили реабілітацію в умовах санаторію протягом 18-21 дня. Оцінка якості життя, пов'язаного зі здоров'ям, проводилась з використанням міжнародного запитальника EuroQol-5D-European Quality of Life instrument (EQ-5D).Результати. У всіх хворих на остеоартроз виявлено проблеми зі здоров'ям різного ступеня. Через 12 місяців за даними запитальника достовірна позитивна динаміка якості життя спостерігалася у пацієнтів, що проходили санаторно-куротне лікування, за рахунок покращення здатності до пересування, зменшення болю і дискомфорту та збільшення повсякденної активності.Висновки. Наявність санаторно-курортного етапу реабілітації у комплексному лікуванні остеоартрозу дозволяє вплинути на якість життя та зберегти ремісію на більш тривалий термін порівняно з амбулаторним лікуванням.КЛЮЧОВІ СЛОВА: якість життя, санаторно-курортне лікування, остеоартроз.
This is an open-access article distributed under the terms of the Creative Commons Attribution License.-- CIMBA et al. ; BRCA1-associated breast and ovarian cancer risks can be modified by common genetic variants. To identify further cancer risk-modifying loci, we performed a multi-stage GWAS of 11,705 BRCA1 carriers (of whom 5,920 were diagnosed with breast and 1,839 were diagnosed with ovarian cancer), with a further replication in an additional sample of 2,646 BRCA1 carriers. We identified a novel breast cancer risk modifier locus at 1q32 for BRCA1 carriers (rs2290854, P = 2.7 × 10(-8), HR = 1.14, 95% CI: 1.09-1.20). In addition, we identified two novel ovarian cancer risk modifier loci: 17q21.31 (rs17631303, P = 1.4 × 10(-8), HR = 1.27, 95% CI: 1.17-1.38) and 4q32.3 (rs4691139, P = 3.4 × 10(-8), HR = 1.20, 95% CI: 1.17-1.38). The 4q32.3 locus was not associated with ovarian cancer risk in the general population or BRCA2 carriers, suggesting a BRCA1-specific association. The 17q21.31 locus was also associated with ovarian cancer risk in 8,211 BRCA2 carriers (P = 2×10(-4)). These loci may lead to an improved understanding of the etiology of breast and ovarian tumors in BRCA1 carriers. Based on the joint distribution of the known BRCA1 breast cancer risk-modifying loci, we estimated that the breast cancer lifetime risks for the 5% of BRCA1 carriers at lowest risk are 28%-50% compared to 81%-100% for the 5% at highest risk. Similarly, based on the known ovarian cancer risk-modifying loci, the 5% of BRCA1 carriers at lowest risk have an estimated lifetime risk of developing ovarian cancer of 28% or lower, whereas the 5% at highest risk will have a risk of 63% or higher. Such differences in risk may have important implications for risk prediction and clinical management for BRCA1 carriers. ; The study was supported by NIH grant CA128978, an NCI Specialized Program of Research Excellence (SPORE) in Breast Cancer (CA116201), a U.S. Department of Defense Ovarian Cancer Idea award (W81XWH-10-1-0341), grants from the Breast Cancer Research Foundation and the Komen Foundation for the Cure; Cancer Research UK grants C12292/A11174 and C1287/A10118; the European Commission's Seventh Framework Programme grant agreement 223175 (HEALTH-F2-2009-223175). Breast Cancer Family Registry Studies (BCFR): supported by the National Cancer Institute, National Institutes of Health under RFA # CA-06-503 and through cooperative agreements with members of the Breast Cancer Family Registry (BCFR) and Principal Investigators, including Cancer Care Ontario (U01 CA69467), Cancer Prevention Institute of California (U01 CA69417), Columbia University (U01 CA69398), Fox Chase Cancer Center (U01 CA69631), Huntsman Cancer Institute (U01 CA69446), and University of Melbourne (U01 CA69638). The Australian BCFR was also supported by the National Health and Medical Research Council of Australia, the New South Wales Cancer Council, the Victorian Health Promotion Foundation (Australia), and the Victorian Breast Cancer Research Consortium. Melissa C. Southey is a NHMRC Senior Research Fellow and a Victorian Breast Cancer Research Consortium Group Leader. Carriers at FCCC were also identified with support from National Institutes of Health grants P01 CA16094 and R01 CA22435. The New York BCFR was also supported by National Institutes of Health grants P30 CA13696 and P30 ES009089. The Utah BCFR was also supported by the National Center for Research Resources and the National Center for Advancing Translational Sciences, NIH grant UL1 RR025764, and by Award Number P30 CA042014 from the National Cancer Institute. Baltic Familial Breast Ovarian Cancer Consortium (BFBOCC): BFBOCC is partly supported by Lithuania (BFBOCC-LT), Research Council of Lithuania grant LIG-19/2010, and Hereditary Cancer Association (Paveldimo vėžio asociacija). ; Latvia (BFBOCC-LV) is partly supported by LSC grant 10.0010.08 and in part by a grant from the ESF Nr.2009/0220/1DP/1.1.1.2.0/09/APIA/VIAA/016.BRCA-gene mutations and breast cancer in South African women (BMBSA): BMBSA was supported by grants from the Cancer Association of South Africa (CANSA) to Elizabeth J. van Rensburg. Beckman Research Institute of the City of Hope (BRICOH): Susan L. Neuhausen was partially supported by the Morris and Horowitz Families Endowed Professorship. BRICOH was supported by NIH R01CA74415 and NIH P30 CA033752. Copenhagen Breast Cancer Study (CBCS): The CBCS study was supported by the NEYE Foundation. Spanish National Cancer Centre (CNIO): This work was partially supported by Spanish Association against Cancer (AECC08), RTICC 06/0020/1060, FISPI08/1120, Mutua Madrileña Foundation (FMMA) and SAF2010-20493. City of Hope Cancer Center (COH): The City of Hope Clinical Cancer Genetics Community Research Network is supported by Award Number RC4A153828 (PI: Jeffrey N. Weitzel) from the National Cancer Institute and the Office of the Director, National Institutes of Health. CONsorzio Studi ITaliani sui Tumori Ereditari Alla Mammella (CONSIT TEAM): CONSIT TEAM was funded by grants from Fondazione Italiana per la Ricerca sul Cancro (Special Project "Hereditary tumors"), Italian Association for Cancer Research (AIRC, IG 8713), Italian Minitry of Health (Extraordinary National Cancer Program 2006, "Alleanza contro il Cancro" and "Progetto Tumori Femminili), Italian Ministry of Education, University and Research (Prin 2008) Centro di Ascolto Donne Operate al Seno (CAOS) association and by funds from Italian citizens who allocated the 5×1000 share of their tax payment in support of the Fondazione IRCCS Istituto Nazionale Tumori, according to Italian laws (INT-Institutional strategic projects '5×1000'). German Cancer Research Center (DKFZ): The DKFZ study was supported by the DKFZ. The Hereditary Breast and Ovarian Cancer Research Group Netherlands (HEBON): HEBON is supported by the Dutch Cancer Society grants NKI1998-1854, NKI2004-3088, NKI2007-3756, the NWO grant 91109024, the Pink Ribbon grant 110005, and the BBMRI grant CP46/NWO. ; Epidemiological study of BRCA1 & BRCA2 mutation carriers (EMBRACE): EMBRACE is supported by Cancer Research UK Grants C1287/A10118 and C1287/A11990. D. Gareth Evans and Fiona Lalloo are supported by an NIHR grant to the Biomedical Research Centre, Manchester. The Investigators at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust are supported by an NIHR grant to the Biomedical Research Centre at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust. Rosalind A. Eeles and Elizabeth Bancroft are supported by Cancer Research UK Grant C5047/A8385. Fox Chase Cancer Canter (FCCC): The authors acknowledge support from The University of Kansas Cancer Center and the Kansas Bioscience Authority Eminent Scholar Program. Andrew K. Godwin was funded by 5U01CA113916, R01CA140323, and by the Chancellors Distinguished Chair in Biomedical Sciences Professorship. German Consortium of Hereditary Breast and Ovarian Cancer (GC-HBOC): The German Consortium of Hereditary Breast and Ovarian Cancer (GC-HBOC) is supported by the German Cancer Aid (grant no 109076, Rita K. Schmutzler) and by the Center for Molecular Medicine Cologne (CMMC). Genetic Modifiers of cancer risk in BRCA1/2 mutation carriers (GEMO): The GEMO study was supported by the Ligue National Contre le Cancer; the Association "Le cancer du sein, parlons-en!" Award and the Canadian Institutes of Health Research for the "CIHR Team in Familial Risks of Breast Cancer" program. Gynecologic Oncology Group (GOG): This study was supported by National Cancer Institute grants to the Gynecologic Oncology Group (GOG) Administrative Office and Tissue Bank (CA 27469), Statistical and Data Center (CA 37517), and GOG's Cancer Prevention and Control Committtee (CA 101165). Drs. Mark H. Greene and Phuong L. Mai were supported by funding from the Intramural Research Program, NCI, NIH. Hospital Clinico San Carlos (HCSC): HCSC was supported by RETICC 06/0020/0021, FIS research grant 09/00859, Instituto de Salud Carlos III, Spanish Ministry of Economy and Competitivity, and the European Regional Development Fund (ERDF). ; Helsinki Breast Cancer Study (HEBCS): The HEBCS was financially supported by the Helsinki University Central Hospital Research Fund, Academy of Finland (132473), the Finnish Cancer Society, the Nordic Cancer Union, and the Sigrid Juselius Foundation. Study of Genetic Mutations in Breast and Ovarian Cancer patients in Hong Kong and Asia (HRBCP): HRBCP is supported by The Hong Kong Hereditary Breast Cancer Family Registry and the Dr. Ellen Li Charitable Foundation, Hong Kong. Molecular Genetic Studies of Breast and Ovarian Cancer in Hungary (HUNBOCS): HUNBOCS was supported by Hungarian Research Grant KTIA-OTKA CK-80745 and the Norwegian EEA Financial Mechanism HU0115/NA/2008-3/ÖP-9. Institut Català d'Oncologia (ICO): The ICO study was supported by the Asociación Española Contra el Cáncer, Spanish Health Research Foundation, Ramón Areces Foundation, Carlos III Health Institute, Catalan Health Institute, and Autonomous Government of Catalonia and contract grant numbers: ISCIIIRETIC RD06/0020/1051, PI09/02483, PI10/01422, PI10/00748, 2009SGR290, and 2009SGR283. International Hereditary Cancer Centre (IHCC): Supported by the Polish Foundation of Science. Katarzyna Jaworska is a fellow of International PhD program, Postgraduate School of Molecular Medicine, Warsaw Medical University. Iceland Landspitali–University Hospital (ILUH): The ILUH group was supported by the Icelandic Association "Walking for Breast Cancer Research" and by the Landspitali University Hospital Research Fund. INterdisciplinary HEalth Research Internal Team BReast CAncer susceptibility (INHERIT): INHERIT work was supported by the Canadian Institutes of Health Research for the "CIHR Team in Familial Risks of Breast Cancer" program, the Canadian Breast Cancer Research Alliance grant 019511 and the Ministry of Economic Development, Innovation and Export Trade grant PSR-SIIRI-701. Jacques Simard is Chairholder of the Canada Research Chair in Oncogenetics. ; Istituto Oncologico Veneto (IOVHBOCS): The IOVHBOCS study was supported by Ministero dell'Istruzione, dell'Università e della Ricerca and Ministero della Salute ("Progetto Tumori Femminili" and RFPS 2006-5-341353,ACC2/R6.9"). Kathleen Cuningham Consortium for Research into Familial Breast Cancer (kConFab): kConFab is supported by grants from the National Breast Cancer Foundation and the National Health and Medical Research Council (NHMRC) and by the Queensland Cancer Fund; the Cancer Councils of New South Wales, Victoria, Tasmania, and South Australia; and the Cancer Foundation of Western Australia. Amanda B. Spurdle is an NHMRC Senior Research Fellow. The Clinical Follow Up Study was funded from 2001–2009 by NHMRC and currently by the National Breast Cancer Foundation and Cancer Australia #628333. Mayo Clinic (MAYO): MAYO is supported by NIH grant CA128978, an NCI Specialized Program of Research Excellence (SPORE) in Breast Cancer (CA116201), a U.S. Department of Defence Ovarian Cancer Idea award (W81XWH-10-1-0341) and grants from the Breast Cancer Research Foundation and the Komen Foundation for the Cure. McGill University (MCGILL): The McGill Study was supported by Jewish General Hospital Weekend to End Breast Cancer, Quebec Ministry of Economic Development, Innovation, and Export Trade. Memorial Sloan-Kettering Cancer Center (MSKCC): The MSKCC study was supported by Breast Cancer Research Foundation, Niehaus Clinical Cancer Genetics Initiative, Andrew Sabin Family Foundation, and Lymphoma Foundation. Modifier Study of Quantitative Effects on Disease (MODSQUAD): MODSQUAD was supported by the European Regional Development Fund and the State Budget of the Czech Republic (RECAMO, CZ.1.05/2.1.00/03.0101). Women's College Research Institute, Toronto (NAROD): NAROD was supported by NIH grant: 1R01 CA149429-01. National Cancer Institute (NCI): Drs. Mark H. Greene and Phuong L. Mai were supported by the Intramural Research Program of the US National Cancer Institute, NIH, and by support services contracts NO2-CP-11019-50 and N02-CP-65504 with Westat, Rockville, MD. National Israeli Cancer Control Center (NICCC): NICCC is supported by Clalit Health Services in Israel. Some of its activities are supported by the Israel Cancer Association and the Breast Cancer Research Foundation (BCRF), NY. N. N. Petrov Institute of Oncology (NNPIO): The NNPIO study has been supported by the Russian Foundation for Basic Research (grants 11-04-00227, 12-04-00928, and 12-04-01490), the Federal Agency for Science and Innovations, Russia (contract 02.740.11.0780), and through a Royal Society International Joint grant (JP090615). The Ohio State University Comprehensive Cancer Center (OSU-CCG): OSUCCG is supported by the Ohio State University Comprehensive Cancer Center. ; South East Asian Breast Cancer Association Study (SEABASS): SEABASS is supported by the Ministry of Science, Technology and Innovation, Ministry of Higher Education (UM.C/HlR/MOHE/06) and Cancer Research Initiatives Foundation. Sheba Medical Centre (SMC): The SMC study was partially funded through a grant by the Israel Cancer Association and the funding for the Israeli Inherited Breast Cancer Consortium. Swedish Breast Cancer Study (SWE-BRCA): SWE-BRCA collaborators are supported by the Swedish Cancer Society. The University of Chicago Center for Clinical Cancer Genetics and Global Health (UCHICAGO): UCHICAGO is supported by grants from the US National Cancer Institute (NIH/NCI) and by the Ralph and Marion Falk Medical Research Trust, the Entertainment Industry Fund National Women's Cancer Research Alliance, and the Breast Cancer Research Foundation. University of California Los Angeles (UCLA): The UCLA study was supported by the Jonsson Comprehensive Cancer Center Foundation and the Breast Cancer Research Foundation. University of California San Francisco (UCSF): The UCSF study was supported by the UCSF Cancer Risk Program and the Helen Diller Family Comprehensive Cancer Center. United Kingdom Familial Ovarian Cancer Registries (UKFOCR): UKFOCR was supported by a project grant from CRUK to Paul Pharoah. University of Pennsylvania (UPENN): The UPENN study was supported by the National Institutes of Health (NIH) (R01-CA102776 and R01-CA083855), Breast Cancer Research Foundation, Rooney Family Foundation, Susan G. Komen Foundation for the Cure, and the Macdonald Family Foundation. Victorian Familial Cancer Trials Group (VFCTG): The VFCTG study was supported by the Victorian Cancer Agency, Cancer Australia, and National Breast Cancer Foundation. Women's Cancer Research Initiative (WCRI): The WCRI at the Samuel Oschin Comprehensive Cancer Institute, Cedars Sinai Medical Center, Los Angeles, is funded by the American Cancer Society Early Detection Professorship (SIOP-06-258-01-COUN). ; Peer Reviewed
