@@1845 Alternative medicine is any practice that is put forward as having the healing effects of medicine , but is not based on evidence gathered using the scientific method . Alternative medicine is usually based on religion , tradition , superstition , belief in supernatural energies , pseudoscience , errors in reasoning , propaganda , or fraud . Alternative therapies lack scientific validation , and their effectiveness is either unproved or disproved . The treatments are those that are not part of the conventional , science-based healthcare system . Alternative medicine consists of a wide range of health care practices , products and therapies , using alternative medical diagnoses and treatments which typically are not included in the degree courses of medical schools or used in conventional medicine . Examples include new and traditional medicine practices such as homeopathy , naturopathy , chiropractic , energy medicine , various forms of acupuncture , Traditional Chinese medicine , Ayurvedic medicine , and Christian faith healing . Regulation and licensing of alternative medicine and health care providers varies from country to country , and state to state . Complementary medicine is alternative medicine used together with conventional medical treatment in a belief , not proven by using scientific methods , that it complements the treatment . CAM is the abbreviation for Complementary and alternative medicine . Integrative medicine ( or integrative health ) is the combination of the practices and methods of alternative medicine with conventional medicine . The scientific community has criticized alternative medicine as being based on misleading statements , quackery , pseudoscience , antiscience , fraud , or poor scientific methodology . Promoting alternative medicine has been called dangerous and unethical . Testing alternative medicine has been called a waste of scarce medical research resources . Critics have said ' ' there is really no such thing as alternative medicine , just medicine that works and medicine that does n't ' ' , or ' ' Can there be any reasonable ' alternative ' ( to medicine based on science ) ? ' ' # Examples of alternative medicine practices # Alternative medicine practices are diverse in their foundations and methodologies . Alternative medicine practices may be classified by their cultural origins or by the types of beliefs upon which they are based . Methods may incorporate or base themselves on traditional medicinal practices of a particular culture , folk knowledge , supersition , spiritual beliefs , belief in supernatural energies ( antiscience ) , pseudoscience , errors in reasoning , propaganda , fraud , new or different concepts of health and disease , and any bases other than being proven by scientific methods . Different cultures may have their own unique traditional or belief based practices developed recently or over thousands of years , and specific practices or entire systems of practices . # Systems based on unscientific beliefs or traditional practices # Alternative medical practices can be based on an underlying belief system inconsistent with science , or on traditional cultural practices . # #Unscientific belief systems# # Alternative medical systems can be based on a common belief systems that are not consistent with facts of science , such as in Naturopathy or Homeopathy . # #Homeopathy# # Homeopathy is a system developed in a belief that a substance that causes the symptoms of a disease in healthy people will cure similar symptoms in sick people . It was developed before knowledge of atoms and molecules , and of basic chemistry , which shows that repeated dilution as practiced in homeopathy produces only water and that homeopathy is false . Homeopathy is considered quackery in the medical community . # #Naturopathic medicine# # Naturopathic medicine is based on a belief that the body heals itself using a supernatural vital energy that guides bodily processes , a view in conflict with the paradigm of evidence-based medicine . Many naturopaths have opposed vaccination , and scientific evidence does not support claims that naturopathic medicine can cure cancer or any other disease . # #Traditional ethnic systems# # Alternative medical systems may be based on traditional medicine practices , such as Traditional Chinese medicine , Ayurveda in India , or practices of other cultures around the world . # #Traditional Chinese Medicine# # Traditional Chinese Medicine is a combination of traditional practices and beliefs developed over thousands of years in China , together with modifications made by the Communist party . Common practices include herbal medicine , acupuncture ( insertion of needles in the body at specified points , massage ( Tui na ) , exercise ( qigong ) , and dietary therapy . The practices are based on belief in a supernatural energy called qi , considerations of Chinese Astrology and Chinese numerology , traditional use of herbs and other substances found in China , a belief that a map of the body is contained on the tongue which reflects changes in the body , and an incorrect model of the anatomy and physiology of internal organs . The Chinese Communist Party Chairman Mao Zedong , in response to the lack of modern medical practitioners , revived acupuntcure and its theory was rewritten to adhere to the political , economic and logistic necessities of providing for the medical needs of China 's population . In the 1950s the history and theory of Traditional Chinese Medicine was rewritten as communist propoganda , at Mao 's insistence , to correct the supposed bourgeois thought of Western doctors of medicine ( p. 109 ) . Acupuncture gained attention in the United States when President Richard Nixon visited China in 1972 , and the delegation was shown a patient undergoing major surgery while fully awake , ostensibly receiving acupuncture rather than anesthesia . Later it was found that the patients selected for the surgery had both a high pain tolerance and received heavy indoctrination before the operation ; these demonstration cases were also frequently receiving morphine surreptitiously through an intravenous drip that observers were told contained only fluids and nutrients . # #Ayurvedic medicine# # Ayurvedic medicine is a traditional medicine of India . It includes a belief that health can be influenced by use of traditional herbs , and by achieving the spiritual balance of the religions of Hinduism and Buddhism . Ayurveda stresses the use of plant-based medicines and treatments , with some animal products , and added minerals , including sulfur , arsenic , lead , copper sulfate . Andrew Weil , an American promoter of alternative medicine , wrote that in Ayurvedic medicine , ' ' being ' healthy ' is more than the absence of disease - it is a radiant state of vigor and energy , which is achieved by balance , or moderation , in food intake , sleep , sexual intercourse and other activities of daily life , complemented by various treatments including a wide variety of plant-based medicines ' ' . Safety concerns have been raised about Ayurveda , with two U.S. studies finding about 20 percent of Ayurvedic Indian-manufactured patent medicines contained toxic levels of heavy metals such as lead , mercury and arsenic . Other concerns include the use of herbs containing toxic compounds and the lack of quality control in Ayurvedic facilities . Incidents of heavy metal poisoning have been attributed to the use of these compounds in the United States . # Supernatural energies and misunderstanding of energy in physics # Bases of belief may include belief in existence of supernatural energies undetected by the science of physics , as in biofields , or in belief in properties of the energies of physics that are inconsistent with the laws of physics , as in energy medicine . # #Biofields# # Biofield therapies are intended to influence energy fields that , it is purported , surround and penetrate the body . Writers such as noted astrophysicist and advocate of skeptical thinking ( Scientific skepticism ) Carl Sagan ( 1934-1996 ) have described the lack of empirical evidence to support the existence of the putative energy fields on which these therapies are predicated . Acupuncture is a component of Traditional Chinese Medicine . In acupuncture , it is believed that a supernatural energy called qi flows through the universe and through the body , and helps propel the blood , blockage of which leads to disease . It is believed that insertion of needles at various parts of the body determined by astrological calculations can restore balance to the blocked flows , and thereby cure disease . Chiropractic was developed in the belief that manipulating the spine affects the flow of a supernatural vital energy and thereby affects health and disease . In the western version of Japanese Reiki , the palms are placed on the patient near Chakras , believed to be centers of supernatural energies , in a belief that the supernatural energies can transfered from the palms of the practitioner , to heal the patient . # #Energy medicines# # Bioelectromagnetic-based therapies use verifiable electromagnetic fields , such as pulsed fields , alternating-current , or direct-current fields in an unconventional manner . Magnetic healing does not claim existence of supernatural energies , but asserts that magnets can be used to defy the laws of physics to influence health and disease . # Holistic health and mind body medicine # Mind-body medicine takes a holistic approach to health that explores the interconnection between the mind , body , and spirit . It works under the premise that the mind can affect bodily functions and symptoms . Mind body medicines includes healing claims made in yoga , meditation , deep-breathing exercises , guided imagery , hypnotherapy , progressive relaxation , qi gong , and tai chi . Yoga , a method of traditional stretches , excercises , and meditations in Hinduism , may also be classified as an energy medicine insofar as its healing effects are believed by to be due to a healing life energy that is absorbed into the body through the breath , and is thereby believed to treat a wide variety of illnesses and complaints . Since the 1990 's , tai chi ( t'ai chi ch'uan ) classes that purely emphasise health have become popular in hospitals , clinics , as well as community and senior centers . This has occurred as the baby boomers generation has aged and the art 's reputation as a low-stress training method for seniors has become better known . There has been some divergence between those that say they practice t'ai chi ch'uan primarily for self-defence , those that practice it for its aesthetic appeal ( see ' ' wushu ' ' below ) , and those that are more interested in its benefits to physical and mental health . Qigong , chi kung , or chi gung , is a practice of aligning body , breath , and mind for health , meditation , and martial arts training . With roots in Chinese Traditional Chinese Medicine , philosophy , and martial arts , qigong is traditionally viewed as a practice to cultivate and balance qi ( chi ) or what has been translated as life energy . # Herbal remedies and other substances used # Substance based practices use substances found in nature such as herbs , foods , non-vitamin supplments and megavitmins , and minerals , and includes traditional herbal remedies with herbs specific to regions in which the cultural practices arose . Herbalism , herbology , or herbal medicine , is use of plants for medicinal purposes , and the study of such use . Plants have been the basis for medical treatments through much of human history , and such traditional medicine is still widely practiced today . Nonvitamin supplements include fish oil , Omega-3 fatty acid , glucosamine , echinacea , flaxseed oil or pills , and ginseng , when used under a claim to have healing effects . Although the practice of herbalism is not strictly based on evidence gathered using the scientific method , modern medicine , does , however , make use of many plant-derived compounds as the basis for evidence-tested pharmaceutical drugs , and phytotherapy works to apply modern standards of effectiveness testing to herbs and medicines that are derived from natural sources . The scope of herbal medicine is sometimes extended to include fungal and bee products , as well as minerals , shells and certain animal parts . Herbal remedies in this case , may include use of nonherbal toxic chemicals from a nonbiological sources , such as use of the poison lead in Traditional Chinese Medicine . # Body manipulation # Manipulative and body-based practices feature manipulation or movement of body parts , such as is done in chiropractic manipulation . Osteopathic manipulative medicine , also known as osteopathic manipulative treatment , is a core set of techniques of osteopathy and osteopathic medicine distinguishing these fields from mainstream medicine . # Religion , faith healing , and prayer # Religion based healing practices , such as use of prayer and the laying of hands in Christian faith healing , and shamanism , rely on belief in divine or spiritual intervention for healing . Shamanism is a practice of many cultures around the world , in which a practitioner reaches an altered states of consciousness in order to encounter and interact with the spirit world or channel supernatural energies in the belief they can heal . In the United States , the 1974 Child Abuse Prevention and Treatment Act ( CAPTA ) required states to grant religious exemptions to child neglect and abuse laws in order to receive federal money . Thirty-one states have child-abuse religious exemptions . # Alternative medicines based on exploitation of ignorance and flawed reasoning # Some alternative medicine practices may be based on pseudoscience , ignorance , or flawed reasoning . This can lead to fraud . Homeopathy was developed prior to knowledge of the theory of molecules and basic chemistry , which proved that its remedies contained nothing more than distilled water . Practitioners of electricity and magnetism based healing methods may deliberately exploit a patient 's ignorance of physics in order to defraud them . # Background # # Terms and definitions # The expression complementary and alternative medicine ( CAM ) resists easy definition because the health systems and practices to which it refers are diffuse and its boundaries are poorly defined . others , such as homeopathy and chiropractic , have origins in Europe or the United States and emerged in the eighteenth and nineteenth centuries . Some , such as osteopathy and chiropractic , employ manipulative physical methods of treatment ; others , such as meditation and prayer , are based on mind-body interventions . Treatments considered alternative in one location may be considered conventional in another . Thus , chiropractic is not considered alternative in Denmark and likewise osteopathic medicine is no longer thought of as an alternative therapy in the United States . One common feature of all definitions of alternative medicine is its designation as other than conventional medicine . Some definitions seek to specify alternative medicine in terms of its social and political marginality to mainstream healthcare . This can refer to the lack of support that alternative therapies receive from the medical establishment and related bodies regarding access to research funding , sympathetic coverage in the medical press , or inclusion in the standard medical curriculum . In 1993 , the British Medical Association ( BMA ) , one among many professional organizations who have attempted to define alternative medicine , stated that it referred to those forms of treatment which are not widely used by the conventional healthcare professions , and the skills of which are not taught as part of the undergraduate curriculum of conventional medical and paramedical healthcare courses . In a US context , an influential definition coined in 1993 by the Harvard-based physician , David M. Eisenberg , characterized alternative medicine as interventions neither taught widely in medical schools nor generally available in US hospitals . These descriptive definitions are inadequate in the present-day when some conventional doctors offer alternative medical treatments and CAM introductory courses or modules can be offered as part of standard undergraduate medical training ; Paul Offit , while criticizing alternative medicine , has provided a similar type of definition : : ... there 's no such thing as conventional or alternative or complementary or integrative or holistic medicine . There 's only medicine that works and medicine that does n't . And the best way to sort it out is by carefully evaluating scientific studies--not by visiting Internet chat rooms , reading magazine articles , or talking to friends . Joseph A. Schwarcz has stated : There 's a name for alternative medicines that work . It 's called medicine . Tim Minchin states : Alternative medicine has either not been proved to work , or been proved not to work . You know what they call alternative medicine that 's been proved to work ? Medicine . Complementary medicine refers to use of alternative medicine alongside conventional science based medicine , in the belief that it may help patients feel better and recover faster . In ' ' Science and Technology : Public Attitudes and Public Understanding ' ' , chapter 7 of a report ' ' Science and Engineering Indicators 2002 ' ' , issued by a US government agency ( The National Science Foundation ) , it was stated that the term alternative medicine was there being used to refer to all treatments that had not been proven effective using scientific methods . # Regional definitions # Public information websites maintained by the governments of the US and of the UK make a distinction between alternative medicine and complementary medicine , but mention that these two overlap . The National Center for Complementary and Alternative Medicine ( NCCAM ) of the National Institutes of Health ( NIH ) ( a part of the US Department of Health and Human Services ) states that alternative medicine refers to using a non-mainstream approach in place of conventional medicine and that complementary medicine generally refers to using a non-mainstream approach together with conventional medicine , and comments that the boundaries between complementary and conventional medicine overlap and change with time . The National Health Service ( NHS ) website ' ' NHS Choices ' ' ( owned by the UK Department of Health ) , adopting the terminology of NCCAM , states that when a treatment is used alongside conventional treatments , to help a patient cope with a health condition , and not as an alternative to conventional treatment , this use of treatments can be called complementary medicine ; but when a treatment is used instead of conventional medicine , with the intention of treating or curing a health condition , the use can be called alternative medicine . Similarly , the public information website maintained by the National Health and Medical Research Council ( NHMRC ) of the Commonwealth of Australia uses the acronym CAM for a wide range of health care practices , therapies , procedures and devices not within the domain of conventional medicine . In the Australian context this is stated to include acupuncture ; aromatherapy ; chiropractic ; homeopathy ; massage ; meditation and relaxation therapies ; naturopathy ; osteopathy ; reflexology , traditional Chinese medicine ; and the use of vitamin supplements . The Danish National Board of Health 's Council for Alternative Medicine ( Sundhedsstyrelsens Rd for Alternativ Behandling ( SRAB ) , an independent institution under the National Board of Health ( Danish : ' ' Sundhedsstyrelsen ' ' ) , uses the term alternative medicine for :  Treatments performed by therapists that are not authorized healthcare professionals .  Treatments performed by authorized healthcare professionals , but those based on methods otherwise used mainly outside the healthcare system . People without a healthcare authorisation are also allowed to perform the treatments . # #Institutions# # In ' ' General Guidelines for Methodologies on Research and Evaluation of Traditional Medicine ' ' , published in 2000 by the World Health Organization ( WHO ) , complementary and alternative medicine were there defined as a broad set of health care practices that are not part of that country 's own tradition and are not integrated into the dominant health care system . Some herbal therapies are mainstream in Europe but are alternative in the US. # #Special terminology used by selected individuals# # Two advocates of integrative medicine , writing in 2002 of the American healthcare system , claimed that it also addresses alleged problems with medicine based on science , which are not addressed by CAM ; Ralph Snyderman and Andrew Weil stated that integrative medicine is not synonymous with complementary and alternative medicine . It has a far larger meaning and mission in that it calls for restoration of the focus of medicine on health and healing and emphasizes the centrality of the patient-physician relationship . # History 19th century onwards # ' ' Further information : Rise of modern medicine ' ' Dating from the 1970s , medical professionals , sociologists , anthropologists and other commentators noted the increasing visibility of a wide variety of health practices that had neither derived directly from nor been verified by biomedical science . Since that time , those who have analyzed this trend have deliberated over the most apt language with which to describe this emergent health field . A variety of terms have been used , including heterodox , irregular , fringe and alternative medicine while others , particularly medical commentators , have been satisfied to label them as instances of quackery . The most persistent term has been alternative medicine but its use is problematic as it assumes a value-laden dichotomy between a medical fringe , implicitly of borderline acceptability at best , and a privileged medical orthodoxy , associated with validated medico-scientific norms . The use of the category of alternative medicine has also been criticized as it can not be studied as an independent entity but must be understood in terms of a regionally and temporally specific medical orthodoxy . Its use can also be misleading as it may erroneously imply that a real medical alternative exists . As with near-synonymous expressions , such as unorthodox , complementary , marginal , or quackery , these linguistic devices have served , in the context of processes of professionalisation and market competition , to establish the authority of official medicine and police the boundary between it and its unconventional rivals . An early instance of the influence of this modern , or western , scientific medicine outside Europe and North America is Peking Union Medical College . From a historical perspective , the emergence of alternative medicine , if not the term itself , is typically dated to the 19th century . # In the condemnation phase , from the late 1960s to the early 1970s , authors had ridiculed , exaggerated the risks , and petitioned the state to contain CAM ; in the reassessment phase ( mid-1970s through early 1990s ) , when increased consumer utilization of CAM was prompting concern , authors had pondered whether patient dissatisfaction and shortcomings in conventional care contributed to the trend ; in the integration phase of the 1990s physicians began learning to work around or administer CAM , and the subjugation of CAM to scientific scrutiny had become the primary means of control . # Use and regulation # # Prevalence of use # Complementary and alternative medicine ( CAM ) has been described as a broad domain of healing resources that encompasses all health systems , modalities , and practices and their accompanying theories and beliefs , other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period . CAM includes all such practices and ideas self-defined by their users as preventing or treating illness or promoting health and well-being . Boundaries within CAM and between the CAM domain and that of the dominant system are not always sharp or fixed . About 50% of people in developed countries use some kind of complementary and alternative medicine other than prayer for health . A British telephone survey by the BBC of 1209 adults in 1998 shows that around 20% of adults in Britain had used alternative medicine in the past 12 months . About 40% of cancer patients use some form of CAM . In developing nations , access to essential medicines is severely restricted by lack of resources and poverty . Traditional remedies , often closely resembling or forming the basis for alternative remedies , may comprise primary healthcare or be integrated into the healthcare system . In Africa , traditional medicine is used for 80% of primary healthcare , and in developing nations as a whole over one-third of the population lack access to essential medicines . # #In USA# # In respect of taxation in the USA , the Internal Revenue Service has discriminated in favour of medical expenses for acupuncture and chiropractic ( and others including Christian Science practitioners ) but against homeopathy and the use of non-prescription required medicine . The use of alternative medicine in the US has increased , with a 50 percent increase in expenditures and a 25 percent increase in the use of alternative therapies between 1990 and 1997 in America . Americans spend many billions on the therapies annually . Most Americans used CAM to treat and/or prevent musculoskeletal conditions or other conditions associated with chronic or recurring pain . In America , women were more likely than men to use CAM , with the biggest difference in use of mind-body therapies including prayer specifically for health reasons . In 2008 , more than 37% of American hospitals offered alternative therapies , up from 26.5 percent in 2005 , and 25% in 2004 . More than 70% of the hospitals offering CAM were in urban areas . A survey of Americans found that 88 percent agreed that there are some good ways of treating sickness that medical science does not recognize . Use of magnets was the most common tool in energy medicine in America , and among users of it , 58 percent described it as at least sort of scientific , when it is not at all scientific . In 2002 , at least 60 percent of US medical schools have at least some class time spent teaching alternative therapies . Therapeutic touch , was taught at more than 100 colleges and universities in 75 countries before the practice was debunked by a nine-year-old child for a school science project . A 1997 survey found that 13.7% of respondents in the US had sought the services of both a medical doctor and an alternative medicine practitioner . The same survey found that 96% of respondents who sought the services of an alternative medicine practitioner also sought the services of a medical doctor in the past 12 months . Medical doctors are often unaware of their patient 's use of alternative medical treatments as only 38.5% of the patients alternative therapies were discussed with their medical doctor . According to Michael H. Cohen , US regulation of alternative includes state licensure of healthcare providers and scope of practice limits on practice by non-MD healthcare professionals ; state-law malpractice rules ( standard of care limits on professional negligence ) ; discipline of practitioners by state regulatory boards ; and federal regulation such as food and drug law . He argues that US regulation of alternative medicine seeks to integrate biomedical , holistic , and social models of health care in ways that maximize patients well-being while still protecting patients from fraud . # #Prevalence of use of specific therapies# # The most common CAM therapies used in the US in 2002 were prayer ( 45.2% ) , herbalism ( 18.9% ) , breathing meditation ( 11.6% ) , meditation ( 7.6% ) , chiropractic medicine ( 7.5% ) , yoga ( 5.1%-6.1% ) , body work ( 5.0% ) , diet-based therapy ( 3.5% ) , progressive relaxation ( 3.0% ) , mega-vitamin therapy ( 2.8% ) and Visualization ( 2.1% ) In Britain , the most often used alternative therapies were Alexander technique , Aromatherapy , Bach and other flower remedies , Body work therapies including massage , Counseling stress therapies , hypnotherapy , Meditation , Reflexology , Shiatsu , Ayurvedic medicine , Nutritional medicine , and Yoga . Ayurvedic medicine remedies are mainly plant based with some use of animal materials . Safety concerns include the use of herbs containing toxic compounds and the lack of quality control in Ayurvedic facilities . According to the National Health Service ( England ) , the most commonly used complementary and alternative medicines ( CAM ) supported by the NHS in the UK are : acupuncture , aromatherapy , chiropractic , homeopathy , massage , osteopathy and clinical hypnotherapy . Complementary medicine treatments used for pain include : acupuncture , low-level laser therapy , meditation , aroma therapy , Chinese medicine , dance therapy , music therapy , massage , herbalism , therapeutic touch , yoga , osteopathy , chiropractic , naturopathy , and homeopathy . # #In palliative care# # Complementary therapies are often used in palliative care or by practitioners attempting to manage chronic pain in patients . Integrative medicine is considered more acceptable in the interdisciplinary approach used in palliative care than in other areas of medicine . From its early experiences of care for the dying , palliative care took for granted the necessity of placing patient values and lifestyle habits at the core of any design and delivery of quality care at the end of life . If the patient desired complementary therapies , and as long as such treatments provided additional support and did not endanger the patient , they were considered acceptable . The non-pharmacologic interventions of complementary medicine can employ mind-body interventions designed to reduce pain and concomitant mood disturbance and increase quality of life . # Regulation # In Austria and Germany complementary and alternative medicine is mainly in the hands of doctors with MDs , and half or more of the American alternative practitioners are licensed MDs . In Germany herbs are tightly regulated : half are prescribed by doctors and covered by health insurance . Some professions of *37;34322;TOOLONG medicine , such as chiropractic , have achieved full regulation in North America and other parts of the world Government bodies in the USA and elsewhere have published information or guidance about alternative medicine . One of those is the U.S. Food and Drug Administration ( FDA ) , which mentions specifically homeopathic products , traditional Chinese medicine and Ayurvedic products . A document which the FDA has issued for comment is headed ' ' Guidance for Industry : Complementary and Alternative Medicine Products and Their Regulation by the Food and Drug Administration ' ' , last updated on March 2 , 2007 . The document opens with three preliminary paragraphs which explain that ' ' in the document ' ' :  complementary and alternative medicine ( CAM ) are being used to encompass a wide array of health care practices , products , and therapies which are distinct from those used in conventional or allopathic medicine .  some forms of CAM , such as traditional Chinese medicine and Ayurvedic medicine , have been practiced for centuries , and others , such as electrotherapy , are of more recent origin .  in a publication of The Institute of Medicine it has been stated that more than one-third of American adults reported using some form of CAM and that visits to CAM providers each year exceed those to primary care physicians ( Institute of Medicine , Complementary and Alternative Medicine in the United States , pages 3435 , 2005 ) .  no mention ( in the document ) of a particular CAM therapy , practice or product should be taken as expressing FDA 's support or endorsement of it or as an agency determination that a particular product is safe and effective . The FDA has also issued online warnings for consumers about medication health fraud . This includes a section on Alternative Medicine Fraud , such as a warning that Ayurvedic products generally have not been approved by the FDA before marketing . # Efficacy # Alternative therapies lack the requisite scientific validation , and their effectiveness is either unproved or disproved . Many of the claims regarding the efficacy of alternative medicines are controversial , since research on them is frequently of low quality and methodologically flawed . Selective publication of results ( misleading results from only publishing positive results , and not all results ) , marked differences in product quality and standardisation , and some companies making unsubstantiated claims , call into question the claims of efficacy of isolated examples where herbs may have some evidence of containing chemicals that may affect health . ' ' The Scientific Review of Alternative Medicine ' ' points to confusions in the general population - a person may attribute symptomatic relief to an otherwise-ineffective therapy just because they are taking something ( the placebo effect ) ; the natural recovery from or the cyclical nature of an illness ( the regression fallacy ) gets misattributed to an alternative medicine being taken ; a person not diagnosed with science based medicine may never originally have had a true illness diagnosed as an alternative disease category . Edzard Ernst characterized the evidence for many alternative techniques as weak , nonexistent , or negative and in 2011 published his estimate that about 7.4% were based on sound evidence , although he believes that may be an overestimate due to various reasons . Ernst has concluded that 95% of the alternative treatments he and his team studied , including acupuncture , herbal medicine , homeopathy , and reflexology , are statistically indistinguishable from placebo treatments , but he also believes there is something that conventional doctors can usefully learn from the chiropractors and homeopath : this is the therapeutic value of the placebo effect , one of the strangest phenomena in medicine . In 2003 , a project funded by the CDC identified 208 condition-treatment pairs , of which 58% had been studied by at least one randomized controlled trial ( RCT ) , and 23% had been assessed with a meta-analysis . According to a 2005 book by a US Institute of Medicine panel , the number of RCTs focused on CAM has risen dramatically . The book cites Vickers ( 1998 ) , who found that many of the CAM-related RCTs are in the Cochrane register , but 19% of these trials were not in MEDLINE , and 84% were in conventional medical journals . As of 2005 , the Cochrane Library had 145 CAM-related Cochrane systematic reviews and 340 non-Cochrane systematic reviews . An analysis of the conclusions of only the 145 Cochrane reviews was done by two readers . In 83% of the cases , the readers agreed . In the 17% in which they disagreed , a third reader agreed with one of the initial readers to set a rating . These studies found that , for CAM , 38.4% concluded positive effect or possibly positive ( 12.4% ) , 4.8% concluded no effect , 0.69% concluded harmful effect , and 56.6% concluded insufficient evidence . An assessment of conventional treatments found that 41.3% concluded positive or possibly positive effect , 20% concluded no effect , 8.1% concluded net harmful effects , and 21.3% concluded insufficient evidence . However , the CAM review used the more developed 2004 Cochrane database , while the conventional review used the initial 1998 Cochrane database . Most alternative medical treatments are not patentable , which may lead to less research funding from the private sector . In addition , in most countries , alternative treatments ( in contrast to pharmaceuticals ) can be marketed without any proof of efficacyalso a disincentive for manufacturers to fund scientific research . Some have proposed adopting a prize system to reward medical research . However , public funding for research exists . Increasing the funding for research on alternative medicine techniques is the purpose of the US National Center for Complementary and Alternative Medicine . NCCAM and its predecessor , the Office of Alternative Medicine , have spent more than $2.5 billion on such research since 1992 ; this research has largely not demonstrated the efficacy of alternative treatments . In the same way as for conventional therapies , drugs , and interventions , it can be difficult to test the efficacy of alternative medicine in clinical trials . In instances where an established , effective , treatment for a condition is already available , the Helsinki Declaration states that withholding such treatment is unethical in most circumstances . Use of standard-of-care treatment in addition to an alternative technique being tested may produce confounded or difficult-to-interpret results . Cancer researcher Andrew J. Vickers has stated : : Contrary to much popular and scientific writing , many alternative cancer treatments have been investigated in good-quality clinical trials , and they have been shown to be ineffective . In this article , clinical trial data on a number of alternative cancer cures including Livingston-Wheeler , Di Bella Multitherapy , antineoplastons , vitamin C , hydrazine sulfate , Laetrile , and psychotherapy are reviewed . The label ' unproven ' is inappropriate for such therapies ; it is time to assert that many alternative cancer therapies have been ' disproven ' . Homeopathy is based on the belief that a disease can be cured by a very low dose of substance that creates similar symptoms in a healthy person . Other governments have various levels of funding ; the Dutch government funded CAM research between 1986 and 2003 , but formally ended it in 2006. # Appeal # Physicians who practice complementary medicine usually discuss and advise patients as to available complementary therapies . Patients often express interest in mind-body complementary therapies because they offer a non-drug approach to treating some health conditions . Some mind-body techniques , such as cognitive-behavioral therapy , were once considered complementary medicine , but are now a part of conventional medicine in the United States . Against alternative medicine it has been argued that in addition to the social-cultural underpinnings of the popularity of alternative medicine , there are several psychological issues that are critical to its growth . One of the most critical is the placebo effect , which is a well-established observation in medicine . Related to it are similar psychological effects such as the will to believe , cognitive biases that help maintain self-esteem and promote harmonious social functioning , and the ' ' post hoc , ergo propter hoc ' ' fallacy . # In UK # CAM 's popularity may be related to other factors which Edzard Ernst mentioned in an interview in ' ' The Independent ' ' : # Why is it so popular , then ? Ernst blames the providers , customers and the doctors whose neglect , he says , has created the opening into which alternative therapists have stepped . People are told lies . There are 40 million websites and 39.9 million tell lies , sometimes outrageous lies . They mislead cancer patients , who are encouraged not only to pay their last penny but to be treated with something that shortens their lives . At the same time , people are gullible . It needs gullibility for the industry to succeed . It does n't make me popular with the public , but it 's the truth . # In a paper published in October 2010 entitled ' ' The public 's enthusiasm for complementary and alternative medicine amounts to a critique of mainstream medicine ' ' , Ernst described these views in greater detail and concluded : # CAM is popular . An analysis of the reasons why this is so points towards the therapeutic relationship as a key factor . Providers of CAM tend to build better therapeutic relationships than mainstream healthcare professionals . In turn , this implies that much of the popularity of CAM is a poignant criticism of the failure of mainstream healthcare . We should consider it seriously with a view of improving our service to patients . # # In USA and Canada # A study published in 1998 indicates that a majority of alternative medicine use was in conjunction with standard medical treatments . Approximately 4.4 percent of those studied used alternative medicine as a replacement for conventional medicine . The research found that those having used alternative medicine tended to have higher education or report poorer health status . Dissatisfaction with conventional medicine was not a meaningful factor in the choice , but rather the majority of alternative medicine users appear to be doing so largely because they find these healthcare alternatives to be more congruent with their own values , beliefs , and philosophical orientations toward health and life . In particular , subjects reported a holistic orientation to health , a transformational experience that changed their worldview , identification with a number of groups committed to environmentalism , feminism , psychology , and/or spirituality and personal growth , or that they were suffering from a variety of common and minor ailments notable ones being anxiety , back problems , and chronic pain . Authors have speculated on the socio-cultural and psychological reasons for the appeal of alternative medicines among that minority using them ' ' in lieu ' ' of conventional medicine . There are several socio-cultural reasons for the interest in these treatments centered on the low level of scientific literacy among the public at large and a concomitant increase in antiscientific attitudes and new age mysticism . Related to this are vigorous marketing of extravagant claims by the alternative medical community combined with inadequate media scrutiny and attacks on critics . There is also an increase in conspiracy theories toward conventional medicine and pharmaceutical companies , mistrust of traditional authority figures , such as the physician , and a dislike of the current delivery methods of scientific biomedicine , all of which have led patients to seek out alternative medicine to treat a variety of ailments . Many patients lack access to contemporary medicine , due to a lack of private or public health insurance , which leads them to seek out lower-cost alternative medicine . Medical doctors are also aggressively marketing alternative medicine to profit from this market . Patients can also be averse to the painful , unpleasant , and sometimes-dangerous side effects of biomedical treatments . Treatments for severe diseases such as cancer and HIV infection have well-known , significant side-effects . Even low-risk medications such as antibiotics can have potential to cause life-threatening anaphylactic reactions in a very few individuals . Also , many medications may cause minor but bothersome symptoms such as cough or upset stomach . In all of these cases , patients may be seeking out alternative treatments to avoid the adverse effects of conventional treatments . Schofield and others , in a systematic review published in 2011 , make ten recommendations which they think may increase the effectiveness of consultations in a conventional ( here : oncology ) setting , such as Ask questions about CAM use at critical points in the illness trajectory ; Respond to the person 's emotional state ; and Provide balanced , evidence-based advice . They suggest that this approach may address .. concerns surrounding CAM use and encourage informed decision-making about CAM and ultimately , improve outcomes for patients . 
@@4746 ICDO = Plague is a deadly infectious disease that is caused by the enterobacteria ' ' Yersinia pestis ' ' , named after the French-Swiss bacteriologist Alexandre Yersin . Until June 2007 , plague was one of the three epidemic diseases specifically reportable to the World Health Organization ( the other two being cholera and yellow fever ) . Depending on lung infection , or sanitary conditions , plague can be spread in the air , by direct contact , or by contaminated undercooked food or materials . The symptoms of plague depend on the concentrated areas of infection in each person : bubonic plague in lymph nodes , septicemic plague in blood vessels , pneumonic plague in lungs , and so on . It is treatable if detected early . Plague is still endemic in some parts of the world . # Name # The epidemiological use of the term ' ' plague ' ' is currently applied to bacterial infections that cause ' ' buboes ' ' , although historically the medical use of the term plague has been applied to pandemic infections in general . Plague is often synonymous with bubonic plague , but this describes just one of its manifestations . Other names have been used to describe this disease , such as The Black Plague and The Black Death ; the latter is now used primarily by scholars to describe the second , and most devastating , pandemic of the disease . The etymology of the word ' ' plague ' ' is believed to come from the Latin word ' ' plga ' ' ( blow , wound ) and ' ' plangere ' ' ( to strike , or to strike down ) , cf. German ' ' Plage ' ' ( infestation ) . # Epidemiology and distribution # # Infection and transmission # Transmission of ' ' Y. pestis ' ' to an uninfected individual is possible by any of the following means .  droplet contact coughing or sneezing on another person  direct physical contact touching an infected person , including sexual contact  indirect contact usually by touching soil contamination or a contaminated surface  airborne transmission if the microorganism can remain in the air for long periods  fecal-oral transmission usually from contaminated food or water sources  vector borne transmission carried by insects or other animals . ' ' Yersinia pestis ' ' circulates in animal reservoirs , particularly in rodents , in the natural foci of infection found on all continents except Australia . The natural foci of plague are situated in a broad belt in the tropical and subtropical latitudes and the warmer parts of the temperate latitudes around the globe , between the parallels 55 degrees North and 40 degrees South . Contrary to popular belief , rats did not directly start the spread of the bubonic plague . It is mainly a disease in the fleas ( ' ' Xenopsylla cheopis ' ' ) that infested the rats , making the rats themselves the first victims of the plague . Infection in a human occurs when a person is bitten by a flea that has been infected by biting a rodent that itself has been infected by the bite of a flea carrying the disease . The bacteria multiply inside the flea , sticking together to form a plug that blocks its stomach and causes it to starve . The flea then bites a host and continues to feed , even though it can not quell its hunger , and consequently the flea vomits blood tainted with the bacteria back into the bite wound . The bubonic plague bacterium then infects a new victim , and the flea eventually dies from starvation . Serious outbreaks of plague are usually started by other disease outbreaks in rodents , or a rise in the rodent population . In 1894 , two bacteriologists , Alexandre Yersin of France and Kitasato Shibasabur of Japan , independently isolated the bacterium in Hong Kong responsible for the Third Pandemic . Though both investigators reported their findings , a series of confusing and contradictory statements by Kitasato eventually led to the acceptance of Yersin as the primary discoverer of the organism . Yersin named it ' ' Pasteurella pestis ' ' in honor of the Pasteur Institute , where he worked , but in 1967 it was moved to a new genus , renamed ' ' Yersinia pestis ' ' in honor of Yersin . Yersin also noted that rats were affected by plague not only during plague epidemics but also often preceding such epidemics in humans , and that plague was regarded by many locals as a disease of rats : villagers in China and India asserted that , when large numbers of rats were found dead , plague outbreaks soon followed . In 1898 , the French scientist Paul-Louis Simond ( who had also come to China to battle the Third Pandemic ) established the rat-flea vector that drives the disease . He had noted that persons who became ill did not have to be in close contact with each other to acquire the disease . In Yunnan , China , inhabitants would flee from their homes as soon as they saw dead rats , and on the island of Formosa ( Taiwan ) , residents considered the handling of dead rats heightened the risks of developing plague . These observations led him to suspect that the flea might be an intermediary factor in the transmission of plague , since people acquired plague only if they were in contact with recently dead rats , who had died less than 24 hours before . In a now classic experiment , Simond demonstrated how a healthy rat died of plague , after infected fleas had jumped to it , from a rat which had recently died of the plague . # Plague immunization # Since human plague is rare in most parts of the world , routine vaccination is not needed other than for those at particularly high risk of exposure , nor for people living in areas with enzootic plague , such as the western United States . It is not even indicated for most travellers to countries with known recent reported cases , particularly if their travel is limited to urban areas with modern hotels . The CDC thus only recommends vaccination for : ( 1 ) all laboratory and field personnel who are working with ' ' Y. pestis ' ' organisms resistant to antimicrobials ; ( 2 ) people engaged in aerosol experiments with ' ' Y. pestis ' ' ; and ( 3 ) people engaged in field operations in areas with enzootic plague where preventing exposure is not possible ( such as some disaster areas ) . A systematic review by the Cochrane Collaboration found no studies of sufficient quality to make any statement on the efficacy of the vaccine . # Pathology # # Bubonic plague # When a flea bites a human and contaminates the wound with regurgitated blood , the plague carrying bacteria are passed into the tissue . ' ' Y. pestis ' ' can reproduce inside cells , so even if phagocytosed , they can still survive . Once in the body , the bacteria can enter the lymphatic system , which drains interstitial fluid . Plague bacteria secrete several toxins , one of which is known to cause dangerous beta-adrenergic blockade . ' ' Y. pestis ' ' spreads through the lymphatics of the infected human until it reaches a lymph node , where it stimulates severe haemorrhagic inflammation that causes the lymph nodes to expand . The expansion of lymph nodes is the cause of the characteristic bubo associated with the disease . If the lymph node is overwhelmed , the infection can pass into the bloodstream , causing ' ' secondary septicemic plague ' ' and if the lungs are seeded , it can cause ' ' secondary pneumonic plague ' ' . # Septicemic plague # Lymphatics ultimately drain into the bloodstream , so the plague bacteria may enter the blood and travel to almost any part of the body . In septicemic plague , bacterial endotoxins cause disseminated intravascular coagulation ( DIC ) , causing tiny clots throughout the body and possibly ischaemic necrosis ( tissue death due to lack of circulation/perfusion to that tissue ) from the clots . DIC results in depletion of the body 's clotting resources , so that it can no longer control bleeding . Consequently , there is bleeding into the skin and other organs , which can cause red and/or black patchy rash and hemoptysis/hematemesis ( coughing up/ vomiting of blood ) . There are bumps on the skin that look somewhat like insect bites ; these are usually red , and sometimes white in the center . Untreated , septicemic plague is usually fatal . Early treatment with antibiotics reduces the mortality rate to between 4 and 15 percent . People who die from this form of plague often die on the same day symptoms first appear . # Pneumonic plague # The pneumonic form of plague arises from infection of the lungs . It causes coughing and sneezing and thereby produces airborne droplets that contain bacterial cells and are likely to infect anyone inhaling them . The incubation period for pneumonic plague is short , usually two to four days , but sometimes just a few hours . The initial signs are indistinguishable from several other respiratory illnesses ; they include headache , weakness , and hemoptysis or hematemesis ( spitting or vomiting of blood ) . The course of the disease is rapid ; unless diagnosed and treated soon enough , typically within a few hours , death may follow in one to six days ; in untreated cases mortality is nearly 100%. # Pharyngeal plague # This is an uncommon form of plague that resembles tonsillitis found in cases of close contact of patients with other forms of plague . # Meningeal plague # This form of plague occurs when bacteria cross the blood-brain barrier , leading to infectious meningitis . # Other clinical forms # There are a few other rare manifestations of plague , including asymptomatic plague and abortive plague . ' ' Cellulocutaneous plague ' ' sometimes results in infection of the skin and soft tissue , often around the bite site of a flea. # Treatments # Waldemar Haffkine , a doctor who worked in Bombay , India , was the first to invent and test a plague vaccine against bubonic plague in 1897 . If diagnosed in time the various forms of plague are usually highly responsive to antibiotic therapy . The antibiotics often used are streptomycin , chloramphenicol and tetracycline . Amongst the newer generation of antibiotics , gentamicin and doxycycline have proven effective in monotherapeutic treatment of plague . # History # # Antiquity # The earliest account describing a possible plague epidemic is found in I Samuel 5:6 of the Hebrew Bible ( Tanakh ) . In this account , the Philistines of Ashdod were stricken with a plague for the crime of stealing the Ark of the Covenant from the Children of Israel . The word tumors is used in most English translations to describe the sores that came upon the Philistines . The account indicates that the Philistine city and its political territory were stricken with a ravaging of mice and a plague , bringing death to a large segment of the population . In the second year of the Peloponnesian War ( 430 BC ) , Thucydides described an epidemic disease which was said to have begun in Ethiopia , passed through Egypt and Libya , then come to the Greek world . In the Plague of Athens , the city lost possibly one third of its population , including Pericles . Modern historians disagree on whether the plague was a critical factor in the loss of the war . Although this epidemic has long been considered an outbreak of plague , many modern scholars believe that typhus , smallpox , or measles may better fit the surviving descriptions . A recent study of DNA found in the dental pulp of plague victims suggests that typhoid was actually responsible . In the first century AD , Rufus of Ephesus , a Greek anatomist , refers to an outbreak of plague in Libya , Egypt , and Syria . He records that Alexandrian doctors named Dioscorides and Posidonius described symptoms including acute fever , pain , agitation , and delirium . Buboeslarge , hard , and non-suppuratingdeveloped behind the knees , around the elbows , and in the usual places . The death toll of those infected was very high . Rufus also wrote that similar buboes were reported by a Dionysius Curtus , who may have practiced medicine in Alexandria in the third century BC . If this is correct , the eastern Mediterranean world may have been familiar with bubonic plague at that early date . In the second century , the Antonine Plague , named after Marcus Aurelius family name of Antoninus and also known as the Plague of Galen , who had first hand knowledge of the disease , may in fact have been smallpox . Galen was in Rome when it struck in 166 AD , and was also present in the winter of 16869 during an outbreak among troops stationed at Aquileia ; he had experience with the epidemic , referring to it as very long lasting , and describes its symptoms and his treatment of it . Unfortunately , his references are scattered and brief . According to Barthold Georg Niebuhr this pestilence must have raged with incredible fury ; it carried off innumerable victims . The ancient world never recovered from the blow inflected upon it by the plague which visited it in the reign of M. Aurelius . The mortality rate of the plague was 710 percent ; the outbreak in 1656168 would have caused approximately 3.5 to 5 million deaths . Otto Seek believes that over half the population of the empire perished . J. F. Gilliam believes that the Antonine plague probably caused more deaths than any other epidemic during the empire before the mid-3rd century . # Medieval and post-medieval pandemics # Local outbreaks of the plague are grouped into three plague pandemics , whereby the respective start and end dates and the assignment of some outbreaks to either pandemic are still subject to discussion . According to Joseph P. Byrne from Belmont University , the pandemics were :  the first plague pandemic from 541 to 750 , spreading from Egypt to the Mediterranean ( starting with the Plague of Justinian ) and northwestern Europe  the second plague pandemic from 1345 to 1840 , spreading from Central Asia to the Mediterranean and Europe ( starting with the Black Death ) , and probably also to China  the third plague pandemic from 1866 to the 1960s , spreading from China to various places around the world , notably India and the West Coast of the United States . However , the late medieval Black Death is sometimes seen not as the start of the second , but as the end of the first pandemic in that case , the second pandemic 's start would be 1361 ; also vary the end dates of the second pandemic given in literature , e.g. 1890 instead of 1840. # First Pandemic : Early Middle Ages ( Plague of Justinian ) # The Plague of Justinian in AD 541542 is the first known attack on record , and marks the first firmly recorded pattern of bubonic plague . This disease is thought to have originated in China . It then spread to Africa from where the huge city of Constantinople imported massive amounts of grain , mostly from Egypt , to feed its citizens . The grain ships were the source of contagion for the city , with massive public granaries nurturing the rat and flea population . At its peak the plague was killing 10,000 people in Constantinople every day and ultimately destroyed perhaps 40% of the city 's inhabitants . It went on to destroy up to a quarter of the human population of the eastern Mediterranean . In AD 588 a second major wave of plague spread through the Mediterranean into what is now France . It is estimated that the Plague of Justinian killed as many as people across the world . It caused Europe 's population to drop by around 50% between 541 and 700 . It also may have contributed to the success of the Arab conquests . An outbreak of it in the AD 560s was described in AD 790 as causing swellings in the glands .. in the manner of a nut or date in the groin and in other rather delicate places followed by an unbearable fever . While the swellings in this description have been identified by some as buboes , there is some contention as to whether the pandemic should be attributed to the bubonic plague , ' ' Yersinia pestis ' ' , known in modern times . # Second Pandemic : from 14th century ( Black Death ) to 19th century # From 1347 to 1351 , the Black Death , a massive and deadly pandemic originating in China , spread along the Silk Road and swept through Asia , Europe and Africa . It may have reduced the world 's population from to between 350 and . China lost around half of its population , from around to around ; Europe around 1/3 of its population , from about to about ; and Africa approximately 1/8 of its population , from around to ( mortality rates tended to be correlated with population density so Africa , being less dense overall , had the lowest death rate ) . This makes the Black Death the largest death toll from any known non-viral epidemic . Although accurate statistical data does not exist , it is thought that 1.4 million died in England ( 1/3 of England 's 4.2 million people ) , while an even higher percentage of Italy 's population was likely wiped out . On the other hand , Northeastern Germany , Bohemia , Poland and Hungary are believed to have suffered less , and there are no estimates available for Russia or the Balkans . It is conceivable that Russia may not have been as affected due to its very cold climate and large size , hence often less close contact with the contagion . The plague repeatedly returned to haunt Europe and the Mediterranean throughout the 14th to 17th centuries . According to Biraben , plague was present somewhere in Europe in every year between 1346 and 1671 . The Second Pandemic was particularly widespread in the following years : 13601363 ; 1374 ; 1400 ; 14381439 ; 14561457 ; 14641466 ; 14811485 ; 15001503 ; 15181531 ; 15441548 ; 15631566 ; 15731588 ; 15961599 ; 16021611 ; 16231640 ; 16441654 ; and 16641667 ; subsequent outbreaks , though severe , marked the retreat from most of Europe ( 18th century ) and northern Africa ( 19th century ) . According to Geoffrey Parker , France alone lost almost a million people to plague in the epidemic of 162831 . In England , in the absence of census figures , historians propose a range of pre-incident population figures from as high as 7 million to as low as 4 million in 1300 , and a postincident population figure as low as 2 million . By the end of 1350 , the Black Death subsided , but it never really died out in England . Over the next few hundred years , further outbreaks occurred in 136162 , 1369 , 137983 , 138993 , and throughout the first half of the 15th century . An outbreak in 1471 took as much as 1015% of the population , while the death rate of the plague of 147980 could have been as high as 20% . The most general outbreaks in Tudor and Stuart England seem to have begun in 1498 , 1535 , 1543 , 1563 , 1589 , 1603 , 1625 , and 1636 , and ended with the Great Plague of London in 1665 . In 1466 , perhaps 40,000 people died of plague in Paris . During the 16th and 17th centuries , plague visited Paris for almost one year out of three . The Black Death ravaged Europe for three years before it continued on into Russia , where the disease hit somewhere once every five or six years from 1350 to 1490 . Plague epidemics ravaged London in 1563 , 1593 , 1603 , 1625 , 1636 , and 1665 , reducing its population by 10 to 30% during those years . Over 10% of Amsterdam 's population died in 16231625 , and again in 16351636 , 1655 , and 1664 . There were 22 outbreaks of plague in Venice between 1361 and 1528 . The plague of 15761577 killed 50,000 in Venice , almost a third of the population . Late outbreaks in central Europe included the Italian Plague of 16291631 , which is associated with troop movements during the Thirty Years ' War , and the Great Plague of Vienna in 1679 . Over 60% of Norway 's population died from 1348 to 1350 . The last plague outbreak ravaged Oslo in 1654 . In the first half of the 17th century , a plague claimed some 1.7 million victims in Italy , or about 14% of the population . In 1656 , the plague killed about half of Naples ' 300,000 inhabitants . More than 1.25 million deaths resulted from the extreme incidence of plague in 17th-century Spain . The plague of 1649 probably reduced the population of Seville by half . In 17091713 , a plague epidemic that followed the Great Northern War ( 17001721 , Sweden v. Russia and allies ) Plague was present in at least one location in the Islamic world virtually every year between 1500 and 1850 . Plague repeatedly struck the cities of North Africa . Algiers lost 30,00050,000 to it in 162021 , and again in 165457 , 1665 , 1691 , and 174042 . Plague remained a major event in Ottoman society until the second quarter of the 19th century . Between 1701 and 1750 , 37 larger and smaller epidemics were recorded in Constantinople , and 31 between 1751 and 1800 . Baghdad has suffered severely from visitations of the plague , and sometimes two-thirds of its population has been wiped out . # #Nature of the Black Death# # In the early 20th century , following the identification by Yersin and Kitasato of the plague bacterium that caused the late 19th and early 20th century Asian bubonic plague ( the Third Pandemic ) , most scientists and historians came to believe that the Black Death was an incidence of this plague , with a strong presence of the more contagious pneumonic and septicemic varieties increasing the pace of infection , spreading the disease deep into inland areas of the continents . Some modern researchers have argued that the disease was more likely to have been viral , pointing to the absence of rats from some parts of Europe that were badly affected and to the conviction of people at the time that the disease was spread by direct human contact . According to the accounts of the time the Black Death was extremely virulent , unlike the 19th and early 20th century bubonic plague . Samuel K. Cohn has made a comprehensive attempt to rebut the bubonic plague theory . Researchers have offered a mathematical model based on the changing demography of Europe from AD 1000 to 1800 demonstrating how plague epidemics , 1347 to 1670 , could have provided the selection pressure that raised the frequency of a mutation to the level seen today that prevent HIV from entering macrophages and CD4+ T cells that carry the mutation ( the average frequency of this allele is 10% in European populations ) . It is suggested that the original single mutation appeared over 2,500 years ago and that persistent epidemics of a haemorrhagic fever struck at the early classical civilizations . However recent research published in the open-access scientific journal ' ' PloS Pathogens ' ' in October 2010 presented conclusive evidence that two previously unknown clades ( variant strains ) of ' ' Y. pestis ' ' were responsible for the Black Death . A multinational team conducted new surveys that used both ancient DNA analyses and protein-specific detection to find DNA and protein signatures specific for ' ' Y. pestis ' ' in human skeletons from widely distributed mass graves in northern , central and southern Europe that were associated archaeologically with the Black Death and subsequent resurgences . The authors concluded that this research , together with prior analyses from the south of France and Germany , : .. ends the debate about the etiology of the Black Death , and unambiguously demonstrates that ' ' Y. pestis ' ' was the causative agent of the epidemic plague that devastated Europe during the Middle Ages . The study also identified two previously unknown but related strains of ' ' Y. pestis ' ' that were associated with distinct medieval mass graves . These were found to be ancestral to modern isolates of the present-day ' ' Y. pestis ' ' strains ' Orientalis ' and ' Medievalis ' , suggesting that these variant strains ( which are now presumed to be extinct ) may have entered Europe in two waves . Surveys of plague pit remains in France and England indicate that the first variant entered Europe through the port of Marseille around November 1347 and spread through France over the next two years , eventually reaching England in the spring of 1349 , where it spread through the country in three successive epidemics . Surveys of plague pit remains from the Netherlands town of Bergen op Zoom showed evidence of a second ' ' Y. pestis ' ' genotype which differed from that found in Britain and France and this second strain is now thought to have been responsible for the pandemic that spread through the Low Countries from 1350 . This discovery implies that Bergen op Zoom ( and possibly other parts of the southern Netherlands ) was not directly infected from England or France c . AD 1349 , and the researchers have suggested that a second wave of plague infection , distinct from that which occurred in Britain and France , may have been carried to the Low Countries from Norway , the Hanseatic cities , or another site . # Third Pandemic : 19th and 20th centuries # The Third Pandemic began in China 's Yunnan province in 1855 , spreading plague to all inhabited continents and ultimately killing more than people in India and China alone . Casualty patterns indicate that waves of this pandemic may have come from two different sources . The first was primarily bubonic and was carried around the world through ocean-going trade , transporting infected persons , rats , and cargoes harboring fleas . The second , more virulent strain was primarily pneumonic in character , with a strong person-to-person contagion . This strain was largely confined to Manchuria and Mongolia . Researchers during the Third Pandemic identified plague vectors and the plague bacterium ( see above ) , leading in time to modern treatment methods . Plague occurred in Russia in 18771889 in rural areas near the Ural Mountains and the Caspian Sea . Efforts in hygiene and patient isolation reduced the spread of the disease , with approximately 420 deaths in the region . Significantly , the region of Vetlianka in this area is near a population of the bobak marmot , a small rodent considered a very dangerous plague reservoir . The last significant Russian outbreak of Plague was in Siberia in 1910 after sudden demand for marmot skins ( a substitute for sable ) increased the price by 400 percent . The traditional hunters would not hunt a sick Marmot and it was taboo to eat the fat from under the arm ( the axillary lymphatic gland that often harboured the plague ) so outbreaks tended to be confined to single individuals . The price increase , however , attracted thousands of Chinese hunters from Manchuria who not only caught the sick animals but also ate the fat , which was considered a delicacy . The plague spread from the hunting grounds to the terminus of the Chinese Eastern Railway and then followed the track for 2,700 km . The plague lasted 7 months and killed 60,000 people . The bubonic plague continued to circulate through different ports globally for the next fifty years ; however , it was primarily found in Southeast Asia . An epidemic in Hong Kong in 1894 had particularly high death rates , 90% . As late as 1897 , medical authorities in the European powers organized a conference in Venice , seeking ways to keep the plague out of Europe . Mumbai plague epidemic struck the city of Bombay ( Mumbai ) in 1896 . The disease reached the Territory of Hawaii in December 1899 , and the Board of Health 's decision to initiate controlled burns of select buildings in Honolulu 's Chinatown turned into an uncontrolled fire which led to the inadvertent burning of most of Chinatown on January 20 , 1900 . Shortly thereafter , plague reached the continental US , initiating the San Francisco plague of 19001904 . Plague persisted in Hawaii on the outer islands of Maui and Hawaii ( The Big Island ) until it was finally eradicated in 1959 . Although the outbreak that began in China in 1855 is conventionally known as the Third Pandemic ( see above ) , it is unclear whether there have been fewer , or more , than three major outbreaks of bubonic plague . Most modern outbreaks of bubonic plague amongst humans have been preceded by a striking , high mortality amongst rats , yet this phenomenon is absent from descriptions of some earlier plagues , especially the Black Death . The buboes , or swellings in the groin , that are especially characteristic of bubonic plague , are a feature of other diseases as well . Research done by a team of biologists from the Institute of Pasteur in Paris and Johannes Gutenberg University Mainz in Germany by analyzing the DNA and proteins from plague pits was published in October 2010 , reported beyond doubt that all ' the three major plagues ' were due to at least two previously unknown strains of ' ' Yersinia pestis ' ' and originated from China . A team of medical geneticists led by Mark Achtman of University College Cork in Ireland reconstructed a family tree of the bacterium and concluded in an online issue of Nature Genetics published on 31 October 2010 that all three of the great waves of plague originated from China . # Plague as a biological weapon # Plague has a long history as a biological weapon . Historical accounts from ancient China and medieval Europe detail the use of infected animal carcasses , such as cows or horses , and human carcasses , by the Xiongnu/Huns , Mongols , Turks , and other groups , to contaminate enemy water supplies . Han Dynasty General Huo Qubing is recorded to have died of such a contamination while engaging in warfare against the Xiongnu . Plague victims were also reported to have been tossed by catapult into cities under siege . In 1347 , the Genoese possession of Caffa , a great trade emporium on the Crimean peninsula , came under siege by an army of Mongol warriors of the Golden Horde under the command of Janibeg . After a protracted siege during which the Mongol army was reportedly withering from the disease , they decided to use the infected corpses as a biological weapon . The corpses were catapulted over the city walls , infecting the inhabitants . The Genoese traders fled , transferring the plague ( Black Death ) via their ships into the south of Europe , whence it rapidly spread . During World War II , the Japanese Army developed weaponised plague , based on the breeding and release of large numbers of fleas . During the Japanese occupation of Manchuria , Unit 731 deliberately infected Chinese , Korean , and Manchurian civilians and prisoners of war with the plague bacterium . These subjects , termed maruta , or logs , were then studied by dissection , others by vivisection while still conscious . Members of the unit such as Shiro Ishii were exonerated from the Tokyo tribunal by Douglas MacArthur but 12 of them were prosecuted in the Khabarovsk War Crime Trials in 1949 during which some admitted having spread bubonic plague within a 36-km radius around the city of Changde . Ishii innovated bombs containing live mice and fleas , with very small explosive loads , to deliver the weaponized microbes , overcoming the problem of the explosive killing the infected animal and insect by the use of a ceramic , rather than metal , casing for the warhead . While no records survive of the actual usage of the ceramic shells , prototypes exist and are believed to have been used in experiments during WWII . After World War II , both the United States and the Soviet Union developed means of weaponising pneumonic plague . Experiments included various delivery methods , vacuum drying , sizing the bacterium , developing strains resistant to antibiotics , combining the bacterium with other diseases ( such as diphtheria ) , and genetic engineering . Scientists who worked in Soviet Union # 1994 epidemic in Surat , India # In 1994 , there was a pneumonic plague epidemic in Surat , India that resulted in 52 deaths and in a large internal migration of about 300,000 residents , who fled fearing quarantine . A combination of heavy monsoon rain and clogged sewers led to massive flooding which resulted in unhygienic conditions and a number of uncleared animal carcasses . It is believed that this situation precipitated the epidemic . There was widespread fear that the sudden rush of people from this area might spread the epidemic to other parts of India and the world , but that scenario was averted , probably as a result of effective public health response mounted by the Indian health authorities . Some countries , especially those in the nearby Gulf region , took the step of cancelling some flights and putting a pause on shipments from India . Much like the Black Death that spread through medieval Europe , some questions still remain unanswered about the 1994 epidemic in Surat . Initial questions about whether it was an epidemic of plague arose because the Indian health authorities were unable to culture ' ' Yersinia pestis ' ' , but this could have been due to poor laboratory procedures . Yet , there are several lines of evidence strongly suggesting that it was a plague epidemic : blood tests for Yersinia were positive , a number of individuals showed antibodies against Yersinia and the clinical symptoms displayed by the affected were all consistent with the disease being plague . # Other contemporary cases #  On August 31 , 1984 , the Centers for Disease Control and Prevention reported a case of pneumonic plague in Claremont , California . The CDC believes that the patient , a veterinarian , contracted plague from a stray cat . As the cat was n't available for necropsy , this could not be ultimately confirmed .  From 1995 to 1998 , annual outbreaks of plague were witnessed in Mahajanga , Madagascar .  In the U.S. , about half of all fatal cases of plague since 1970 have occurred in New Mexico . There were 2 plague deaths in the state in 2006 , the first fatalities in 12 years .  In February 2002 , a small outbreak of pneumonic plague took place in the Shimla District of Himachal Pradesh state in northern India .  In the fall of 2002 , a New Mexico couple contracted the disease , just prior to a visit to New York City . They both were treated by antibiotics , but the male required amputation of both feet to fully recover , due to the lack of blood flow to his feet , cut off by the bacteria .  On April 19 , 2006 , CNN News and others reported a case of plague in Los Angeles , California , lab technician Nirvana Kowlessar , the first reported case in that city since 1984.  In May 2006 , KSL Newsradio reported a case of plague found in dead field mice and chipmunks at Natural Bridges National Monument about 40mi km west of Blanding in San Juan County , Utah .  In May 2006 , Arizona media reported a case of plague found in a cat .  One hundred deaths resulting from pneumonic plague were reported in Ituri district of the eastern Democratic Republic of the Congo in June 2006 . Control of the plague was proving difficult due to the ongoing conflict .  It was reported in September 2006 that three mice infected with ' ' Yersinia pestis ' ' apparently disappeared from a laboratory belonging to the Public Health Research Institute , located on the campus of the University of Medicine and Dentistry of New Jersey , which conducts anti-bioterrorism research for the United States government .  On May 16 , 2007 , an 8-year-old hooded capuchin monkey in the Denver Zoo died of the bubonic plague . Five squirrels and a rabbit were also found dead on zoo grounds and tested positive for the disease .  On June 5 , 2007 in Torrance County , New Mexico a 58-year-old woman developed bubonic plague , which progressed to pneumonic plague .  On November 2 , 2007 , Eric York , a 37 year old wildlife biologist for the National Park Service 's and , was found dead in his home at Grand Canyon National Park . On October 27 , York performed a necropsy on a mountain lion that had likely perished from the disease and three days afterward York complained of flu-like symptoms and called in sick from work . He was treated at a local clinic but was not diagnosed with any serious ailment . The discovery of his death sparked a minor health scare , with officials stating he likely died of either plague or hantavirus , and 49 people who had come into contact with York were given aggressive antibiotic treatments . None of them fell ill . Autopsy results released on November 9 , confirmed the presence of ' ' Y. pestis ' ' in his body , confirming plague as a likely cause of death .  In January 2008 , at least 18 people died of bubonic plague in Madagascar .  On June 16 , 2009 , Libyan authorities reported an outbreak of bubonic plague in Tobruk , Libya . 16-18 cases were reported , including one death .  On August 2 , 2009 , Chinese authorities quarantined the town of Ziketan , Xinghai County in Hainan Tibetan Autonomous Prefecture , Qinghai Province ( Northwestern China ) after an outbreak of pneumonic plague . As of this writing , three have died and ten more are ill , being treated in hospital .  On September 13 , 2009 , Dr. Malcolm Casadaban died following an accidental laboratory exposure to an attenuated strain of the plague bacterium . This has happened due to his undiagnosed hereditary hemochromatosis ( iron overload ) . He was an Associate Professor of Molecular Genetics and Cell Biology and of Microbiology at the University of Chicago .  On 1 July 2010 , eight cases of Bubonic plague were reported in humans in the District of Chicama , Peru . One 32 year old man was affected , as well as three boys and four girls ranging in age from 8 to 14 years old . 425 houses were fumigated and 1210 guinea pigs , 232 dogs , 128 cats and 73 rabbits were given anti flea treatment in an effort to stop the epidemic .  On May 3 , 2012 , a ground squirrel trapped during routine testing at a popular campground on Palomar Mountain in San Diego County , California , tested positive for the plague bacteria .  On June 2 , 2012 , a man in Crook County , Oregon , attempting to rescue a cat choking on a mouse , was bitten and became infected with septicemic plague .  On July 16 , 2013 , A squirrel trapped in the Table Mountain Campgrounds of Angeles National Forest , tested positive for the plague , prompting a health advisory and the closing of the campground while investigators tested other squirrels and dusted the area for plague-infected fleas.  On August 26 , 2013 Temir Isakunov , a teenage boy , died of bubonic plague in northern Kyrgyzstan .  December 2013 reports of Pneumonic Plague epidemic in 5 of 112 districts of Madagascar , believed to be caused by large brush fires forcing rats into towns .  On July 13 , 2014 a Colorado man was diagnosed with the pneumonic plague  On July 22 , 2014 the city of Yumen , China was sealed off and 151 people were put in quarantine after a man died of bubonic plague 
@@5876 ICDO = Coronary artery disease ( CAD ) also known as atherosclerotic heart disease , coronary heart disease , or ischemic heart disease ( IHD ) , is the most common type of heart disease and cause of heart attacks . The disease is caused by plaque building up along the inner walls of the arteries of the heart , which narrows the arteries and reduces blood flow to the heart . While the symptoms and signs of coronary artery disease are noted in the advanced state of disease , most individuals with coronary artery disease show no evidence of disease for decades as the disease progresses before the first onset of symptoms , often a sudden heart attack , finally arises . Symptoms of stable ischaemic heart disease include angina ( characteristic chest pain on exertion ) and decreased exercise tolerance . Unstable IHD presents itself as chest pain or other symptoms at rest , or rapidly worsening angina . The risk of artery narrowing increases with age , smoking , high blood cholesterol , diabetes , high blood pressure , and is more common in men and those who have close relatives with CAD . Other causes include coronary vasospasm , a spasm of the blood vessels of the heart , it is usually called Prinzmetal 's angina . Diagnosis of IHD is with an electrocardiogram , blood tests ( cardiac markers ) , cardiac stress testing or a coronary angiogram . Depending on the symptoms and risk , treatment may be with medication , percutaneous coronary intervention ( angioplasty ) or coronary artery bypass surgery ( CABG ) . It was as of 2012 the most common cause of death in the world , and a major cause of hospital admissions . There is limited evidence for population screening , but prevention ( with a healthy diet and sometimes medication for diabetes , cholesterol and high blood pressure ) is used both to prevent IHD and to decrease the risk of complications . # Signs and symptoms # Angina ( chest pain ) that occurs regularly with activity , after heavy meals , or at other predictable times is termed stable angina and is associated with high grade narrowings of the heart arteries . The symptoms of angina are often treated with betablocker therapy such as metoprolol or atenolol . Nitrate preparations such as nitroglycerin , which come in short-acting and long-acting forms are also effective in relieving symptoms but are not known to reduce the chances of future heart attacks . Many other more effective treatments , especially of the underlying atheromatous disease , have been developed . Angina that changes in intensity , character or frequency is termed unstable . Unstable angina may precede myocardial infarction . About 80% of chest pains have nothing to do with the heart . # Risk factors # Coronary artery disease has a number of well determined risk factors . The most common risk factors include smoking , family history , hypertension , obesity , diabetes , lack of exercise , stress , and hyperlipidemia . Smoking is associated with about 54% of cases and obesity 20% . Lack of exercise has been linked to 712% of cases . Job stress appears to play a minor role accounting for about 3% of cases . In one study , women who were free of stress from work life saw an increase in the diameter of their blood vessels , leading to decreased progression of atherosclerosis . Contrastingly , women who had high levels of work-related stress experienced a decrease in the diameter of their blood vessels and significantly increased disease progression . Also , having a type A behavior pattern , a group of personality characteristics including time urgency , competitiveness , hostility , and impatience is linked to an increased risk of coronary disease . Risk factors can be classified as : fixed ( such as age , sex , family history ) and modifiable ( such as smoking , hypertension , diabetes mellitus , obesity , etc. ) Hypercholesterolemia ( specifically , serum LDL concentrations ) Type A personality  Hemostatic factors : High levels of fibrinogen and coagulation factor VII are associated with an increased risk of CAD . Factor VII levels are higher in individuals with a high intake of dietary fat . Decreased fibrinolytic activity has been reported in patients with coronary atherosclerosis .  High levels of Lipoprotein(a) , a compound formed when LDL cholesterol combines with a substance known as Apoliprotein ( a ) .  Men over 60 ; Women over 65  Low hemoglobin High blood triglycerides may play a role . # Pathophysiology # Limitation of blood flow to the heart causes ischemia ( cell starvation secondary to a lack of oxygen ) of the myocardial cells . Myocardial cells may die from lack of oxygen and this is called a myocardial infarction ( commonly called a heart attack ) . It leads to heart muscle damage , heart muscle death and later myocardial scarring without heart muscle regrowth . Chronic high-grade stenosis of the coronary arteries can induce transient ischemia which leads to the induction of a ventricular arrhythmia , which may terminate into ventricular fibrillation leading to death . Typically , coronary artery disease occurs when part of the smooth , elastic lining inside a coronary artery ( the arteries that supply blood to the heart muscle ) develops atherosclerosis . With atherosclerosis , the artery 's lining becomes hardened , stiffened , and swollen with all sorts of gunge - including calcium deposits , fatty deposits , and abnormal inflammatory cells - to form a plaque . Deposits of calcium phosphates ( hydroxyapatites ) in the muscular layer of the blood vessels appear to play not only a significant role in stiffening arteries but also for the induction of an early phase of coronary arteriosclerosis . This can be seen in a so-called metastatic mechanism of calcification as it occurs in chronic kidney disease and haemodialysis ( Rainer Liedtke 2008 ) . Although these patients suffer from a kidney dysfunction , almost fifty percent of them die due to coronary artery disease . Plaques can be thought of as large pimples that protrude into the channel of an artery , causing a partial obstruction to blood flow . Patients with coronary artery disease might have just one or two plaques , or might have dozens distributed throughout their coronary arteries . However , there is a term in medicine called cardiac syndrome X , which describes chest pain ( Angina pectoris ) and chest discomfort in people who do not show signs of blockages in the larger coronary arteries of their hearts when an angiogram ( coronary angiogram ) is being performed . No one knows exactly what causes cardiac syndrome X. One explanation is microvascular dysfunction . It is not completely clear why women are more likely than men to have it however , hormones and other risk factors unique to women may play a role . # Diagnosis # For symptomatic patients , stress echocardiography can be used to make a diagnosis for obstructive coronary artery disease . The use of echocardiography is not recommended on individuals who are exhibiting no symptoms and are otherwise at low risk for developing coronary disease . CAD has always been a tough disease to diagnose without the use of invasive or stressful activities . The development of the Multifunction Cardiogram ( MCG ) has changed the way CAD is diagnosed . The MCG consists of a 2 lead resting EKG signal is transformed into a mathematical model and compared against tens of thousands of clinical trials to diagnose a patient with an objective severity score , as well as secondary and tertiary results about the patients condition . The results from MCG tests have been validated in 8 clinical trials This level of accuracy comes from the application of advanced techniques in signal processing and systems analysis combined with a large scale clinical database which allows MCG to provide quantitative , evidence-based results to assist physicians in reaching a diagnosis . The MCG has also been awarded a Category III CPT code by the American Medical Association in the July 2009 CPT update The diagnosis of Cardiac Syndrome X - the rare coronary artery disease that is more common in women , as mentioned , an exclusion diagnosis . Therefore , usually the same tests are used as in any patient with the suspicion of coronary artery disease :  Baseline electrocardiography ( ECG )  Exercise ECG Stress test  Exercise radioisotope test ( nuclear stress test , myocardial scintigraphy )  Echocardiography ( including stress echocardiography )  Coronary angiography  Intravascular ultrasound  Magnetic resonance imaging ( MRI ) The diagnosis of coronary disease underlying particular symptoms depends largely on the nature of the symptoms . The first investigation is an electrocardiogram ( ECG/EKG ) , both for stable angina and acute coronary syndrome . An X-ray of the chest and blood tests may be performed . # Stable angina # In stable angina , chest pain with typical features occurring at predictable levels of exertion , various forms of cardiac stress tests may be used to induce both symptoms and detect changes by way of electrocardiography ( using an ECG ) , echocardiography ( using ultrasound of the heart ) or scintigraphy ( using uptake of radionuclide by the heart muscle ) . If part of the heart seems to receive an insufficient blood supply , coronary angiography may be used to identify stenosis of the coronary arteries and suitability for angioplasty or bypass surgery . # Acute coronary syndrome # Diagnosis of acute coronary syndrome generally takes place in the emergency department , where ECGs may be performed sequentially to identify evolving changes ( indicating ongoing damage to the heart muscle ) . Diagnosis is clear-cut if ECGs show elevation of the ST segment , which in the context of severe typical chest pain is strongly indicative of an acute myocardial infarction ( MI ) ; this is termed a STEMI ( ST-elevation MI ) , and is treated as an emergency with either urgent coronary angiography and percutaneous coronary intervention ( angioplasty with or without stent insertion ) or with thrombolysis ( clot buster medication ) , whichever is available . In the absence of ST-segment elevation , heart damage is detected by cardiac markers ( blood tests that identify heart muscle damage ) . If there is evidence of damage ( infarction ) , the chest pain is attributed to a non-ST elevation MI ( NSTEMI ) . If there is no evidence of damage , the term unstable angina is used . This process usually necessitates admission to hospital , and close observation on a coronary care unit for possible complications ( such as cardiac arrhythmias irregularities in the heart rate ) . Depending on the risk assessment , stress testing or angiography may be used to identify and treat coronary artery disease in patients who have had an NSTEMI or unstable angina. # Risk assessment # There are various risk assessment systems for determining the risk of coronary artery disease , with various emphasis on different variables above . A notable example is Framingham Score , used in the Framingham Heart Study . It is mainly based on age , gender , diabetes , total cholesterol , HDL cholesterol , tobacco smoking and systolic blood pressure . # Prevention # Prevention involves : exercise , decreasing obesity , treating hypertension , a healthy diet , decreasing cholesterol levels , and stopping smoking . Medications and exercise are roughly equally effective . In diabetes mellitus , there is little evidence that very tight blood sugar control improves cardiac risk although improved sugar control appears to decrease other problems like kidney failure and blindness . The World Health Organization ( WHO ) recommends low to moderate alcohol intake to reduce risk of coronary artery disease although this remains without scientific cause and effect proof . # Diet # It has been suggested that coronary artery disease is partially reversible using an intense dietary regimen coupled with regular cardiovascular exercise . A high fiber diet appears to lower the risk . Vegetarian diet : Vegetarians have been shown to have a 24% reduced risk of dying of heart disease . Cretan Mediterranean diet : The Seven Countries Study found that Cretan men had exceptionally low death rates from heart disease , despite moderate to high intake of fat . The Cretan diet is similar to other traditional Mediterranean diets : consisting mostly of olive oil , bread , abundant fruit and vegetables , a moderate amount of wine and fat-rich animal products such as lamb , and goat cheese . The consumption of trans fat ( commonly found in hydrogenated products such as margarine ) has been shown to cause the development of endothelial dysfunction , a precursor to atherosclerosis . The consumption of trans fatty acids has been shown to increase the risk of coronary artery disease Avoiding fats that are readily oxidized ( e.g. , trans-fats ) , and limiting carbohydrates and processed sugars may reduce low density lipoproteins , triacylglycerol and apolipoprotein-B thus decreasing the risk . Evidence does not support a beneficial role for omega-3 fatty acid supplementation in preventing cardiovascular disease ( including myocardial infarction and sudden cardiac death ) . Menaquinone ( Vitamin K <sub> 2 </sub> ) , but not phylloquinone ( Vitamin K <sub> 1 </sub> ) , intake may reduce the risk of CAD mortality . # Secondary prevention # Secondary prevention is preventing further sequelae of already established disease . Regarding coronary artery disease , this can mean risk factor management that is carried out during cardiac rehabilitation , a 4-phase process beginning in hospital after MI , angioplasty or heart surgery and continuing for a minimum of three months . Exercise is a main component of cardiac rehabilitation along with diet , smoking cessation , and blood pressure and cholesterol management . Beta blockers may also be used for this purpose . # Treatment # There are three main treatment options for coronary artery disease : #Medical treatment - drugs ( e.g. cholesterol lowering medications , beta-blockers , nitroglycerin , calcium antagonists , etc. ) ; #Coronary interventions as angioplasty and coronary stent ; #Coronary artery bypass grafting ( CABG ) # Lifestyle # Lifestyle changes have been shown to be effective in reducing ( and in the case of diet , reversing ) coronary disease : A whole-food plant-based diet Weight control Smoking cessation  Avoiding the consumption of trans fats ( in hydrogenated oils ) Exercise Aerobic exercise , like walking , jogging , or swimming , can help decrease blood pressure and the amount of blood cholesterol(LDL) over time . It also increases HDL cholesterol which is considered as a good cholesterol  Decrease psychosocial stress . In people with coronary artery disease , aerobic exercise can reduce the risk of mortality . Separate to the question of the benefits of exercise ; it is unclear whether doctors should spend time counseling patients to exercise . The U.S. Preventive Services Task Force , found ' insufficient evidence ' to recommend that doctors counsel patients on exercise , but it did not review the evidence for the effectiveness of physical activity to reduce chronic disease , morbidity and mortality , it only examined the effectiveness of the counseling itself . The American Heart Association , based on a non-systematic review , recommends that doctors counsel patients on exercise . # Medications # Statins , which reduce cholesterol , reduce risk of coronary disease Nitroglycerin Angiotensin-converting enzyme Calcium channel blockers and/or beta-blockers Aspirin # #Aspirin# # In those with no other heart problems aspirin decreases the risk of a myocardial infarction in men but not women and increases the risk of bleeding , most of which is from the stomach . It does not affect the overall risk of death in either men or women . It is thus only recommended in adults who are at increased risk for coronary artery disease # Surgery # Revascularization for acute coronary syndrome has a mortality benefit . Revascularization for ' ' stable ' ' ischaemic heart disease does not appear to have benefits over medical therapy alone . In those with disease in more than one artery coronary artery bypass grafts appear better than percutaneous coronary interventions . # Epidemiology # CAD as of 2010 was the leading cause of death globally resulting in over 7 million deaths . This is up from 5.2 million deaths in 1990 . It may affect individuals at any age but becomes dramatically more common at progressively older ages , with approximately a tripling with each decade of life . Males are affected more often than females . Coronary heart disease ( CHD ) is the leading cause of death for both men and women and accounts for approximately 600,000 deaths in the United States every year . According to present trends in the United States , half of healthy 40-year-old males will develop CAD in the future , and one in three healthy 40-year-old women . It is the most common reason for death of men and women over 20 years of age in the United States . The Maasai of Africa have almost no heart disease . # Research # Recent research efforts focus on new angiogenic treatment modalities ( angiogenesis ) and various ( adult ) stem cell therapies . A region on Chromosome 17 was confined to families with multiple cases of myocardial infarction . A more controversial link is that between ' ' Chlamydophila pneumoniae ' ' infection and atherosclerosis . While this intracellular organism has been demonstrated in atherosclerotic plaques , evidence is inconclusive as to whether it can be considered a causative factor . Treatment with antibiotics in patients with proven atherosclerosis has not demonstrated a decreased risk of heart attacks or other coronary vascular diseases . Since the 1990s the search for new treatment options for coronary artery disease patients , particularly for so called no-option coronary patients , focused on usage of angiogenesis and ( adult ) stem cell therapies . Numerous clinical trials were performed , either applying protein ( angiogenic growth factor ) therapies , such as FGF-1 or VEGF , or cell therapies using different kinds of adult stem cell populations . Research is still going on - with first promising results particularly for FGF-1 and utilization of endothelial progenitor cells . Myeloperoxidase has been proposed as a biomarker. 
@@5992 p=zhng y Traditional Chinese medicine ( TCM ; ) is a broad range of medicine practices sharing common concepts which have been developed in China and are based on a tradition of more than 2,000 years , including various forms of herbal medicine , acupuncture , massage ( Tui na ) , exercise ( qigong ) , and dietary therapy . TCM holds that the body 's vital energy ( ' ' chi ' ' or ' ' qi ' ' ) circulates through channels , called ' ' meridians ' ' , that have branches connected to bodily organs and functions . Concepts of the body and of disease used in TCM has notions of a pre-scientific culture , similar to European humoral theory . Attempts to find a scientific basis or mechanism of action for concepts used in TCM such as the circulation of Qi , the meridian system , and other related theories have failed . The TCM theory and practice are not based upon scientific knowledge , and its own practitioners disagree widely on what diagnosis and treatments should be used for any one patient . The effectiveness of Chinese herbal medicine remains poorly documented . There are concerns over a number of potentially toxic plants , animal parts , and mineral Chinese medicinals . There is a lack of existing cost-effectiveness research for TCM . Pharmaceutical research has explored the potential for creating new drugs from traditional remedies . Successful results have however been scarce . TCM is largely pseudoscience , with no valid mechanism of action for the majority of its treatments . The doctrines of Chinese medicine are rooted in books such as the ' ' Yellow Emperor 's Inner Canon ' ' and the ' ' Treatise on Cold Damage ' ' , as well as in cosmological notions such as yin-yang and the five phases . Starting in the 1950s , these precepts were standardized in the People 's Republic of China , including attempts to integrate them with modern notions of anatomy and pathology . TCM 's view of the body places little emphasis on anatomical structures , but is mainly concerned with the identification of functional entities ( which regulate digestion , breathing , aging etc . ) . While health is perceived as harmonious interaction of these entities and the outside world , disease is interpreted as a disharmony in interaction . TCM diagnosis aims to trace symptoms to patterns of an underlying disharmony , by measuring the pulse , inspecting the tongue , skin , and eyes , and looking at the eating and sleeping habits of the person as well as many other things . # History # Traces of therapeutic activities in China date from the Shang dynasty ( 14th11th centuries BCE ) . Though the Shang did not have a concept of medicine as distinct from other fields , their oracular inscriptions on bones and tortoise shells refer to illnesses that affected the Shang royal family : eye disorders , toothaches , bloated abdomen , etc. , which Shang elites usually attributed to curses sent by their ancestors . There is no evidence that the Shang nobility used herbal remedies . According to a 2006 overview , the Documentation of Chinese materia medica ( CMM ) dates back to around 1,100 BC when only dozens of drugs were first described . By the end of the 16th century , the number of drugs documented had reached close to 1,900 . And by the end of the last century , published records of CMM have reached 12,800 drugs . Stone and bone needles found in ancient tombs led Joseph Needham to speculate that acupuncture might have been carried out in the Shang dynasty . But most historians now make a distinction between medical lancing ( or bloodletting ) and acupuncture in the narrower sense of using metal needles to treat illnesses by stimulating specific points along circulation channels ( meridians ) in accordance with theories related to the circulation of Qi . The earliest public evidence for acupuncture in this sense dates to the second or first century BCE . The ' ' Yellow Emperor 's Inner Canon ' ' , the oldest received work of Chinese medical theory , was compiled around the first century BCE on the basis of shorter texts from different medical lineages . Written in the form of dialogues between the legendary Yellow Emperor and his ministers , it offers explanations on the relation between humans , their environment , and the cosmos , on the contents of the body , on human vitality and pathology , on the symptoms of illness , and on how to make diagnostic and therapeutic decisions in light of all these factors . Unlike earlier texts like ' ' Recipes for Fifty-Two Ailments ' ' , which was excavated in the 1970s from a tomb that had been sealed in 168 BCE , the ' ' Inner Canon ' ' rejected the influence of spirits and the use of magic . It was also one of the first books in which the cosmological doctrines of Yinyang and the Five Phases were brought to a mature synthesis . The ' ' Treatise on Cold Damage Disorders and Miscellaneous Illnesses ' ' was collated by Zhang Zhongjing sometime between 196 and 220 CE , at the end of the Han dynasty . Focusing on drug prescriptions rather than acupuncture , it was the first medical work to combine Yinyang and the Five Phases with drug therapy . This formulary was also the earliest public Chinese medical text to group symptoms into clinically useful patterns ( ' ' zheng ' ' ) that could serve as targets for therapy . Having gone through numerous changes over time , the formulary now circulates as two distinct books : the ' ' Treatise on Cold Damage Disorders ' ' and the ' ' Essential Prescriptions of the Golden Casket ' ' , which were edited separately in the eleventh century , under the Song dynasty . In the centuries that followed the completion of the ' ' Yellow Emperor 's Inner Canon ' ' , several shorter books tried to summarize or systematize its contents . The ' ' Canon of Problems ' ' ( probably second century CE ) tried to reconcile divergent doctrines from the ' ' Inner Canon ' ' and developed a complete medical system centered on needling therapy . The ' ' AB Canon of Acupuncture and Moxibustion ' ' ( ' ' Zhenjiu jiayi jing ' ' , compiled by Huangfu Mi sometime between 256 and 282 CE ) assembled a consistent body of doctrines concerning acupuncture ; whereas the ' ' Canon of the Pulse ' ' ( ' ' Maijing ' ' ; ca. 280 ) presented itself as a comprehensive handbook of diagnostics and therapy . In 1950 , Chairman Mao Zedong made a speech in support of traditional Chinese medicine which was influenced by political necessity . In 1952 , the president of the Chinese Medical Association said that , This One Medicine , will possess a basis in modern natural sciences , will have absorbed the ancient and the new , the Chinese and the foreign , all medical achievementsand will be Chinas New Medicine ! # Historical physicians # These include Zhang Zhongjing , Hua Tuo , Sun Simiao , Tao Hongjing , Zhang Jiegu , and Li Shizhen. # Philosophical background # Traditional Chinese medicine ( TCM ) is a broad range of medicine practices sharing common concepts which have been developed in China and are based on a tradition of more than 2,000 years , including various forms of herbal medicine , acupuncture , massage ( Tui na ) , exercise ( qigong ) , and dietary therapy . Its philosophy is based on Yinyangism ( i.e. , the combination of Five Phases theory with Yin-yang theory ) , which was later absorbed by Daoism. # Yin and yang # Yin and yang are ancient Chinese concepts which can be traced back to the Shang dynasty ( 16001100 BC ) . They represent two abstract and complementary aspects that every phenomenon in the universe can be divided into . Primordial analogies for these aspects are the sun-facing ( yang ) and the shady ( yin ) side of a hill . Two other commonly used representational allegories of yin and yang are water and fire . In the yin-yang theory , detailed attributions are made regarding the yin or yang character of things : The concept of yin and yang is also applicable to the human body ; for example , the upper part of the body and the back are assigned to yang , while the lower part of the body are believed to have the yin character . Yin and yang characterization also extends to the various body functions , and more importantly to disease symptoms ( e.g. , cold and heat sensations are assumed to be yin and yang symptoms , respectively ) . Thus , yin and yang of the body are seen as phenomena whose lack ( or overabundance ) comes with characteristic symptom combinations : Yin vacuity ( also termed vacuity-heat ) : heat sensations , possible night sweats , insomnia , dry pharynx , dry mouth , dark urine , a red tongue with scant fur , and a fine and rapid pulse . Yang vacuity ( vacuity-cold ) : aversion to cold , cold limbs , bright white complexion , long voidings of clear urine , diarrhea , pale and enlarged tongue , and a slightly weak , slow and fine pulse . TCM also identifies drugs believed to treat these specific symptom combinations , i.e. , to reinforce yin and yang . # Five Phases theory # Five Phases ( , ) , sometimes also translated as the Five Elements theory , presumes that all phenomena of the universe and nature can be broken down into five elemental qualities represented by wood ( , ) , fire ( ) , earth ( , ) , metal ( , ) , and water ( , ) . In this way , lines of correspondence can be drawn : Strict rules are identified to apply to the relationships between the Five Phases in terms of sequence , of acting on each other , of counteraction etc . All these aspects of Five Phases theory constitute the basis of the zng-f concept , and thus have great influence regarding the TCM model of the body . Five Phase theory is also applied in diagnosis and therapy . Correspondences between the body and the universe have historically not only been seen in terms of the Five Elements , but also of the Great Numbers ( , ) For example , the number of acu-points has at times been seen to be 365 , in correspondence with the number of days in a year ; and the number of main meridians 12 has been seen in correspondence with the number of rivers flowing through the ancient Chinese empire . # Model of the body # TCM holds that the body 's vital energy ( ' ' chi ' ' or ' ' qi ' ' ) circulates through channels , called ' ' meridians ' ' , that have branches connected to bodily organs and functions . Its view of the human body is only marginally concerned with anatomical structures , but focuses primarily on the body 's ' ' functions ' ' ( such as digestion , breathing , temperature maintenance , etc . ) : These functions are aggregated and then associated with a primary functional entity for instance , nourishment of the tissues and maintenance of their moisture are seen as connected functions , and the entity postulated to be responsible for these functions is xu ( blood ) . These functional entities thus constitute ' ' concepts ' ' rather than something with biochemical or anatomical properties . The primary functional entities used by traditional Chinese medicine are q , xu , the five zng organs , the six f organs , and the meridians which extend through the organ systems . These are all theoretically interconnected : each zng organ is paired with a f organ , which are nourished by the blood and concentrate qi for a particular function , with meridians being extensions of those functional systems throughout the body . Concepts of the body and of disease used in TCM has notions of a pre-scientific culture , similar to European humoral theory . Nonetheless , attempts to reconcile traditional Eastern medical concepts such as the circulation of Qi , the meridian system , and other related theories with modern science have failed &amp;ndash ; TCM is characterized as full of pseudoscience . Scientific investigation has not found any histological or physiological correlates for traditional Chinese concepts such as ' ' qi ' ' , meridians , and acupuncture points . Similarly , the scientific evidence for the anatomical existence of either meridians or acupuncture points is not compelling . Stephen Barrett of Quackwatch writes that , TCM has been the subject of controversy within China . In 2006 , the Chinese scholar Zhang Gongyao triggered a national debate when he published an article entitled Farewell to Traditional Chinese Medicine , arguing that TCM was a pseudoscience that should be abolished in public healthcare and academia . The Chinese government however , interested in the opportunity of export revenues , took the stance that TCM is a science and continued to encourage its development . # Qi # TCM distinguishes several kinds of qi ( ) . In a general sense , qi is something that is defined by five cardinal functions : # Actuation ( , tudng ) of all physical processes in the body , especially the circulation of all body fluids such as blood in their vessels . This includes actuation of the functions of the zang-fu organs and meridians. # Warming ( , ) the body , especially the limbs . # Defense ( , ) against Exogenous Pathogenic Factors # Containment ( , ) of body fluids , i.e. , keeping blood , sweat , urine , semen , etc. from leakage or excessive emission . # Transformation ( , ) of food , drink , and breath into qi , xue ( blood ) , and jinye ( fluids ) , and/or transformation of all of the latter into each other . Vacuity of qi will especially be characterized by pale complexion , lassitude of spirit , lack of strength , spontaneous sweating , laziness to speak , non-digestion of food , shortness of breath ( especially on exertion ) , and a pale and enlarged tongue . Qi is believed to be partially generated from food and drink , and partially from air ( by breathing ) . Another considerable part of it is inherited from the parents and will be consumed in the course of life . TCM uses special terms for qi running inside of the blood vessels and for qi that is distributed in the skin , muscles , and tissues between those . The former is called yng-q ( ) ; its function is to complement xu and its nature has a strong yin aspect ( although qi in general is considered to be yang ) . The latter is called we-q ( ) ; its main function is defence and it has pronounced yang nature . Qi is said to circulate in the meridians . Just as the qi held by each of the zang-fu organs , this is considered to be part of the ' principal ' qi ( , ) of the body ( also called , true qi , or , original qi ) . # Xue # In contrast to the majority of other functional entities , xu ( , blood ) is correlated with a physical form the red liquid running in the blood vessels . Its concept is , nevertheless , defined by its functions : nourishing all parts and tissues of the body , safeguarding an adequate degree of moisture , and sustaining and soothing both consciousness and sleep . Typical symptoms of a lack of xu ( usually termed blood vacuity , ) are described as : Pale-white or withered-yellow complexion , dizziness , flowery vision , palpitations , insomnia , numbness of the extremities ; pale tongue ; fine pulse . # #Jinye# # Closely related to xu are the jny ( , usually translated as body fluids ) , and just like xu they are considered to be yin in nature , and defined first and foremost by the functions of nurturing and moisturizing the different structures of the body . Their other functions are to harmonize yin and yang , and to help with the secretion of waste products . Jny are ultimately extracted from food and drink , and constitute the raw material for the production of xu ; conversely , xu can also be transformed into jny . Their palpable manifestations are all bodily fluids : tears , sputum , saliva , gastric acid , joint fluid , sweat , urine , etc. # Zang-fu # The zng-f ( ) constitute the centre piece of TCM 's systematization of bodily functions . Bearing the names of organs , they are , however , only secondarily tied to ( rudimentary ) anatomical assumptions ( the f a little more , the zng much less ) . As they are primarily defined by their functions , they are not equivalent to the anatomical organs to highlight this fact , their names are usually capitalized . The term zng ( ) refers to the five entities considered to be yin in nature Heart , Liver , Spleen , Lung , Kidney , while f ( ) refers to the six yang organs Small Intestine , Large Intestine , Gallbladder , Urinary Bladder , Stomach and Snjia . The zng 's essential functions consist in production and storage of q and xu ; in a wider sense they are stipulated to regulate digestion , breathing , water metabolism , the musculoskeletal system , the skin , the sense organs , aging , emotional processes , mental activity etc . The f organs ' main purpose is merely to transmit and digest ( , ) substances like waste , food , etc . Since their concept was developed on the basis of W Xng philosophy , each zng is paired with a f , and each zng-f pair is assigned to one of five elemental qualities ( i.e. , the Five Elements or Five Phases ) . These correspondences are stipulated as : Fire ( ) = Heart ( , ) and Small Intestine ( , ) ( and , secondarily , Snjia , Triple Burner and Pericardium , ) Earth ( ) = Spleen ( , ) and Stomach ( , ) Metal ( ) = Lung ( , ) and Large Intestine ( , ) Water ( ) = Kidney ( , ) and Bladder ( , ) Wood ( ) = Liver ( , ) and Gallbladder ( , ) The zng-f are also connected to the twelve standard meridians each yang meridian is attached to a f organ and five of the yin meridians are attached to a zng . As there are only five zng but six yin meridians , the sixth is assigned to the Pericardium , a peculiar entity almost similar to the Heart zng. # Jing-luo # The meridians ( , ) are believed to be channels running from the zng-f in the interior ( , ) of the body to the limbs and joints ( the surface , ) , transporting qi and xu . TCM identifies 12 regular and 8 extraordinary meridians ; the Chinese terms being ( , lit. the Twelve Vessels ) and ( ) respectively . There 's also a number of less customary channels branching off from the regular meridians. # Concept of disease # In general , disease is perceived as a disharmony ( or imbalance ) in the functions or interactions of yin , yang , qi , xu , zng-f , meridians etc. and/or of the interaction between the human body and the environment . Therapy is based on which pattern of disharmony can be identified . Thus , pattern discrimination is the most important step in TCM diagnosis . It is also known to be the most difficult aspect of practicing TCM . In order to determine which pattern is at hand , practitioners will examine things like the color and shape of the tongue , the relative strength of pulse-points , the smell of the breath , the quality of breathing or the sound of the voice . For example , depending on tongue and pulse conditions , a TCM practitioner might diagnose bleeding from the mouth and nose as : Liver fire rushes upwards and scorches the Lung , injuring the blood vessels and giving rise to reckless pouring of blood from the mouth and nose . . He might then go on to prescribe treatments designed to clear heat or supplement the Lung . # Disease entities # In TCM , a disease has two aspects : bng and zhng . The former is often translated as disease entity , illness , The latter , and more important one , is usually translated as pattern ( or sometimes also as syndrome ) . For example , the disease entity of a common cold might present with a pattern of wind-cold in one person , and with the pattern of wind-heat in another . From a scientific point of view , most of the disease entitites ( , ) listed by TCM constitute mere symptoms . Examples include headache , cough , abdominal pain , constipation etc . Since therapy will not be chosen according to the disease entity but according to the pattern , two people with the same disease entity but different patterns will receive different therapy . Vice versa , people with similar patterns might receive similar therapy even if their disease entities are different . This is called ( , different diseases , same treatment ; same disease , different treatments ) . # Patterns # In TCM , pattern ( , ) refers to a pattern of disharmony or functional disturbance within the functional entities the TCM model of the body is composed of . There are disharmony patterns of qi , xu , the body fluids , the zng-f , and the meridians . They are ultimately defined by their symptoms and signs ( i.e. , for example , pulse and tongue findings ) . In clinical practice , the identified pattern usually involves a combination of affected entities ( compare with typical examples of patterns ) . The concrete pattern identified should account for ' ' all ' ' the symptoms a person has . # #Six Excesses# # The Six Excesses ( , , sometimes also translated as Pathogenic Factors , or Six Pernicious Influences ; with the alternative term of , , Six Evils or Six Devils ) are allegorical terms used to describe disharmony patterns displaying certain typical symptoms . These symptoms resemble the effects of six climatic factors . In the allegory , these symptoms can occur because one or more of those climatic factors ( called , , the six qi ) were able to invade the body surface and to proceed to the interior . This is sometimes used to draw causal relationships ( i.e. , prior exposure to wind/cold/etc. is identified as the cause of a disease ) , while other authors explicitly deny a direct cause-effect relationship between weather conditions and disease , pointing out that the Six Excesses are primarily descriptions of a certain combination of symptoms It is undisputed , though , that the Six Excesses can manifest inside the body without an external cause . In this case , they might be denoted internal , e.g. , internal wind The Six Excesses and their characteristic clinical signs are : #Wind ( , ) : rapid onset of symptoms , wandering location of symptoms , itching , nasal congestion , floating pulse ; #Cold ( , ) : cold sensations , aversion to cold , relief of symptoms by warmth , watery/clear excreta , severe pain , abdominal pain , *25;27488;TOOLONG of muscles , ( slimy ) white tongue fur , deep / hidden or string-like pulse , or slow pulse . #Fire/Heat ( , ) : aversion to heat , high fever , thirst , concentrated urine , red face , red tongue , yellow tongue fur , rapid pulse . #Dampness ( , ) : sensation of heaviness , sensation of fullness , symptoms of Spleen dysfunction , greasy tongue fur , slippery pulse . #Dryness ( , ) : dry cough , dry mouth , dry throat , dry lips , nosebleeds , dry skin , dry stools . #Summerheat ( , ) : either heat or mixed damp-heat symptoms . Six-Excesses-patterns can consist of only one or a combination of Excesses ( e.g. , wind-cold , wind-damp-heat ) . # #Typical examples of patterns# # For each of the functional entities ( qi , xu , zng-f , meridians etc. ) , typical disharmony patterns are recognized ; for example : qi vacuity and qi stagnation in the case of qi ; blood vacuity , blood stasis , and blood heat in the case of xu ; Spleen qi vacuity , Spleen yang vacuity , Spleen qi vacuity with down-bearing qi , Spleen qi vacuity with lack of blood containment , cold-damp invasion of the Spleen , damp-heat invasion of Spleen and Stomach in case of the Spleen zng ; TCM gives detailed prescriptions of these patterns regarding their typical symptoms , mostly including characteristic tongue and/or pulse findings . For example :  Upflaming Liver fire ( , ) : Headache , red face , reddened eyes , dry mouth , nosebleeds , constipation , dry or hard stools , profuse menstruation , sudden tinnitus or deafness , vomiting of sour or bitter fluids , expectoration of blood , irascibility , impatience ; red tongue with dry yellow fur ; slippery and string-like pulse . # #Basic principles of pattern discrimination# # The process of determining which actual pattern is on hand is called ( , usually translated as pattern diagnosis , or pattern discrimination ) . Generally , the first and most important step in pattern diagnosis is an evaluation of the present signs and symptoms on the basis of the Eight Principles ( , ) . These eight principles refer to four pairs of fundamental qualities of a disease : exterior/interior , heat/cold , vacuity/repletion , and yin/yang . Out of these , heat/cold and vacuity/repletion have the biggest clinical importance . The yin/yang quality , on the other side , has the smallest importance and is somewhat seen aside from the other three pairs , since it merely presents a general and vague conclusion regarding what other qualities are found . In detail , the Eight Principles refer to the following :  ' ' Exterior ' ' ( , ) refers to a disease manifesting in the superficial layers of the body skin , hair , flesh , and meridians . It is characterized by aversion to cold and/or wind , headache , muscle ache , mild fever , a floating pulse , and a normal tongue appearance .  ' ' Interior ' ' ( , ) refers to disease manifestation in the zng-f , or ( in a wider sense ) to any disease that can not be counted as exterior . There are no generalized characteristic symptoms of interior patterns , since they 'll be determined by the affected zng or f entity .  ' ' Cold ' ' ( , ) is generally characterized by aversion to cold , absence of thirst , and a white tongue fur . More detailed characterization depends on whether cold is coupled with vacuity or repletion.  ' ' Heat ' ' ( , ) is characterized by absence of aversion to cold , a red and painful throat , a dry tongue fur and a rapid and floating pulse , if it falls together with an exterior pattern . In all other cases , symptoms depend on whether heat is coupled with vacuity or repletion.  ' ' Vacuity ' ' ( , ) often referred to as deficiency , can be further differentiated into vacuity of qi , xu , yin and yang , with all their respective characteristic symptoms . Yin vacuity can also be termed vacuity-heat , while yang vacuity is equivalent to vacuity-cold .  ' ' Repletion ' ' ( , ) often called excess , generally refers to any disease that ca n't be identified as a vacuity pattern , and usually indicates the presence of one of the Six Excesses , or a pattern of stagnation ( of qi , xu , etc . ) . In a concurrent exterior pattern , repletion is characterized by the absence of sweating . The signs and symptoms of repletion-cold patterns are equivalent to cold excess patterns , and repletion-heat is similar to heat excess patterns .  ' ' Yin and yang ' ' are universal aspects all things can be classified under , this includes diseases in general as well as the Eight Principles ' first three couples . For example , cold is identified to be a yin aspect , while heat is attributed to yang . Since descriptions of patterns in terms of yin and yang lack complexity and clinical practicality , though , patterns are usually not labelled this way anymore . Exceptions are vacuity-cold and repletion-heat patterns , who are sometimes referred to as yin patterns and yang patterns respectively . After the fundamental nature of a disease in terms of the Eight Principles is determined , the investigation focuses on more specific aspects . By evaluating the present signs and symptoms against the background of typical disharmony patterns of the various entities , evidence is collected whether or how specific entities are affected . This evaluation can be done # in respect of the meridians ( , ) # in respect of qi ( , ) # in respect of xu ( , ) # in respect of the body fluids ( , ) # in respect of the zng-f ( , ) very similar to this , though less specific , is disharmony pattern description in terms of the Five Elements , ) There are also three special pattern diagnosis systems used in case of febrile and infectious diseases only ( Six Channel system or six division pattern , ; Wei Qi Ying Xue system or four division pattern , ; San Jiao system or three burners pattern , ) . # #Considerations of disease causes# # Although TCM and its concept of disease do not strongly differentiate between cause and effect , pattern discrimination can include considerations regarding the disease cause ; this is called ( , disease-cause pattern discrimination ) . There are three fundamental categories of disease causes ( , ) recognized : # external causes : these include the Six Excesses and Pestilential Qi . # internal causes : the Seven Affects ( , , sometimes also translated as Seven Emotions These are believed to be able to cause damage to the functions of the zng-f , especially of the Liver . # *25;27515;TOOLONG causes : dietary irregularities ( especially : too much raw , cold , spicy , fatty or sweet food ; voracious eating ; too much alcohol ) , fatigue , sexual intemperance , trauma , and parasites ( , ) . # Diagnostics # In TCM , there are five diagnostic methods : inspection , auscultation , olfaction , inquiry , and palpation. Inspection focuses on the face and particularly on the tongue , including analysis of the tongue size , shape , tension , color and coating , and the absence or presence of teeth marks around the edge . Auscultation refers to listening for particular sounds ( such as wheezing ) . Olfaction refers to attending to body odor. Inquiry focuses on the seven inquiries , which involve asking the person about the regularity , severity , or other characteristics of : chills , fever , perspiration , appetite , thirst , taste , defecation , urination , pain , sleep , menses , leukorrhea , and palpation which includes feeling the body for tender A-shi points , and the palpation of the wrist pulses as well as various other pulses , and palpation of the abdomen . # Tongue and pulse # Examination of the tongue and the pulse are among the principal diagnostic methods in TCM . Certain sectors of the tongue 's surface are believed to correspond to the zng-f . For example , teeth marks on one part of the tongue might indicate a problem with the Heart , while teeth marks on another part of the tongue might indicate a problem with the Liver . Pulse palpation involves measuring the pulse both at a superficial and at a deep level at three different locations on the radial artery ( ' ' Cun , Guan , Chi ' ' , located two fingerbreadths from the wrist crease , one fingerbreadth from the wrist crease , and right at the wrist crease , respectively , usually palpated with the index , middle and ring finger ) of each arm , for a total of twelve pulses , all of which are thought to correspond with certain zng-f . The pulse is examined for several characteristics including rhythm , strength and volume , and described with qualities like floating , slippery , bolstering-like , feeble , thready and quick ; each of these qualities indicate certain disease patterns . Learning TCM pulse diagnosis can take several years . # Herbal medicine # The term herbal medicine is misleading in so far as plant elements are by far the most commonly , but not solely used substances in TCM ; animal , human , and mineral products are also utilized . Thus , the term medicinal ( instead of herb ) is usually preferred . # Prescriptions # Typically , one batch of medicinals is prepared as a decoction of about 9 to 18 substances . Some of these are considered as main herbs , some as ancillary herbs ; within the ancillary herbs , up to three categories can be distinguished . # Raw materials # There are roughly 13,000 medicinals used in China and over 100,000 medicinal recipes recorded in the ancient literature . Plant elements and extracts are by far the most common elements used . In the classic ' ' Handbook of Traditional Drugs ' ' from 1941 , 517 drugs were listed out of these , 45 were animal parts , and 30 were minerals . # #Animal substances# # Some animal parts used as medicinals can be considered rather strange such as cows ' gallstones , hornet 's nest , leech , and scorpion . Other examples of animal parts include horn of the antelope or buffalo , deer antlers , testicles and penis bone of the dog , and snake bile . Some TCM textbooks still recommend preparations containing animal tissues , but there has been little research to justify the claimed clinical efficacy of many TCM animal products . Some medicinals can include the parts of endangered species , including tiger bones and rhinoceros horn . The black market in rhinoceros horn reduced the world 's rhino population by more than 90 percent over the past 40 years . Concerns have also arisen over the use of turtle plastron , seahorses , and the gill plates of mobula and manta rays . Poachers hunt restricted or endangered species animals to supply the black market with TCM products . There is no scientific evidence of efficacy for tiger medicines . Concern over China considering to legalize the trade in tiger parts prompted the 171-nation Convention on International Trade in Endangered Species ( CITES ) to endorse a decision opposing the resurgence of trade in tigers . Fewer than 30,000 saiga antelopes remain , which are exported to China for use in traditional fever therapies . Organized gangs illegally export the horn of the antelopes to China . The pressures on seahorses ( Hippocampus spp. ) used in traditional medicine is large ; tens of millions of animals are unsustainably caught annually . Many species of syngnathid are currently part of the IUCN Red List of Threatened Species or national equivalents . Since TCM recognizes bear bile as a medicinal , more than 12,000 asiatic black bears are held in bear farms . The bile is extracted through a permanent hole in the abdomen leading to the gall bladder , which can cause severe pain . This can lead to bears trying to kill themselves . As of 2012 , approximately 10,000 bears are farmed in China for their bile . This unethical practice has spurred public outcry across the country . The bile is collected from live bears via a surgical procedure . The deer penis is believed to have therapeutic benefits according to traditional Chinese medicine . It is typically very big and , proponents believe , in order to preserve its properties , it should be extracted from a living deer . Medicinal tiger parts from poached animals include tiger penis , believed to improve virility , and tiger eyes . The illegal trade for tiger parts in China has driven the species to near-extinction because of its popularity in traditional medicine . Laws protecting even critically endangered species such as the Sumatran tiger fail to stop the display and sale of these items in open markets . Shark fin soup is traditionally regarded in Chinese medicine as beneficial for health in East Asia , and its status as an elite dish has led to huge demand with the increase of affluence in China , devastating shark populations . The shark fins have been a part of traditional Chinese medicine for centuries . Shark finning is banned in many countries , but the trade is thriving in Hong Kong , China , where the fins are part of shark fin soup , a dish considered a delicacy , and used in some types of traditional Chinese medicine . The tortoise ( guiban ) and the turtle ( biejia ) species used in traditional Chinese medicine are raised on farms , while restrictions are made on the accumulation and export of other endangered species . However , issues concerning the overexploitation of Asian turtles in China have not been completely solved . Australian scientists have developed methods to identify medicines containing DNA traces of endangered species . # #Human body parts# # Traditional Chinese Medicine also includes some human parts : the classic Materia medica ( Bencao Gangmu ) describes the use of 35 human body parts and excreta in medicines , including bones , fingernail , hairs , dandruff , earwax , impurities on the teeth , feces , urine , sweat , organs , but most are no longer in use . Human placenta has been used an ingredient in certain traditional Chinese medicines , # Efficacy # there were not enough good-quality trials of herbal therapies to allow their effectiveness to be determined . A high percentage of relevant studies on traditional Chinese medicine are in Chinese databases . Fifty percent of systematic reviews on TCM did not search Chinese databases , which could lead to a bias in the results . Many systematic reviews of TCM interventions published in Chinese journals are incomplete , some contained errors or were misleading . A 2013 review found the data is too weak to support use of Chinese herbal medicine ( CHM ) for benign prostatic hyperplasia . A 2013 review found the research on the benefit and safety of CHM for idiopathic sudden sensorineural hearing loss is of poor quality and can not be relied upon to support their use . A 2013 Cochrane review found inconclusive evidence that CHM reduces the severity of eczema . The traditional medicine ginger , which has shown anti-inflammatory properties in laboratory experiments , has been used to treat rheumatism , headache and digestive and respiratory issues , though there is no firm evidence supporting these uses . A 2012 Cochrane review found no difference in decreased mortality when Chinese herbs were used alongside Western medicine versus Western medicine exclusively . A 2012 Cochrane review found insufficient evidence to support the use of TCM for people with adhesive small bowel obstruction . A 2011 review found low quality evidence that suggests CHM improves the symptoms of Sjogren 's syndrome . A 2010 review found TCM seems to be effective for the treatment of fibromyalgia but the finding were of insufficient methodological rigor . A 2009 Cochrane review found insufficient evidence to recommend the use of TCM for the treatment of epilepsy . A 2008 Cochrane review found promising evidence for the use of Chinese herbal medicine in relieving painful menstruation , but the trials assessed were of such low methodological quality that no conclusion could be drawn about the remedies ' suitability as a recommendable treatment option . Turmeric has been used in traditional Chinese medicine for centuries to treat various conditions . This includes jaundice and hepatic disorders , rheumatism , anorexia , diabetic wounds , and menstrual complications . Most of its effects have been attributed to curcumin . Research that curcumin shows strong anti-inflammatory and antioxidant activities have instigated mechanism of action studies on the possibility for cancer and inflammatory diseases prevention and treatment . It also exhibits immunomodulatory effects . A 2005 Cochrane review found insufficient evidence for the use of CHM in HIV-infected people and people with AIDS. # Toxicity # From the earliest records regarding the use of medicinals to today , the toxicity of certain substances has been described in all Chinese materiae medicae . Since TCM has become more popular in the Western world , there are increasing concerns about the potential toxicity of many traditional Chinese medicinals including plants , animal parts and minerals . Traditional Chinese herbal remedies are conveniently available from grocery stores in most Chinese neighborhoods ; some of these items may contain toxic ingredients , are imported into the U.S. illegally , and are associated with claims of therapeutic benefit without evidence . For most medicinals , efficacy and toxicity testing are based on traditional knowledge rather than laboratory analysis . The toxicity in some cases could be confirmed by modern research ( i.e. , in scorpion ) ; in some cases it could n't ( i.e. , in ' ' Curculigo ' ' ) . Traditional herbal medicines can contain extremely toxic chemicals and heavy metals , and naturally occurring toxins , which can cause illness , exacerbate pre-existing poor health or result in death . Botanical misidentification of plants can cause toxic reactions in humans . The description on some plants used in traditional Chinese medicine have changed , leading to unintended intoxication of the wrong plants . A concern is also contaminated herbal medicines with microorganisms and fungal toxins , including aflatoxin . Traditional herbal medicines are sometimes contaminated with toxic heavy metals , including lead , arsenic , mercury and cadmium , which inflict serious health risks to consumers . Substances known to be potentially dangerous include ' ' Aconitum ' ' , secretions from the Asiatic toad , powdered centipede , the Chinese beetle ( ' ' Mylabris phalerata ' ' ) , certain fungi , ' ' Aristolochia ' ' , Arsenic sulfide ( Realgar ) , mercury sulfide , and cinnabar . Asbestos ore ( Actinolite , Yang Qi Shi , ) is used to treat impotence in TCM . Due to galena 's ( litharge , lead oxide ) high lead content , it is known to be toxic . Lead , mercury , arsenic , copper , cadmium , and thallium have been detected in TCM products sold in the U.S. and China . To avoid its toxic adverse effects ' ' Xanthium sibiricum ' ' must be processed . Hepatotoxicity has been reported with products containing ' ' Polygonum multiflorum ' ' , glycyrrhizin , ' ' Senecio ' ' and ' ' Symphytum ' ' . The evidence suggests that hepatotoxic herbs also include ' ' Dictamnus dasycarpus ' ' , ' ' Astragalus membranaceous ' ' , and ' ' Paeonia lactiflora ' ' ; although there is no evidence that they cause liver damage . Contrary to popular belief , ' ' Ganoderma lucidum ' ' mushroom extract , as an adjuvant for cancer immunotherapy , appears to have the potential for toxicity . A 2013 review suggested that although the antimalarial herb ' ' Artemisia annua ' ' may not cause hepatotoxicity , haematotoxicity , or hyperlipidemia , it should be used cautiously during pregnancy due to a potential risk of embryotoxicity at a high dose . However , many adverse reactions are due misuse or abuse of Chinese medicine . For example , the misuse of the dietary supplement ' ' Ephedra ' ' ( containing ephedrine ) can lead to adverse events including gastrointestinal problems as well as sudden death from cardiomyopathy . Products adulterated with pharmaceuticals for weight loss or erectile dysfunction are one of the main concerns . Chinese herbal medicine has been a major cause of acute liver failure in China . # Drug research # With an eye to the enormous Chinese market , pharmaceutical companies have explored the potential for creating new drugs from traditional remedies . Successful results have however been scarce : an editorial in ' ' Nature ' ' said that while this is simply because TCM is largely pseudoscience without a rational mechanism of action for the majority of its treatments , advocates have argued that it is because research had missed some key features of TCM , such as the subtle interrelationships between ingredients . One of the few successes was the development in the 1970s of the antimalarial drug artemisinin , which is a processed extract of ' ' Artemisia annua ' ' , a herb traditionally used as a fever treatment . Researcher Tu Youyou discovered that a low-temperature extraction process could isolate an effective antimalarial substance from the plant . She says she was influenced by a traditional source saying that this herb should be steeped in cold water , after initially finding high-temperature extraction unsatisfactory . The extracted substance , once subject to detoxification and purification processes , is a usable antimalarial drug a 2012 review found that artemisinin-based remedies were the most effective drugs for the treatment of malaria . Despite global efforts in combating malaria , it remains a large burden for the population . Although WHO recommends artemisinin-based remedies for treating uncomplicated malaria , artemisinin resistance can no longer be ignored . Also in the 1970s Chinese researcher Zhang TingDong and colleagues investigated the potential use of the traditionally used substance arsenic trioxide to treat acute promyelocytic leukemia ( APL ) . Building on his work , research both in China and the West eventually led to the development of the drug Trisenox , which was approved for leukemia treatment by the FDA in 2000 . Huperzine A , which is extracted from traditional herb ' ' Huperzia serrata ' ' , has attracted the interest of medical science because of alleged neuroprotective properties . Despite earlier promising results , a 2013 systematic review and meta-analysis found poor quality evidence that huperzine A seems to improve cognitive function and daily living activity for Alzheimer 's disease . # Cost-effectiveness # A 2012 systematic review found there is a lack of available cost-effectiveness evidence in TCM. # Acupuncture and moxibustion # Acupuncture means insertion of needles into superficial structures of the body ( skin , subcutaneous tissue , muscles ) usually at acupuncture points ( acupoints ) and their subsequent manipulation ; this aims at influencing the flow of qi . According to TCM it relieves pain and treats ( and prevents ) various diseases . Acupuncture is often accompanied by moxibustion the Chinese characters for acupuncture ( ) literally meaning acupuncture-moxibustion which involves burning mugwort on or near the skin at an acupuncture point . According to the American Cancer Society , available scientific evidence does not support claims that moxibustion is effective in preventing or treating cancer or any other disease . # Efficacy # A 2013 editorial by Steven P. Novella and David Colquhoun found that the inconsistency of results of acupuncture studies ( i.e. acupuncture relieved pain in some conditions but had no effect in other very similar conditions ) suggests false positive results , which may be caused by factors like biased study designs , poor blinding , and the classification of electrified needles ( a type of TENS ) as a form of acupuncture . The same editorial suggested that given the inability to find consistent results despite more than 3,000 studies of acupuncture , the treatment seems to be a placebo effect and the existing equivocal positive results are noise one expects to see after a large number of studies are performed on an inert therapy . The editorial concluded that the best controlled studies showed a clear pattern , in which the outcome does not rely upon needle location or even needle insertion , and since these variables are those that define acupuncture , the only sensible conclusion is that acupuncture does not work . A 2012 meta-analysis concluded that acupuncture was effective for the treatment of four different types of chronic pain . Commenting on this meta-analysis , both Edzard Ernst and David Colquhoun said the results were of negligible clinical significance . A 2011 overview of Cochrane reviews found high quality evidence that suggests acupuncture is effective for some but not all kinds of pain . A 2010 systematic review found that there is evidence that acupuncture provides a short-term clinically relevant effect when compared with a waiting list control or when acupuncture is added to another intervention in the treatment of chronic low back pain . Two review articles discussing the effectiveness of acupuncture , from 2008 and 2009 , have concluded that there is not enough evidence to conclude that it is effective beyond the placebo effect . Acupuncture is generally safe when administered using Clean Needle Technique ( CNT ) . Although serious adverse effects are rare , acupuncture is not without risk . Severe adverse effects , including death have continued to be reported . # Tui na # Tui na ( ) is a form of massage akin to acupressure ( from which shiatsu evolved ) . Oriental massage is typically administered with the person fully clothed , without the application of grease or oils . Choreography often involves thumb presses , rubbing , percussion , and stretches . # Qigong # Qgng ( or ) is a TCM system of exercise and meditation that combines regulated breathing , slow movement , and focused awareness , purportedly to cultivate and balance qi . One branch of qigong is qigong massage , in which the practitioner combines massage techniques with awareness of the acupuncture channels and points . # Other therapies # # Cupping # Cupping ( ) is a type of Chinese massage , consisting of placing several glass cups ( open spheres ) on the body . A match is lit and placed inside the cup and then removed before placing the cup against the skin . As the air in the cup is heated , it expands , and after placing in the skin , cools , creating lower pressure inside the cup that allows the cup to stick to the skin via suction . When combined with massage oil , the cups can be slid around the back , offering reverse-pressure massage . It has not been found to be effective for the treatment of any disease . The 2008 ' ' Trick or Treatment ' ' book said that no evidence exists of any beneficial effects of cupping for any medical condition . # Gua Sha # Gua Sha is abrading the skin with pieces of smooth jade , bone , animal tusks or horns or smooth stones ; until red spots then bruising cover the area to which it is done . It is believed that this treatment is for almost any ailment including cholera . The red spots and bruising take 3 to 10 days to heal , there is often some soreness in the area that has been treated . # Die-da # Di-d ( ) or bone-setting is usually practiced by martial artists who know aspects of Chinese medicine that apply to the treatment of trauma and injuries such as bone fractures , sprains , and bruises . Some of these specialists may also use or recommend other disciplines of Chinese medical therapies ( or Western medicine in modern times ) if serious injury is involved . Such practice of bone-setting ( or ) is not common in the West . # Chinese food therapy # Dating back thousand of years , Chinese food therapy is a component TCM. # Regulations # Many governments have enacted laws to regulate TCM practice . # Australia # From 1 July 2012 Chinese medicine practitioners must be registered under the national registration and accreditation scheme with the Chinese Medicine Board of Australia and meet the Board 's Registration Standards , in order to practise in Australia . # Canada # TCM is regulated in five provinces in Canada : Alberta , British Columbia , Ontario , Quebec , and Newfoundland . # Hong Kong # The Chinese Medicine Council of Hong Kong was established in 1999 . It regulates the medicinals and professional standards for TCM practitioners . All TCM practitioners in Hong Kong are required to register with the Council . The eligibility for registration includes a recognised 5-year university degree of TCM , a 30-week minimum supervised clinical internship , and passing the licensing exam . # Malaysia # The Traditional and Complementary Medicine Bill was passed by Parliament in 2012 establishing the Traditional and Complementary Medicine Council to register and regulate traditional and complementary medicine practitioners , including traditional Chinese medicine practitioners as well as other traditional and complementary medicine practitioners such as those in traditional Malay medicine and traditional Indian medicine . # Singapore # The TCM Practitioners Act was passed by Parliament in 2000 and the TCM Practitioners Board was established in 2001 as a statutory board under the Ministry of Health , to register and regulate TCM practitioners . The requirements for registration include possession of a diploma or degree from a TCM educational institution/university on a gazetted list , either structured TCM clinical training at an approved local TCM educational institution or foreign TCM registration together with supervised TCM clinical attachment/practice at an approved local TCM clinic , and upon meeting these requirements , passing the Singapore TCM Physicians Registration Examination ( STRE ) conducted by the TCM Practitioners Board . # United States # As of July 2012 , only six states do not have existing legislation to regulate the professional practice of TCM . These six states are Alabama , Kansas , North Dakota , South Dakota , Oklahoma , and Wyoming . In 1976 , California established an Acupuncture Board and became the first state licensing professional acupuncturists. # Indonesia # All traditional medicines , including TCM , are regulated on Indonesian Minister of Health Regulation in 2013 about Traditional Medicine . Traditional Medicine License ( ' ' Surat Izin Pengobatan Tradisional ' ' -SIPT ) will be granted to the practitioners whose methods are scientifically recognized as safe and bring the benefit for health . The TCM clinics are registered but there is no explicit regulation for it . The only TCM method which is accepted by medical logic and is empirically proofed is acupuncture . The acupuncturists can get SIPT and participate on health care facilities . 
@@6811 The Centers for Disease Control and Prevention ( CDC ) is the national public health institute of the United States . The CDC is a federal agency under the Department of Health and Human Services and is headquartered in unincorporated DeKalb County , Georgia , a few miles northeast of the Atlanta city limits . Its main goal is to protect public health and safety through the control and prevention of disease , injury , and disability . The CDC focuses national attention on developing and applying disease control and prevention . It especially focuses its attention on infectious disease , food borne pathogens , environmental health , occupational safety and health , health promotion , injury prevention and educational activities designed to improve the health of United States citizens . In addition , the CDC researches and provides information on non-infectious diseases such as obesity and diabetes and is a founding member of the International Association of National Public Health Institutes . # History # The Communicable Diseases Center was founded July 1 , 1946 as the successor to the World War II Malaria Control in War Areas program of the Office of National Defense Malaria Control Activities . ( see National Malaria Eradication Program ) . Among its 369 employees , the main jobs at CDC were originally entomology and engineering . In CDC 's initial years , more than six and a half million homes were sprayed , mostly with DDT . In 1946 , there were only seven medical officers on duty and an early organization chart was drawn , somewhat fancifully , in the shape of a mosquito . Under Dr. Joseph Mountin the CDC continued to advocate for public health issues and pushed to extend its responsibilities to many other communicable diseases . In 1947 , CDC made a token payment of $10 to Emory University for 15 acre of land on Clifton Road in DeKalb County , still the home of CDC headquarters today . CDC employees collected the money to make the purchase . The benefactor behind the gift was Robert Woodruff , chairman of the board of The Coca-Cola Company . Woodruff had a long-time interest in malaria control , which had been a problem in areas where he went hunting . The same year , the PHS transferred its San Francisco based plague laboratory into the CDC as the Epidemiology Division , and a new Veterinary Diseases Division was established . The mission of CDC expanded beyond its original focus on malaria to include sexually transmitted diseases when the Venereal Disease Division of the U.S. Public Health Service ( PHS ) was transferred to the CDC in 1957 . Shortly thereafter , Tuberculosis Control was transferred ( in 1960 ) to the CDC from PHS , and then in 1963 the Immunization program was established . It became the ' ' National Communicable Disease Center ( NCDC ) ' ' effective July 1 , 1967 . The organization was renamed the ' ' Center for Disease Control ( CDC ) ' ' on June 24 , 1970 , and ' ' Centers for Disease Control ' ' effective October 14 , 1980 . An act of the United States Congress appended the words and Prevention to the name effective October 27 , 1992 . However , Congress directed that the initialism ' ' CDC ' ' be retained because of its name recognition . CDC now operates under the Department of Health and Human Services umbrella . Currently the CDC focus has broadened to include chronic diseases , disabilities , injury control , workplace hazards , environmental health threats , and terrorism preparedness . CDC combats emerging diseases and other health risks , including birth defects , West Nile virus , obesity , avian , swine , and pandemic flu , E. coli , and bioterrorism , to name a few . The organization would also prove to be an important factor in preventing the abuse of penicillin . In May 1994 the CDC admitted to having sent several biological warfare agents to the Iraqi government from 1984 through 1989 , including Botulinum toxin , West Nile virus , Yersinia pestis and Dengue fever virus . The CDC has one of the few Biosafety Level 4 laboratories in the country , as well as one of only two official repositories of smallpox in the world . The second smallpox store resides at the State Research Center of Virology and Biotechnology VECTOR in the Russian Federation . The CDC revealed in 2014 that it had discovered several misplaced smallpox samples and that lab workers had also potentially been infected with anthrax . # Budget and workforce # CDCs FY2014 budget is $11.3 billion . As of 2008 , staff numbered approximately 15,000 ( including 6,000 contractors and 840 Commissioned Corps officers ) in 170 occupations . Eighty percent have earned bachelor 's degrees or higher ; almost half have advanced degrees ( a master 's degree or a doctorate such as a PhD , D.O. , or M.D. ) . CDC job titles also include engineer , entomologist , epidemiologist , biologist , physician , veterinarian , behaviorial scientist , Nurse , medical technologist , economist , Public Health Advisor , health communicator , toxicologist , chemist , computer scientist , and statistician . In addition to its Atlanta headquarters , the CDC has other locations in the United States and Puerto Rico . Those locations include Anchorage ; Cleveland ; Cincinnati ; Fort Collins ; Hyattsville ; Morgantown ; Pittsburgh ; Research Triangle Park ; San Juan , Puerto Rico ; Spokane , Washington ; Detroit ; and Washington , D.C. The CDC also conducts the Behavioral Risk Factor Surveillance System , the worlds largest , on-going telephone health survey system . The CDC offers grants that help many organizations each year bring health , safety and awareness to surrounding communities throughout the entire United States . As a government-run department , the Centers for Disease Control and Prevention awards over 85 percent of its annual budget through these grants to accomplish its ultimate goal of disease control and quality health for all . The CDC also operates the Public Health Associate Program ( PHAP ) , a two-year paid fellowship for recent college graduates to work in public health agencies all over the United States . PHAP was founded in 2007 and currently has 159 associates in 34 states . # Directors # The President of the United States appoints the director of the CDC and the appointment does not require Senate confirmation . The director serves at the pleasure of the President and may be fired at any time . Sixteen directors have served the CDC or its predecessor agencies .  Julie Gerberding , MD , MPH ( 20022008 )  Thomas R. Frieden , MD , MPH ( 2009present ) # Organizational restructuring # On April 21 , 2005 , the then-director of CDC , Dr. Julie Gerberding , formally announced the reorganization of CDC to confront the challenges of 21st-century health threats . The four Coordinating Centersestablished under the G. W. Bush Administration and Gerberding diminished the influence of national centers under their umbrella and were ordered cut under the Obama Administration and Frieden in 2009. # Foundation # The CDC Foundation operates independently from CDC as a private , nonprofit 501(c) ( 3 ) organization incorporated in the State of Georgia . The creation of the Foundation was authorized by section 399F of the Public Health Service Act to support the mission of CDC in partnership with the private sector , including organizations , foundations , businesses , educational groups , and individuals . # Data and survey systems #  CDC Scientific Data , Surveillance , Health Statistics , and Laboratory Information .  Behavioral Risk Factor Surveillance System .  Mortality Medical Data System .  Abortion statistics in the United States # Publications #  CDC publications  State of CDC report  CDC Programs in Brief  ' ' Morbidity and Mortality Weekly Report ' '  ' ' Emerging Infectious Diseases ' ' ( monthly journal ) # Diseases with which the CDC is involved # # Influenza # The CDC has launched campaigns targeting the transmission of influenza , including the H1N1 swine flu . The CDC has launched websites including flu.gov to educate people in proper hygiene . # Other infectious diseases # The CDC 's website ( see below ) has information on other infectious diseases , including smallpox , measles , and others . The CDC runs a program that protects the public from rare and dangerous substances such as anthrax and the Ebola virus . The program , called the Select Agents Program , calls for inspections of labs in the U.S. that work with dangerous pathogens . During the 2014 Ebola outbreak in Africa , the CDC helped coordinate the return of two infected American aid workers for treatment at Emory University Hospital , the home of a special unit to handle highly infectious diseases . # Non-infectious disease # The CDC also combats non-infectious diseases , including obesity. # Investigations by the Department of Health and Human Services Office of Inspector General ( OIG ) # On the June 15 , 2011 , the OIG published a report critical of the CDC 's failure to oversee recipients use of Presidents Emergency Plan for AIDS Relief ( PEPFAR ) funds . The report read in part : On June 5 , 2012 , the OIG published a report identifying vulnerabilities in vaccine management in the CDC 's domestic ' Vaccines for Children ' ( VFC ) program . The report read in part : On the November 19 , 2012 , the OIG published a report critical of the CDC Namibia Office 's failure to properly monitor recipients ' use of PEPFAR funds . The report read in part : # CDC zombie apocalypse outreach campaign # On May 16 , 2011 , the Centers for Disease Control and Prevention 's blog published an article instructing the public on what to do to prepare for a zombie invasion . While the article did not claim that such a scenario was possible , it did use the popular culture appeal as a means of urging citizens to prepare for all potential hazards , such as earthquakes , tornadoes , and floods . According to David Daigle , the Associate Director for Communications , Public Health Preparedness and Response , the idea arose when his team was discussing their upcoming hurricane information campaign and Daigle mused that we say pretty much the same things every year , in the same way , and I just wonder how many people are paying attention . A social media employee mentioned that the subject of zombies had come up a lot on Twitter when she had been tweeting about the Fukushima Daiichi nuclear disaster and radiation . The team realized that a campaign like this would most likely reach a different audience than normally pays attention to hurricane preparedness warnings , and went to work on the zombie campaign , launching it right before hurricane season began . The whole idea was , if you 're prepared for a zombie apocalypse , you 're prepared for pretty much anything , said Daigle . Once the blog article became popular , the CDC announced an open contest for YouTube submissions of the most creative and effective videos covering preparedness for a zombie apocalypse ( or apocalypse of any kind ) , to be judged by the CDC Zombie Task Force . Submissions were open until October 11 , 2011 . They also released a zombie themed graphic novella available on their website . Zombie themed educational materials for teachers are also available on the site . 
@@8072 A disease is a particular abnormal , pathological condition that affects part or all of an organism . It is often construed as a medical condition associated with specific symptoms and signs . It may be caused by factors originally from an external source , such as infectious disease , or it may be caused by internal dysfunctions , such as autoimmune diseases . In humans , disease is often used more broadly to refer to any condition that causes pain , dysfunction , distress , social problems , or death to the person afflicted , or similar problems for those in contact with the person . In this broader sense , it sometimes includes injuries , disabilities , disorders , syndromes , infections , isolated symptoms , deviant behaviors , and atypical variations of structure and function , while in other contexts and for other purposes these may be considered distinguishable categories . Diseases usually affect people not only physically , but also emotionally , as contracting and living with many diseases can alter one 's perspective on life , and one 's personality . Death due to disease is called death by natural causes . There are four main types of disease : pathogenic disease , deficiency disease , hereditary disease , and physiological disease . Diseases can also be classified as communicable and non-communicable . The deadliest disease in humans is ischemic heart disease ( blood flow obstruction ) , followed by cerebrovascular disease and lower respiratory infections respectively . # Terminology # # Concepts # In many cases , the terms ' ' disease ' ' , ' ' disorder ' ' , ' ' morbidity ' ' and ' ' illness ' ' are used interchangeably . In some situations , specific terms are considered preferable . ; Disease : The term ' ' disease ' ' broadly refers to any condition that impairs normal function , and is therefore associated with dysfunction of normal homeostasis . Commonly , the term ' ' disease ' ' is used to refer specifically to infectious diseases , which are clinically evident diseases that result from the presence of pathogenic microbial agents , including viruses , bacteria , fungi , protozoa , multicellular organisms , and aberrant proteins known as prions . An infection that does not and will not produce clinically evident impairment of normal functioning , such as the presence of the normal bacteria and yeasts in the gut , or of a passenger virus , is not considered a disease . By contrast , an infection that is asymptomatic during its incubation period , but expected to produce symptoms later , is usually considered a disease . Non-infectious diseases are all other diseases , including most forms of cancer , heart disease , and genetic disease . ; Illness : ' ' Illness ' ' and ' ' sickness ' ' are generally used as synonyms for ' ' disease ' ' . However , this term is occasionally used to refer specifically to the patient 's personal experience of his or her disease . In this model , it is possible for a person to have a disease without being ill ( to have an objectively definable , but asymptomatic , medical condition ) , and to be ' ' ill ' ' without being ' ' diseased ' ' ( such as when a person perceives a normal experience as a medical condition , or medicalizes a non-disease situation in his or her life ) . Illness is often not due to infection , but a collection of evolved responsessickness behavior by the bodythat helps clear infection . Such aspects of illness can include lethargy , depression , anorexia , sleepiness , hyperalgesia , and inability to concentrate . ; : In medicine , a disorder is a functional abnormality or disturbance . Medical disorders can be categorized into mental disorders , physical disorders , genetic disorders , emotional and behavioral disorders , and functional disorders . The term ' ' disorder ' ' is often considered more value-neutral and less stigmatizing than the terms ' ' disease ' ' or ' ' illness ' ' , and therefore is a preferred terminology in some circumstances . In mental health , the term ' ' mental disorder ' ' is used as a way of acknowledging the complex interaction of biological , social , and psychological factors in psychiatric conditions . However , the term ' ' disorder ' ' is also used in many other areas of medicine , primarily to identify physical disorders that are not caused by infectious organisms , such as metabolic disorders . ; Medical condition : A medical condition is a broad term that includes all diseases and disorders . While the term ' ' medical condition ' ' generally includes mental illnesses , in some contexts the term is used specifically to denote any illness , injury , or disease except for mental illnesses . The Diagnostic and Statistical Manual of Mental Disorders ( DSM ) , the widely used psychiatric manual that defines all mental disorders , uses the term ' ' general medical condition ' ' to refer to all diseases , illnesses , and injuries except for mental disorders . This usage is also commonly seen in the psychiatric literature . Some health insurance policies also define a ' ' medical condition ' ' as any illness , injury , or disease except for psychiatric illnesses . : As it is more value-neutral than terms like ' ' disease ' ' , the term ' ' medical condition ' ' is sometimes preferred by people with health issues that they do not consider deleterious . On the other hand , by emphasizing the medical nature of the condition , this term is sometimes rejected , such as by proponents of the autism rights movement . : The term ' ' medical condition ' ' is also a synonym for ' ' medical state ' ' , in which case it describes an individual patient 's current state from a medical standpoint . This usage appears in statements that describe a patient as being ' ' in critical condition ' ' , for example . ; : Morbidity ( ) is a diseased state , disability , or poor health due to any cause . The term may be used to refer to the existence of any form of disease , or to the degree that the health condition affects the patient . Among severely ill patients , the level of morbidity is often measured by ICU scoring systems . Comorbidity is the simultaneous presence of two or more medical conditions , such as schizophrenia and substance abuse . : In epidemiology and actuarial science , the term morbidity rate can refer to either the incidence rate , or the prevalence of a disease or medical condition . This measure of sickness is contrasted with the mortality rate of a condition , which is the proportion of people dying during a given time interval . ; Syndrome : A syndrome is the association of several medical signs , symptoms , and or other characteristics that often occur together . Some syndromes , such as Down syndrome , have only one cause ; others , such as Parkinsonian syndrome , have multiple possible causes . In other cases , the cause of the syndrome is unknown . A familiar syndrome name often remains in use even after an underlying cause has been found , or when there are a number of different possible primary causes . ; Predisease : Predisease is a type of disease creep or medicalization in which currently healthy people with risk factors for disease , but no evidence of actual disease , are told that they are sick . Prediabetes and prehypertension are common examples . Labeling a healthy person with predisease can result in overtreatment , such as taking drugs that only help people with severe disease , or in useful preventive measures , such as motivating the person to get a healthy amount of physical exercise . In addition , there are sexually transmitted diseases . In some cases , microorganisms that are not readily spread from person to person play a role , while other diseases can be prevented or ameliorated with appropriate nutrition or other lifestyle changes . Some diseases , such as most ( but not all ) forms of cancer , heart disease , and mental disorders , are non-infectious diseases . Many non-infectious diseases have a partly or completely genetic basis ( see genetic disorder ) and may thus be transmitted from one generation to another . Social determinants of health are the social conditions in which people live that determine their health . Illnesses are generally related to social , economic , political , and environmental circumstances . Social determinants of health have been recognized by several health organizations such as the Public Health Agency of Canada and the World Health Organization to greatly influence collective and personal well-being . The World Health Organization 's Social Determinants Council also recognizes Social determinants of health in poverty . When the cause of a disease is poorly understood , societies tend to mythologize the disease or use it as a metaphor or symbol of whatever that culture considers evil . For example , until the bacterial cause of tuberculosis was discovered in 1882 , experts variously ascribed the disease to heredity , a sedentary lifestyle , depressed mood , and overindulgence in sex , rich food , or alcoholall the social ills of the time . # Burdens of disease # Disease burden is the impact of a health problem in an area measured by financial cost , mortality , morbidity , or other indicators . There are several measures used to quantify the burden imposed by diseases on people . The years of potential life lost ( YPLL ) is a simple estimate of the number of years that a person 's life was shortened due to a disease . For example , if a person dies at the age of 65 from a disease , and would probably have lived until age 80 without that disease , then that disease has caused a loss of 15 years of potential life . YPLL measurements do not account for how disabled a person is before dying , so the measurement treats a person who dies suddenly and a person who died at the same age after decades of illness as equivalent . In 2004 , the World Health Organization calculated that 932 million years of potential life were lost to premature death . The quality-adjusted life year ( QALY ) and disability-adjusted life year ( DALY ) metrics are similar , but take into account whether the person was healthy after diagnosis . In addition to the number of years lost due to premature death , these measurements add part of the years lost to being sick . Unlike YPLL , these measurements show the burden imposed on people who are very sick , but who live a normal lifespan . A disease that has high morbidity , but low mortality , has a high DALY and a low YPLL . In 2004 , the World Health Organization calculated that 1.5 billion disability-adjusted life years were lost to disease and injury . In the developed world , heart disease and stroke cause the most loss of life , but neuropsychiatric conditions like major depressive disorder cause the most years lost to being sick . # Prevention # Many diseases and disorders can be prevented through a variety of means . These include sanitation , proper nutrition , adequate exercise , vaccinations , circumcision of male infants , and other self-care and public health measures . # Treatments # Medical therapies or treatments are efforts to cure or improve a disease or other health problem . In the medical field , therapy is synonymous with the word ' ' treatment ' ' . Among psychologists , the term may refer specifically to psychotherapy or talk therapy . Common treatments include medications , surgery , medical devices , and self-care . Treatments may be provided by an organized health care system , or informally , by the patient or family members . A prevention or preventive therapy is a way to avoid an injury , sickness , or disease in the first place . A treatment or cure is applied after a medical problem has already started . A treatment attempts to improve or remove a problem , but treatments may not produce permanent cures , especially in chronic diseases . Cures are a subset of treatments that reverse diseases completely or end medical problems permanently . Many diseases that can not be completely cured are still treatable . Pain management ( also called pain medicine ) is that branch of medicine employing an interdisciplinary approach to the relief of pain and improvement in the quality of life of those living with pain Treatment for medical emergencies must be provided promptly , often through an emergency department or , in less critical situations , through an urgent care facility . # Epidemiology # Epidemiology is the study of the factors that cause or encourage diseases . Some diseases are more common in certain geographic areas , among people with certain genetic or socioeconomic characteristics , or at different times of the year . Epidemiology is considered a cornerstone methodology of public health research , and is highly regarded in evidence-based medicine for identifying risk factors for disease . In the study of communicable and non-communicable diseases , the work of epidemiologists ranges from outbreak investigation to study design , data collection and analysis including the development of statistical models to test hypotheses and the documentation of results for submission to peer-reviewed journals . Epidemiologists also study the interaction of diseases in a population , a condition known as a syndemic . Epidemiologists rely on a number of other scientific disciplines such as biology ( to better understand disease processes ) , biostatistics ( the current raw information available ) , Geographic Information Science ( to store data and map disease patterns ) and social science disciplines ( to better understand proximate and distal risk factors ) . Epidemiology can help identify causes as well as guide prevention efforts . In studying diseases , epidemiology faces the challenge of defining them . Especially for poorly understood diseases , different groups might use significantly different definitions . Without an agreed-on definition , different researchers may report different numbers of cases and characteristics of the disease . ) , or at European scale ( European Hospital Morbidity Database or HMDB ) but not yet at world scale . # Social and cultural responses # How a society responds to diseases is the subject of medical sociology . A condition may be considered a disease in some cultures or eras but not in others . For example , obesity can represent wealth and abundance , and is a status symbol in famine-prone areas and some places hard-hit by HIV/AIDS . Epilepsy is considered a sign of spiritual gifts among the Hmong people . Sickness confers the social legitimization of certain benefits , such as illness benefits , work avoidance , and being looked after by others . The person who is sick takes on a social role called the sick role . A person who responds to a dreaded disease , such as cancer , in a culturally acceptable fashion may be publicly and privately honored with higher social status . In return for these benefits , the sick person is obligated to seek treatment and work to become well once more . As a comparison , consider pregnancy , which is not interpreted as a disease or sickness , even if the mother and baby may both benefit from medical care . Most religions grant exceptions from religious duties to people who are sick . For example , one whose life would be endangered by fasting on Yom Kippur or during Ramadan is exempted from the requirement , or even forbidden from participating . People who are sick are also exempted from social duties . For example , ill health is the only socially acceptable reason for an American to refuse an invitation to the White House . <ref>  
@@10013 Evidence-based medicine ( EBM ) has been defined as the conscientious , explicit and judicious use of current best evidence in making decisions about the care of individual patients . Trisha Greenhalgh and Anna Donald define it more specifically as the use of mathematical estimates of the risk of benefit and harm , derived from high-quality research on population samples , to inform clinical decision-making in the diagnosis , investigation or management of individual patients . To broaden its application from individual patients to health care services in general and to allied health professions , it is also known as evidence-informed healthcare or evidence-based health care . The clinical approach is known as evidence-based practice . In practice , clinicians contextualize the best available research evidence by integrating it with their individual clinical expertise and their patient 's values and expectations . The incorporation of patient values and clinical expertise in EBM partly recognizes that many aspects of health care depend on individual factors . These include variations in individual physiology and pathology , and quality-of-life and value-of-life judgments . These factors are only partially subjected to scientific inquiry and sometimes can not be assessed in controlled experimental settings . Application of available evidence is therefore dependent on patient circumstances and preferences , and remains subject to input from personal , political , philosophical , religious , ethical , economic , and aesthetic values . This has led to a shift from the original term evidence-'based ' medicine to evidence-'informed ' healthcare , to emphasize that decisions need not necessarily be based or complying with the evidence . The broad field of EBM includes rigorous and systematic analysis of published literature to synthesize high-quality evidence , such as systematic reviews . It could also be referring to a medical movement , where advocates work to popularize the method and usefulness of the practice of EBM in the public , patient communities , educational institutions , and continuing education of practicing professionals . # Background and definition # Evidence-based medicine ( EBM ) has evolved from the critical need to bridge the gap between research and practice . EBM applies research information ( evidence ) to clinical practice , emphasizing the importance of the use of quantitative ( as well as qualitative ) evidence in the art of clinical decision making . It aims to make decision making more structured and objective by better reflecting the evidence from research . By introducing the use of research information in clinical decision making , particularly from clinical epidemiology , EBM has driven a transformation of clinical practice and medical education . In 1996 David Sackett wrote that evidence-based medicine is the conscientious , explicit and judicious use of current best evidence in making decisions about the care of individual patients . This definition , put forward by one of the original proponents of evidence-based medicine , has since been adopted by major organizations , including the Cochrane Collaboration and the Centre for Evidence Based Medicine . # Evidence-based health service # An evidence-based health service tends to generate an increase in the competence of health service decision makers and is the practice of evidence-based medicine at the organizational or institutional level . It strengthens the motivation of any health service decision-maker to use scientific methods when making a decision.More details of this approach to health services and public health have been discussed in a book titled ' ' evidence-based healthcare &amp; public health ' ' . Research by Michael Fischer and colleagues at the University of Oxford finds that evidence-based rules may not readily ' hybridise ' with experience-based practices orientated towards ethical clinical judgement , and can lead to contradictions , contest , and unintended crises . In their recent , large study of the UK health knowledge economy , they find the most effective ' knowledge leaders ' ( managers and clinical leaders ) use a broad range of management knowledge in their decision making , rather than just formal evidence . Evidence-based guidelines may provide the basis for ' governmentality ' in health care and consequently play a central role in the distant governance of contemporary health care systems . # Evidence-based decision making # The results of population-based research form the foundation of EBM . It aims to use the experience of a population of patients reported in the research literature to guide decision making in practice . This practice of evidence-based medicine requires the application of population-based data to the care of an individual patient . In the past , we have relied on the experience of physicians or other health care workers to make decisions about therapy . In the current information era , this approach would be suboptimal as health care workers rapidly find themselves unable to cope with the influx of a huge variety of new information , from the irrelevant to the very important . Therefore , evidence-based decision making gradually emerged as a solution to integrate the best research evidence with clinical expertise and patient values and expectations as practiced by the individual health care provider . The concepts and ideas attributed to and labeled collectively as EBM/EBHC have now become a part of daily clinical lives , and health care professionals increasingly hear about evidence-based guidelines , care paths , questions and solutions . The controversy has shifted from whether to implement the new concepts to how to do so sensibly and efficiently , while avoiding potential problems associated with a number of misconceptions about what EBM/EBHC is and what it is not . The EBM/EBHC-related concepts of hierarchy of evidence , meta-analyses , confidence intervals , study design , and so forth are so widespread , that health care professionals have no choice but to become familiar with EBM/EBHC principles and methodologies. # Process and progress # Five steps of EBM in practice were first described in 1992 and the experience of delegates attending the 2003 Conference of Evidence-Based Health Care Teachers and Developers was summarized into five steps and published in 2005 . This five step process can broadly be categorized as : # Translation of uncertainty to an answerable question and includes critical questioning , study design and levels of evidence # Systematic retrieval of the best evidence available # Critical appraisal of evidence for internal validity that can be broken down into aspects regarding : #* Systematic errors as a result of selection bias , information bias and confounding #* Quantitative aspects of diagnosis and treatment #* The effect size and aspects regarding its precision #* Clinical importance of results #* External validity or generalizability # Application of results in practice # Evaluation of performance Using techniques from science , engineering and statistics , such as the systematic review of medical literature , meta-analysis , risk-benefit analysis , and randomized controlled trials ( RCTs ) , EBM aims for the ideal that healthcare professionals should make conscientious , explicit , and judicious use of current best evidence in their everyday practice . ' ' Ex cathedra ' ' statements by the medical expert are considered to be the least valid form of evidence . All experts are now expected to reference their pronouncements to scientific studies . The systematic review of published research studies is a major method used for evaluating particular treatments . The Cochrane Collaboration is one of the best-known , respected examples of systematic reviews . Like other collections of systematic reviews , it requires authors to provide a detailed and repeatable plan of their literature search and evaluations of the evidence . Once all the best evidence is assessed , treatment is categorized as ( 1 ) likely to be beneficial , ( 2 ) likely to be harmful , or ( 3 ) evidence did not support either benefit or harm . A 2007 analysis of 1,016 systematic reviews from all 50 Cochrane Collaboration Review Groups found that 44% of the reviews concluded that the intervention was likely to be beneficial , 7% concluded that the intervention was likely to be harmful , and 49% concluded that evidence did not support either benefit or harm . 96% recommended further research . A 2001 review of 160 Cochrane systematic reviews ( excluding complementary treatments ) in the 1998 database revealed that , according to two readers , 41.3% concluded positive or possibly positive effect , 20% concluded evidence of no effect , 8.1% concluded net harmful effects , and 21.3% of the reviews concluded insufficient evidence . A review of 145 alternative medicine Cochrane reviews using the 2004 database revealed that 38.4% concluded positive effect or possibly positive ( 12.4% ) effect , 4.8% concluded no effect , 0.69% concluded harmful effect , and 56.6% concluded insufficient evidence . # Assessing the quality of evidence # Evidence quality can be assessed based on the source type ( from meta-analyses and systematic reviews of triple-blind randomized clinical trials with concealment of allocation and no attrition at the top end , down to conventional wisdom at the bottom ) , as well as other factors including statistical validity , clinical relevance , currency , and peer-review acceptance . Evidence-based medicine categorizes different types of clinical evidence and rates or grades them according to the strength of their freedom from the various biases that beset medical research . For example , the strongest evidence for therapeutic interventions is provided by systematic review of randomized , triple-blind , placebo-controlled trials with allocation concealment and complete follow-up involving a homogeneous patient population and medical condition . In contrast , patient testimonials , case reports , and even expert opinion ( however some critics have argued that expert opinion does not belong in the rankings of the quality of empirical evidence because it does not represent a form of empirical evidence and continue that expert opinion would seem to be a separate , complex type of knowledge that would not fit into hierarchies otherwise limited to empirical evidence alone . ) have little value as evidence because of the placebo effect , the biases inherent in observation and reporting of cases , difficulties in ascertaining who is an expert and more . # U.S. Preventive Services Task Force ( USPSTF ) # Systems to stratify evidence by quality have been developed , such as this one by the United States Preventive Services Task Force for ranking evidence about the effectiveness of treatments or screening :  Level I : Evidence obtained from at least one properly designed randomized controlled trial .  Level II-1 : Evidence obtained from well-designed controlled trials without randomization.  Level II-2 : Evidence obtained from well-designed cohort or case-control analytic studies , preferably from more than one center or research group .  Level II-3 : Evidence obtained from multiple time series designs with or without the intervention . Dramatic results in uncontrolled trials might also be regarded as this type of evidence .  Level III : Opinions of respected authorities , based on clinical experience , descriptive studies , or reports of expert committees . # Oxford CEBM Levels of Evidence ( UK ) # Most of the evidence ranking schemes grade evidence for therapy and prevention , but not for diagnostic tests , prognostic markers , or harm . The Oxford CEBM Levels of Evidence addresses this issue and provides ' Levels ' of evidence for claims about prognosis , diagnosis , treatment benefits , treatment harms , and screening . The was first released in September 2000 for Evidence-Based On Call to make the process of finding evidence feasible and its results explicit . In by international team including Jeremy Howick , Sir Iain Chalmers , Paul Glasziou ( chair ) , Trish Greenhalgh , Carl Heneghan , Alessandro Liberati , Ivan Moschetti , Bob Phillips , and Hazel Thornton ( and help from Olive Goddard and Mary Hodgkinson ) re-designed the Oxford CEBM Levels to make it more understandable and to take into account recent developments in evidence ranking schemes . The Oxford CEBM Levels of Evidence have been used by patients , clinicians and also to develop clinical guidelines including recommendations for the optimal use of phototherapy and topical therapy in psoriasis and guidelines for the use of the BCLC staging system for diagnosing and monitoring hepatocellular carcinoma in Canada . # Categories of recommendations # In guidelines and other publications , recommendation for a clinical service is classified by the balance of risk versus benefit of the service ' ' and ' ' the level of evidence on which this information is based . The U.S. Preventive Services Task Force uses :  Level A : Good scientific evidence suggests that the benefits of the clinical service substantially outweigh the potential risks . Clinicians should discuss the service with eligible patients .  Level B : At least fair scientific evidence suggests that the benefits of the clinical service outweighs the potential risks . Clinicians should discuss the service with eligible patients .  Level C : At least fair scientific evidence suggests that there are benefits provided by the clinical service , but the balance between benefits and risks are too close for making general recommendations . Clinicians need not offer it unless there are individual considerations .  Level D : At least fair scientific evidence suggests that the risks of the clinical service outweighs potential benefits . Clinicians should not routinely offer the service to asymptomatic patients .  Level I : Scientific evidence is lacking , of poor quality , or conflicting , such that the risk versus benefit balance can not be assessed . Clinicians should help patients understand the uncertainty surrounding the clinical service . # GRADE working group # A system was developed by the GRADE working group and takes into account more dimensions than just the quality of medical research . It requires users of GRADE ( short for Grading of Recommendations Assessment , Development and Evaluation ) who are performing an assessment of the quality of evidence , usually as part of a systematic review , to consider the impact of different factors on their confidence in the results . Authors of GRADE tables , grade the quality of evidence into four levels , on the basis of their confidence in the observed effect ( a numerical value ) being close to what the true effect is . The confidence value is based on judgements assigned in five different domains in a structured manner . The GRADE working group defines ' quality of evidence ' and ' strength of recommendations ' based on the quality as two different concepts which are commonly confused with each other . Systematic reviews may include Randomized Controlled trials that have low risk of bias , or , observational studies that have high risk of bias . In the case of Randomized controlled trials , the quality of evidence is high , but can be downgraded in five different domains .  Risk of bias : Is a judgement made on the basis of the chance that bias in included studies have influenced the estimate of effect .  Imprecision : Is a judgement made on the basis of the chance that the observed estimate of effect could change completely .  Indirectness : Is a judgement made on the basis of the differences in characteristics of how the study was conducted and how the results are actually going to be applied .  Inconsistency : Is a judgement made on the basis of the variability of results across the included studies .  Publication bias : Is a judgement made on the basis of the question whether all the research evidence has been taken to account . In the case of observational studies , the quality of evidence starts of lower and may be upgraded in three domains in addition to being subject to downgrading .  Large effect : This is when methodologically strong studies show that the observed effect is so large that the probability of it changing completely is less likely .  Plausible confounding would change the effect : This is when despite the presence of a possible confounding factor which is expected to reduce the observed effect , the effect estimate still shows significant effect .  Dose response gradient : This is when the intervention used becomes more effective with increasing dose . This suggests that a further increase will likely bring about more effect . Meaning of the levels of Quality of evidence as per GRADE  High Quality Evidence : The authors are very confident that the estimate that is presented lies very close to the true value . One could interpret it as : there is very low probability of further research completely changing the presented conclusions .  Moderate Quality Evidence : The authors are confident that the presented estimate lies close to the true value , but it is also possible that it may be substantially different . One could also interpret it as : further research may completely change the conclusions .  Low Quality Evidence : The authors are not confident in the effect estimate and the true value may be substantially different . One could interpret it as : further research is likely to change the presented conclusions completely .  Very low quality Evidence : The authors do not have any confidence in the estimate and it is likely that the true value is substantially different from it . One could interpret it as : New research will most probably change the presented conclusions completely . Guideline panelists may make Strong or Weak recommendations on the basis of further criteria . Some of the important criteria are :  Balance between desirable and undesirable effects ( not considering cost )  Quality of the evidence  Values and preferences  Costs ( resource utilization ) Despite the differences between systems , the purposes are the same : to guide users of clinical research information on which studies are likely to be most valid . However , the individual studies still require careful critical appraisal . # Statistical measures # Evidence-based medicine attempts to express clinical benefits of tests and treatments using mathematical methods . Tools used by practitioners of evidence-based medicine include : # Likelihood ratio # The pre-test odds of a particular diagnosis , multiplied by the likelihood ratio , determines the post-test odds . ( Odds can be calculated from , and then converted to , the more familiar probability . ) This reflects Bayes ' theorem . The differences in likelihood ratio between clinical tests can be used to prioritize clinical tests according to their usefulness in a given clinical situation . # AUC-ROC # The area under the receiver operating characteristic curve ( AUC-ROC ) reflects the relationship between sensitivity and specificity for a given test . High-quality tests will have an AUC-ROC approaching 1 , and high-quality publications about clinical tests will provide information about the AUC-ROC . Cutoff values for positive and negative tests can influence specificity and sensitivity , but they do not affect AUC-ROC. # Number needed to treat / harm # Number needed to treat or Number needed to harm are ways of expressing the effectiveness and safety of an intervention in a way that is clinically meaningful . In general , NNT is always computed with respect to two treatments A and B , with A typically a drug and B a placebo ( in our example above , A is a 5-year treatment with the hypothetical drug , and B is no treatment ) . A defined endpoint has to be specified ( in our example : the appearance of colon cancer in the 5 year period ) . If the probabilities pA and pB of this endpoint under treatments A and B , respectively , are known , then the NNT is computed as 1/ ( pB-pA ) . If it is said that the NNT for breast mammography is 285 this means that 285 mammograms need to be performed to diagnose one case of breast cancer . As another example , an NNT of 4 means if 4 patients are treated , only one would respond . An NNT of 1 is the most effective and means each patient treated responds , e.g. , in comparing antibiotics with placebo in the eradication of ' ' Helicobacter pylori ' ' . An NNT of 2 or 3 indicates that a treatment is quite effective ( with one patient in 2 or 3 responding to the treatment ) . An NNT of 20 to 40 can still be considered clinically effective . :  EBM produces quantitative research , especially from randomized controlled trials ( RCTs ) . Accordingly , results may not be relevant for all treatment situations .  RCTs are expensive , influencing research topics according to the sponsor 's interests .  There is a lag between when the RCT is conducted and when its results are published .  There is a lag between when results are published and when these are properly applied .  Certain population segments have been historically under-researched ( racial minorities and people with co-morbid diseases ) , and thus the RCT restricts generalizing.  Not all evidence from an RCT is made accessible . Treatment effectiveness reported from RCTs may be different than that achieved in routine clinical practice .  Published studies may not be representative of all studies completed on a given topic ( published and unpublished ) or may be unreliable due to the different study conditions and variables .  EBM applies to groups of people but this does not preclude clinicians from using their personal experience in deciding how to treat each patient . One author advises that the knowledge gained from clinical research does not directly answer the primary clinical question of what is best for the patient at hand and suggests that evidence-based medicine should not discount the value of clinical experience . Another author stated that the practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research .  Hypocognition ( the absence of a simple , consolidated mental framework that new information can be placed into ) can hinder the application of EBM. # Assessing the teaching of evidence-based medicine # Two instruments , the Berlin questionnaire and the Fresno Test are the most validated . These questionnaires have been used in diverse settings . # In psychiatry # Standard descriptions about mental illnesses , such as the ' ' Diagnostic and Statistical Manual of Mental Disorders ' ' ( DSM ) , have been criticized as incompletely justified by scientific evidence . In many cases , it is unknown whether a particular disease has one , several , or no underlying biological causes , with controversy arising over whether some diseases are merely an artifact of the attempt to construct a unified classification scheme , rather than a real disease . While some experts point to statistics in support of the idea that a lack of adoption of research findings results in suboptimal treatment for psychiatric patients , others emphasize the skill of the practitioner and customization of the treatment to fit individual needs . There is some controversy over whether mental illnesses are too complex for broad population studies to be helpful . Examples of using evidence to support general interpretations in psychiatry :  The rate of incidence of mental illness has increased from 0.003% ( 1 in 300 ) in 1955 to 18.6% today ( 2012 ) .  The mentally ill treated in the public system have a much shorter life span and die ( as reported in 2006 ) about twenty five years earlier than the average . In previous research , it was believed the mentally ill had a ten year shorter life span ( page 11 of report ) .  Studies document progressive brain volume reductions in psychiatric patients , when historically there was no noticeable pathological difference between a normal brain and a schizophrenic one .  Reports show evidence that not all psychiatric patients need treatment with antipsychotics. # History # Traces of evidence-based medicine 's origin can be found in ancient Greece . Although testing medical interventions for efficacy has existed since the time of Avicenna 's ' ' The Canon of Medicine ' ' in the 11th century , it was only in the 20th century that this effort evolved to impact almost all fields of health care and policy . In 1967 , the American physician and mathematician Alvan R. Feinstein published his groundbreaking work ' ' Clinical Judgment ' ' , which together with Archie Cochranes famous book ' ' Effectiveness and Efficiency ' ' ( 1972 ) led to an increasing acceptance of clinical epidemiology and controlled studies during the 1970s and 1980s and paved the way for the institutional development of EBM in the 1990s . Cochrane 's efforts were recognized by the fact that an international network for efficacy assessment in medicine the Cochrane Collaboration was posthumously named after him . However , Cochrane himself did not live to see the foundation and institutionalization of the EBM movement and Feinstein became later in his life one of its sharpest methodological critics . The explicit methodologies used to determine best evidence were largely established by the McMaster University research group led by David Sackett and Gordon Guyatt . Guyatt later coined the term evidence-based in 1990 . The term evidence-based medicine first appeared in the medical literature in 1992 in a paper by Guyatt ' ' et al . ' ' . The term was popularized in the series of articles published as the Users ' Guides to the Medical Literature . Relevant journals include the British Medical Journal 's ' ' Clinical Evidence ' ' , the ' ' Journal of Evidence-Based Healthcare ' ' and ' ' Evidence Based Health Policy ' ' . All of these were co-founded by Anna Donald , an Australian pioneer in the discipline . # EBM and ethics of experimental or risky treatments # Insurance companies in the United States and public insurers in other countries usually wait for drug use approval based on evidence-based guidelines before funding a treatment . Where approval for a drug has been given , and subsequent evidence-based findings indicating that a drug may be less safe than originally anticipated , some insurers in the U.S. have reacted very cautiously and withdrawn funding . For example , an older generic statin drug had been shown to reduce mortality , but a newer and much more expensive statin drug was found to lower cholesterol more effectively . However , evidence came to light about safety concerns with the new drug which caused some insurers to stop funding it even though marketing approval was not withdrawn . Some people are willing to take their chances to gamble their health on the success of new drugs or old drugs in new situations which may not yet have been fully tested in clinical trials . However insurance companies are reluctant to take on the job of funding such treatments , preferring instead to take the safer route of awaiting the results of clinical testing and leaving the funding of such trials to the manufacturer seeking a license . Sometimes caution errs in the other direction . Kaiser Permanente did not change its methods of evaluating whether or not new therapies were too experimental to be covered until it was successfully sued twice : once for delaying in vitro fertilization treatments for two years after the courts determined that scientific evidence of efficacy and safety had reached the reasonable stage ; and in another case where Kaiser refused to pay for liver transplantation in infants when it had already been shown to be effective in adults , on the basis that use in infants was still experimental . <ref> cite journal author=Sugarman M title=Permanente Physicians Determine Use of New Technology : Kaiser Permanente 's Interregional New Technologies Committee journal=The Permanente Journal # Application of the evidence based model on other public policy matters # There has been discussion of applying what has been learned from evidence-based medicine to public policy . In his 1996 inaugural speech as President of the Royal Statistical Society , Adrian Smith held out evidence-based medicine as an exemplar for ' ' all ' ' public policy . He proposed that evidence-based policy should be established for education , prisons and policing policy and all areas of government work . 
@@14194 This article deals with medicine as practiced by trained professionals from ancient times to the present . The ancient Egyptians had a system of medicine that was very advanced for its time and influenced later medical traditions . The Egyptians and Babylonians both introduced the concepts of diagnosis , prognosis , and medical examination . The Greeks went even further , and advanced as well medical ethics . The Hippocratic Oath , still taken by doctors up to today , was written in Greece in the 5th century BCE . In the medieval era , surgical practices inherited from the ancient masters were improved and then systematized in Rogerius 's ' ' The Practice of Surgery ' ' . Universities began systematic training of physicians around the years 1220 in Italy . During the Renaissance , understanding of anatomy improved , and the microscope was invented . The germ theory of disease in the 19th century led to cures for many infectious diseases . Military doctors advanced the methods of trauma treatment and surgery . Public health measures were developed especially in the 19th century as the rapid growth of cities required systematic sanitary measures . Advanced research centers opened in the early 20th century , often connected with major hospitals . The mid-20th century was characterized by new biological treatments , such as antibiotics . These advancements , along with developments in chemistry , genetics , and lab technology ( such as the x-ray ) led to modern medicine . Medicine was heavily professionalized in the 20th century , and new careers opened to women as nurses ( from the 1870s ) and as physicians ( especially after 1970 ) . The 21st century is characterized by highly advanced research involving numerous fields of science . # Prehistoric medicine # Although there is no record to establish when plants were first used for medicinal purposes ( herbalism ) , the use of plants as healing agents is a long-standing practice . Over time through emulation of the behavior of fauna a medicinal knowledge base developed and was passed between generations . As tribal culture specialized specific castes , Shamans and apothecaries performed the ' niche occupation ' of healing . # Antiquity # # Egypt # Ancient Egypt developed a large , varied and fruitful medical tradition . Herodotus described the Egyptians as the healthiest of all men , next to the Libyans , due to the dry climate and the notable public health system that they possessed . According to him , the practice of medicine is so specialized among them that each physician is a healer of one disease and no more . Although Egyptian medicine , to a good extent , dealt with the supernatural , it eventually developed a practical use in the fields of anatomy , public health , and clinical diagnostics . Medical information in the Edwin Smith Papyrus may date to a time as early as 3000 BC . The earliest known surgery was performed around 2750 BC . Imhotep in the 3rd dynasty is sometimes credited with being the founder of ancient Egyptian medicine and with being the original author of the ' ' Edwin Smith Papyrus ' ' , detailing cures , ailments and anatomical observations . The ' ' Edwin Smith Papyrus ' ' is regarded as a copy of several earlier works and was written c. 1600 BC . It is an ancient textbook on surgery almost completely devoid of magical thinking and describes in exquisite detail the ' ' examination , diagnosis , treatment , ' ' and ' ' prognosis ' ' of numerous ailments . The Kahun Gynaecological Papyrus treats women 's complaints , including problems with conception . Thirty four cases detailing diagnosis and Dating to 1800 BCE , it is the oldest surviving medical text of any kind . Medical institutions , referred to as ' ' Houses of Life ' ' are known to have been established in ancient Egypt as early as the First dynasty of Egypt The earliest known physician is also credited to History of ancient Egypt # Middle East # The oldest Babylonian texts on medicine date back to the Old Babylonian period in the first half of the 2nd millennium BCE . The most extensive Babylonian medical text , however , is the ' ' Diagnostic Handbook ' ' written by the ' ' ummn ' ' , or chief scholar , Esagil-kin-apli of Borsippa , during the reign of the Babylonian king Adad-apla-iddina ( 10691046 BCE ) . Along with the Egyptians the Babylonians introduced the practice of diagnosis , prognosis , physical examination , and remedies . In addition , the ' ' Diagnostic Handbook ' ' introduced the methods of therapy and etiology . The text contains a list of medical symptoms and often detailed empirical observations along with logical rules used in combining observed symptoms on the body of a patient with its diagnosis and prognosis . The ' ' Diagnostic Handbook ' ' was based on a logical set of axioms and assumptions , including the modern view that through the examination and inspection of the symptoms of a patient , it is possible to determine the patient 's disease , its aetiology and future development , and the chances of the patient 's recovery . The symptoms and diseases of a patient were treated through therapeutic means such as bandages , herbs and creams . There was little development after the medieval era . Major European treatises on medicine took 200 years to reach the Middle East , where local rulers might consult Western doctors to get the latest treatments . Medical works in Arabic , Turkish , and Persian as late as 1800 were based on medieval Islamic medicine . # India # The Atharvaveda , a sacred text of Hinduism dating from the Early Iron Age , is the first Indian text dealing with medicine , like the medicine of the Ancient Near East based on concepts of the exorcism of demons and magic . The Atharvaveda also contain prescriptions of herbs for various ailments . The use of herbs to treat ailments would later form a large part of Ayurveda . In the first millennium BCE , there emerges in post-Vedic India the traditional medicine system known as Ayurveda , meaning the complete knowledge for long life . Its two most famous texts belong to the schools of Charaka , born c. 600 BCE , and Sushruta , born 600 BCE . While these writings display some limited continuities with the earlier medical ideas known from the Vedas , historians have been able to demonstrate direct historical connections between early Ayurveda and the early literature of the Buddhists and Jains . The earliest foundations of Ayurveda were built on a synthesis of traditional herbal practices together with a massive addition of theoretical conceptualizations , new nosologies and new therapies dating from about 400 BCE onwards , and coming out of the communities of thinkers who included the Buddha and others . According to the compendium of Charaka , the Charakasamhit , health and disease are not predetermined and life may be prolonged by human effort . The compendium of Suruta , the Surutasamhit defines the purpose of medicine to cure the diseases of the sick , protect the healthy , and to prolong life . Both these ancient compendia include details of the examination , diagnosis , treatment , and prognosis of numerous ailments . The Surutasamhit is notable for describing procedures on various forms of surgery , including rhinoplasty , the repair of torn ear lobes , perineal lithotomy , cataract surgery , and several other excisions and other surgical procedures . Most remarkable is Sushruta 's penchant for scientific classification : His medical treatise consists of 184 chapters , 1,120 conditions are listed , including injuries and illnesses relating to ageing and mental illness . The Sushruta Samhita describe 125 surgical instrument , 300 surgical procedures and classifies human surgery in 8 categories The Ayurvedic classics mention eight branches of medicine : kycikits ( internal medicine ) , alyacikits ( surgery including anatomy ) , lkyacikits ( eye , ear , nose , and throat diseases ) , kaumrabhtya ( pediatrics ) , bhtavidy ( spirit medicine ) , and agada tantra ( toxicology ) , rasyana ( science of rejuvenation ) , and vjkaraa ( aphrodisiacs , mainly for men ) . Apart from learning these , the student of yurveda was expected to know ten arts that were indispensable in the preparation and application of his medicines : distillation , operative skills , cooking , horticulture , metallurgy , sugar manufacture , pharmacy , analysis and separation of minerals , compounding of metals , and preparation of alkalis . The teaching of various subjects was done during the instruction of relevant clinical subjects . For example , teaching of anatomy was a part of the teaching of surgery , embryology was a part of training in pediatrics and obstetrics , and the knowledge of physiology and pathology was interwoven in the teaching of all the clinical disciplines . The normal length of the student 's training appears to have been seven years . But the physician was to continue to learn . As an alternative form of medicine in India , Unani medicine got deep roots and royal patronage during medieval times . It progressed during Indian sultanate and mughal periods . Unani medicine is very close to Ayurveda . Both are based on theory of the presence of the elements ( in Unani , they are considered to be fire , water , earth and air ) in the human body . According to followers of Unani medicine , these elements are present in different fluids and their balance leads to health and their imbalance leads to illness . By the 18th century A.D. , Sanskrit medical wisdom still dominated . Muslim rulers built large hospitals in 1595 in Hyderabad , and in Delhi in 1719 , and numerous commentaries on ancient texts were written . Some European plants and medicinals were gradually incorporated into the Indian pharmacopeia , but otherwise there was little intellectual exchange with the West . # China # China also developed a large body of traditional medicine . Much of the philosophy of traditional Chinese medicine derived from empirical observations of disease and illness by Taoist physicians and reflects the classical Chinese belief that individual human experiences express causative principles effective in the environment at all scales . These causative principles , whether material , essential , or mystical , correlate as the expression of the natural order of the universe . The foundational text of Chinese medicine is the Huangdi neijing , or ' ' Yellow Emperor 's Inner Canon ' ' , written 5th century to 3rd century BCE ) . near the end of the 2nd century AD , during the Han dynasty , Zhang Zhongjing , wrote a ' ' Treatise on Cold Damage ' ' , which contains the earliest known reference to the ' ' Neijing Suwen ' ' . The Jin Dynasty practitioner and advocate of acupuncture and moxibustion , Huangfu Mi ( 215-282 ) , also quotes the Yellow Emperor in his ' ' Jiayi jing ' ' , c. 265 . During the Tang Dynasty , the ' ' Suwen ' ' was expanded and revised , and is now the best extant representation of the foundational roots of traditional Chinese medicine . Traditional Chinese Medicine that is based on the use of herbal medicine , acupuncture , massage and other forms of therapy has been practiced in China for thousands of years . In the 18th century , during the Qing dynasty , there was a proliferation of popular books as well as more advanced encyclopedias on traditional medicine . Jesuit missionaries introduced Western science and medicine to the royal court , the Chinese physicians ignored them . Finally in the 19th century , Western medicine was introduced at the local level by Christian medical missionaries from the London Missionary Society ( Britain ) , the Methodist Church ( Britain ) and the Presbyterian Church ( USA ) . Benjamin Hobson ( 18161873 ) in 1839 , set up a highly successful Wai Ai Clinic in Guangzhou , China . The Hong Kong College of Medicine for Chinese was founded in 1887 by the London Missionary Society , with its first graduate ( in 1892 ) being Sun Yat-sen , who later led the Chinese Revolution ( 1911 ) . The Hong Kong College of Medicine for Chinese was the forerunner of the School of Medicine of the University of Hong Kong , which started in 1911 . Due to the social custom that men and women should not be near to one another , the women of China were reluctant to be treated by male doctors . The missionaries sent women doctors such as Dr. Mary Hannah Fulton(18541927) . Supported by the Foreign Missions Board of the Presbyterian Church ( USA ) she in 1902 founded the first medical college for women in China , the Hackett Medical College for Women , in Guangzhou. # Greek and Roman medicine # # Homer # Around 800 BCE Homer in The Iliad gives descriptions of wound treatment by the two sons of Asklepios , the admirable physicians Podaleirius and Machaon and one acting doctor , Patroclus . Because Machaon is wounded and Podaleirius is in combat Eurypylus asks Patroclus to ' ' cut out this arrow from my thigh , wash off the blood with warm water and spread soothing ointment on the wound ' ' . Askelpios like Imhotep becomes god of healing over time . Temples dedicated to the healer-god Asclepius , known as ' ' Asclepieia ' ' ( , sing . , Asclepieion ' ' ) , functioned as centers of medical advice , prognosis , and healing . At these shrines , patients would enter a dream-like state of induced sleep known as ' ' enkoimesis ' ' ( ) not unlike anesthesia , in which they either received guidance from the deity in a dream or were cured by surgery . Asclepeia provided carefully controlled spaces conducive to healing and fulfilled several of the requirements of institutions created for healing . In the Asclepieion of Epidaurus , three large marble boards dated to 350 BCE preserve the names , case histories , complaints , and cures of about 70 patients who came to the temple with a problem and shed it there . Some of the surgical cures listed , such as the opening of an abdominal abscess or the removal of traumatic foreign material , are realistic enough to have taken place , but with the patient in a state of enkoimesis induced with the help of soporific substances such as opium . The first known Greek medical school opened in Cnidus in 700 BCE . Alcmaeon , author of the first anatomical work , worked at this school , and it was here that the practice of observing patients was established . As was the case elsewhere , the ancient Greeks developed a humoral medicine system where treatment sought to restore the balance of humours within the body . # Hippocrates # A towering figure in the history of medicine was the physician Hippocrates of Kos ( c. 460 c. 370 BCE ) , considered the father of Western medicine . The Hippocratic Corpus is a collection of around seventy early medical works from ancient Greece strongly associated with Hippocrates and his students . Most famously , Hippocrates invented the Hippocratic Oath for physicians , which is still relevant and in use today . Hippocrates and his followers were first to describe many diseases and medical conditions . He is given credit for the first description of acute , chronic , endemic and epidemic , and use terms such as , exacerbation , relapse , resolution , crisis , paroxysm , peak , and convalescence . Another of Hippocrates 's major contributions may be found in his descriptions of the symptomatology , physical findings , surgical treatment and prognosis of thoracic empyema , i.e. suppuration of the lining of the chest cavity . His teachings remain relevant to present-day students of pulmonary medicine and surgery . Hippocrates was the first documented chest surgeon and his findings are still valid . Some of the techniques and theories developed by Hippocrates are now put into practice by the fields of Environmental and Integrative Medicine . These include recognizing the importance of taking a complete history which includes environmental exposures as well as foods eaten by the patient which might play a role in his or her illness . # Celsus and Alexandria # Two great Alexandrians laid the foundations for the scientific study of anatomy and physiology , Herophilus of Chalcedon and Erasistratus of Ceos . Other Alexandrian surgeons gave us ; ligature ( hemostasis ) , lithotomy , hernia operations , ophthalmic surgery , plastic surgery , methods of reduction of dislocations and fractures , tracheotomy , and mandrake as anesthesia . Rarly of what we know of them comes from Celsus and Galen of Pergamum ( Greek : ' ' ' ' ) Herophilus of Chalcedon , working at the medical school of Alexandria placed intelligence in the brain , and connected the nervous system to motion and sensation . Herophilus also distinguished between veins and arteries , noting that the latter pulse while the former do not . He and his contemporary , Erasistratus of Chios , researched the role of veins and nerves , mapping their courses across the body . Erasistratus connected the increased complexity of the surface of the human brain compared to other animals to its superior intelligence . He sometimes employed experiments to further his research , at one time repeatedly weighing a caged bird , and noting its weight loss between feeding times . In Erasistratus ' physiology , air enters the body , is then drawn by the lungs into the heart , where it is transformed into vital spirit , and is then pumped by the arteries throughout the body . Some of this vital spirit reaches the brain , where it is transformed into animal spirit , which is then distributed by the nerves . # Galen # The Greek Galen was one of the greatest surgeons of the ancient world and performed many audacious operationsincluding brain and eye surgeries that were not tried again for almost two millennia . Later , in medieval Europe , Galen 's writings on anatomy became the mainstay of the medieval physician 's university curriculum along ; but they suffered greatly from stasis and intellectual stagnation . In the 1530s , however , Belgian anatomist and physician Andreas Vesalius took on a project to translate many of Galen 's Greek texts into Latin . Vesalius 's most famous work , ' ' De humani corporis fabrica ' ' , was greatly influenced by Galenic writing and form . The works of Galen were regarded as authoritative until well into the Middle Ages . The Romans invented numerous surgical instruments , including the first instruments unique to women , as well as the surgical uses of forceps , scalpels , cautery , cross-bladed scissors , the surgical needle , the sound , and speculas . Romans also performed cataract surgery . # Islamic Middle Ages 9th-12th # The Islamic Golden Age # Medieval Europe 400 to 1400 AD # After 400 A.D. , the study and practice of medicine in the Western Roman Empire went into deep decline . Medical services were provided , especially for the poor , in the thousands of monastic hospitals that sprang up across Europe , but the care was rudimentary and mainly palliative . Most of the writings of Galen and Hippocrates were lost to the West , with the summaries and compendia of St. Isidore of Seville being the primary channel for transmitting Greek medical ideas . The Carolingian renaissance brought increased contact with Byzantium and a greater awareness of ancient medicine , but only with the twelfth century renaissance and the new translations coming from Muslim and Jewish sources in Spain , and the fifteenth century flood of resources after the fall of Constantinople did the West fully recover its acquaintance with classical antiquity . Wallis identifies a prestige hierarchy with university educated physicians on top , followed by learned surgeons ; craft-trained surgeons ; barber surgeons ; itinerant specialists such as dentist and oculists ; empirics ; and midwives . # #Schools# # The first medical schools were opened , most notably the Schola Medica Salernitana at Salerno in southern Italy . The cosmopolitan influences from Greek , Latin , Arabic , and Hebrew sources gave it an international reputation as the Hippocratic City . Students from wealthy families came for three years of preliminary studies and five of medical studies . By the thirteenth century the medical school at Montpellier began to eclipse the Salernitan school . In the 12th century universities were founded in Italy , France and England which soon developed schools of medicine . The University of Montpellier in France and Italy 's University of Padua and University of Bologna were leading schools . Nearly all the learning was from lectures and readings in Hippocrates , Galen , Avicenna and Aristotle . There was little clinical work or dissection. # #Humours# # The underlying principle of most medieval medicine was Galen 's theory of humours . This was derived from the ancient medical works , and dominated all western medicine until the 19th century . The theory stated that within every individual there were four humours , or principal fluids - black bile , yellow bile , phlegm , and blood , these were produced by various organs in the body , and they had to be in balance for a person to remain healthy . Too much phlegm in the body , for example , caused lung problems ; and the body tried to cough up the phlegm to restore a balance . The balance of humours in humans could be achieved by diet , medicines , and by blood-letting , using leeches . The four humours were also associated with the four seasons , black bile-autumn , yellow bile-summer , phlegm-winter and blood-spring . Healing included both physical and spiritual therapeutics , such as the right herbs , a suitable , diet , clean bedding , and the sense that care was always at hand . Other procedures used to help patients included the Mass , prayers , relics of saints , and music used to calm a troubled mind or quickened pulse . # Renaissance to Early Modern period 16th-18th century # The Renaissance brought an intense focus on scholarship to Christian Europe . A major effort to translate the Arabic and Greek scientific works into Latin emerged . Europeans gradually became experts not only the ancient writings of the Romans and Greeks , but in the contemporary writings of Islamic scientists . During the later centuries of the Renaissance came an increase in experimental investigation , particularly in the field of dissection and body examination , thus advancing our knowledge of human anatomy . The development of modern neurology began in the 16th century with Vesalius , who described the anatomy of the brain and other organs ; he had little knowledge of the brain 's function , thinking that it resided mainly in the ventricles . Over his lifetime he corrected over 200 of Galen 's mistakes . Understanding of medical sciences and diagnosis improved , but with little direct benefit to health care . Few effective drugs existed , beyond opium and quinine . Folklore cures and potentially poisonous metal-based compounds were popular treatments . Independently from Ibn al-Nafis , Michael Servetus rediscovered the pulmonary circulation , but this discovery did not reach the public because it was written down for the first time in the Manuscript of Paris in 1546 , and later published in the theological work which he paid with his life in 1553 . Later this was perfected by Renaldus Columbus and Andrea Cesalpino . Later William Harvey provided a refined and complete description of the circulatory system . The most useful tomes in medicine used both by students and expert physicians were Materia Medica and Pharmacopoeia. # Paracelsus # Paracelsus ( 14931541 ) , was an erratic and abusive innovator who rejected Galen and bookish knowledge , calling for experimental research , with heavy doses of mysticism , alchemy and magic mixed in . The point is that he rejected sacred magic ( miracles ) under Church auspisces and looked for cures in nature . He preached but he also pioneered the use of chemicals and minerals in medicine . His hermetical views were that sickness and health in the body relied on the harmony of man ( microcosm ) and Nature ( macrocosm ) . He took an approach different from those before him , using this analogy not in the manner of soul-purification but in the manner that humans must have certain balances of minerals in their bodies , and that certain illnesses of the body had chemical remedies that could cure them . Most of his influence came after his death . Paracelsus is a highly controversial figure in the history of medicine , with most experts hailing him as a Father of Modern Medicine for shaking off religious orthodoxy and inspiring many researchers ; others say he was a mystic more than a scientist and downplay his importance . # Padua and Bologna # University training of physicians began in the 13th century . The University of Padua began teaching medicine in 1222 . It played a leading role in the identification and treatment of diseases and ailments , specializing in autopsies and the inner workings of the body . Starting in 1595 , Padua 's famous anatomical theatre drew artists and scientists studying the human body during public dissections . The intensive study of Galen led to critiques of Galen modeled on his own writing , as in the first book of Vesalius 's ' ' De humani corporis fabrica . ' ' Andreas Vesalius held the chair of Surgery and Anatomy ( ' ' explicator chirurgiae ' ' ) and in 1543 published his anatomical discoveries in De Humani Corporis Fabrica . He portrayed the human body as an interdependent system of organ groupings . The book triggered great public interest in dissections and caused many other European cities to establish anatomical theatres . At the University of Bologna the training of physicians began in 1219 . The Italian city attracted students from across Europe . Taddeo Alderotti built a tradition of medical education that established the characteristic features of Italian learned medicine and was copied by medical schools elsewhere . Turisanus ( d. 1320 ) was his student . The curriculum was revised and strengthened in 15601590 . A representative professor was Julius Caesar Aranzi ( Arantius ) ( 153089 ) . He became Professor of Anatomy and Surgery at the University of Bologna in 1556 , where he established anatomy as a major branch of medicine for the first time . Aranzi combined anatomy with a description of pathological processes , based largely on his own research , Galen , and the work of his contemporary Italians . Aranzi discovered the ' Nodules of Aranzio ' in the semilunar valves of the heart and wrote the first description of the superior levator palpebral and the coracobrachialis muscles . His books ( in Latin ) covered surgical techniques for many conditions , including hydrocephalus , nasal polyp , goitre and tumours to phimosis , ascites , haemorrhoids , anal abscess and fistulae. # Women # Catholic women played large roles in health and healing in medieval and early modern Europe . A life as a nun was a prestigious role ; wealthy families provided dowries for their daughters , and these funded the convents , while the nuns provided free nursing care for the poor . The Catholic elites provided hospital services because of their theology of salvation that good works were the route to heaven . The Protestant reformers rejected the notion that rich men could gain God 's grace through good worksand thereby escape purgatoryby providing cash endowments to charitable institutions . They also rejected the Catholic idea that the poor patients earned grace and salvation through their suffering . Protestants generally closed all the convents and most of the hospitals , sending women home to become housewives , often against their will . *35937;569; Cite journal The Hamoaze flows past Devonport Dockyard , which belongs to the Royal Navy . The presence of large numbers of small watercraft are a challenge and hazard to the warships using the naval base and dockyard . Settlements on the banks of the Hamoaze are Saltash , Wilcove , Torpoint and Cremyll in Cornwall as well as Devonport , Plymouth in Devon . 
@@18957 Medicine ( also called conventional , scientific , or mainstream medicine , especially when compared with alternative medicine or traditional medicine , UK English , US English ) is the field that mixes applied science with art in the diagnosis , treatment , and prevention of disease . It encompasses a variety of health care practices evolved to maintain and restore health by the prevention and treatment of illness in human beings . Contemporary medicine applies biomedical sciences , biomedical research , genetics and medical technology to diagnose , treat , and prevent injury and disease , typically through medication or surgery , but also through therapies as diverse as psychotherapy , external splints &amp; traction , prostheses , biologics , pharmaceuticals , ionizing radiation among others . The word ' ' medicine ' ' is derived from the Latin ' ' ars medicina ' ' , meaning ' ' the art of healing ' ' . # Clinical practice # Medical availability and clinical practice varies across the world due to regional differences in culture and technology . Modern scientific medicine is highly developed in the Western world , while in developing countries such as parts of Africa or Asia , the population may rely more heavily on traditional medicine with limited evidence and efficacy and no required formal training for practitioners . Even in the developed world however , evidence-based medicine is not universally used in clinical practice ; for example , a 2007 survey of literature reviews found that about 49% of the interventions lacked sufficient evidence to support either benefit or harm . In modern clinical practice , doctors personally assess patients in order to diagnose , treat , and prevent disease using clinical judgment . The doctor-patient relationship typically begins an interaction with an examination of the patient 's medical history and medical record , followed by a medical interview and a physical examination . Basic diagnostic medical devices ( e.g. stethoscope , tongue depressor ) are typically used . After examination for signs and interviewing for symptoms , the doctor may order medical tests ( e.g. blood tests ) , take a biopsy , or prescribe pharmaceutical drugs or other therapies . Differential diagnosis methods help to rule out conditions based on the information provided . During the encounter , properly informing the patient of all relevant facts is an important part of the relationship and the development of trust . The medical encounter is then documented in the medical record , which is a legal document in many jurisdictions . Follow-ups may be shorter but follow the same general procedure , and specialists follow a similar process . The diagnosis and treatment may take only a few minutes or a few weeks depending upon the complexity of the issue . The components of the medical interview and encounter are : Chief complaint ( CC ) : the reason for the current medical visit . These are the ' symptoms . ' They are in the patient 's own words and are recorded along with the duration of each one . Also called ' presenting complaint ' . History of present illness/complaint ( HPI ) : the chronological order of events of symptoms and further clarification of each symptom . Current activity : occupation , hobbies , what the patient actually does . Medications ( Rx ) : what drugs the patient takes including prescribed , over-the-counter , and home remedies , as well as alternative and herbal medicines/herbal remedies . Allergies are also recorded . Past medical history ( PMH/PMHx ) : concurrent medical problems , past hospitalizations and operations , injuries , past infectious diseases and/or vaccinations , history of known allergies. Social history ( SH ) : birthplace , residences , marital history , social and economic status , habits ( including diet , medications , tobacco , alcohol ) . Family history ( FH ) : listing of diseases in the family that may impact the patient . A family tree is sometimes used . Review of systems ( ROS ) or ' ' systems inquiry ' ' : a set of additional questions to ask , which may be missed on HPI : a general enquiry ( have you noticed any weight loss , change in sleep quality , fevers , lumps and bumps ? etc. ) , followed by questions on the body 's main organ systems ( heart , lungs , digestive tract , urinary tract , etc . ) . The physical examination is the examination of the patient for medical signs of disease , which are objective and observable , in contrast to symptoms which are volunteered by the patient and not necessarily objectively observable . The healthcare provider uses the senses of sight , hearing , touch , and sometimes smell ( e.g. , in infection , uremia , diabetic ketoacidosis ) . Four actions are the basis of physical examination : inspection , palpation ( feel ) , percussion ( tap to determine resonance characteristics ) , and auscultation ( listen ) , generally in that order although auscultation occurs prior to percussion and palpation for abdominal assessments . The clinical examination involves the study of : Vital signs including height , weight , body temperature , blood pressure , pulse , respiration rate , and hemoglobin oxygen saturation General appearance of the patient and specific indicators of disease ( nutritional status , presence of jaundice , pallor or clubbing ) Skin Head , eye , ear , nose , and throat ( HEENT ) Cardiovascular ( heart and blood vessels ) Respiratory ( large airways and lungs ) Abdomen and rectum Genitalia ( and pregnancy if the patient is or could be pregnant ) Musculoskeletal ( including spine and extremities ) Neurological ( consciousness , awareness , brain , vision , cranial nerves , spinal cord and peripheral nerves ) Psychiatric ( orientation , mental state , evidence of abnormal perception or thought ) . It is to likely focus on areas of interest highlighted in the medical history and may not include everything listed above . The treatment plan may include ordering additional medical laboratory tests and medical imaging studies , starting therapy , referral to a specialist , or watchful observation . Follow-up may be advised . Depending upon the health insurance plan and the managed care system , various forms of utilization review , such as prior authorization of tests , may place barriers on accessing expensive services . The medical decision-making ( MDM ) process involves analysis and synthesis of all the above data to come up with a list of possible diagnoses ( the differential diagnoses ) , along with an idea of what needs to be done to obtain a definitive diagnosis that would explain the patient 's problem . On subsequent visits , the process may be repeated in an abbreviated manner to obtain any new history , symptoms , physical findings , and lab or imaging results or specialist consultations . # Institutions # Contemporary medicine is in general conducted within health care systems . Legal , credentialing and financing frameworks are established by individual governments , augmented on occasion by international organizations , such as churches . The characteristics of any given health care system have significant impact on the way medical care is provided . From ancient times , Christian emphasis on practical charity gave rise to the development of systematic nursing and hospitals and the Catholic Church today remains the largest non-government provider of medical services in the world . Advanced industrial countries ( with the exception of the United States ) and many developing countries provide medical services through a system of universal health care that aims to guarantee care for all through a single-payer health care system , or compulsory private or co-operative health insurance . This is intended to ensure that the entire population has access to medical care on the basis of need rather than ability to pay . Delivery may be via private medical practices or by state-owned hospitals and clinics , or by charities , most commonly by a combination of all three . Most tribal societies , and the United States , provide no guarantee of healthcare for the population as a whole . In such societies , healthcare is available to those that can afford to pay for it or have self-insured it ( either directly or as part of an employment contract ) or who may be covered by care financed by the government or tribe directly . Transparency of information is another factor defining a delivery system . Access to information on conditions , treatments , quality , and pricing greatly affects the choice by patients/consumers and , therefore , the incentives of medical professionals . While the US healthcare system has come under fire for lack of openness , new legislation may encourage greater openness . There is a perceived tension between the need for transparency on the one hand and such issues as patient confidentiality and the possible exploitation of information for commercial gain on the other . # Delivery # Provision of medical care is classified into primary , secondary , and tertiary care categories . Primary care medical services are provided by physicians , physician assistants , nurse practitioners , or other health professionals who have first contact with a patient seeking medical treatment or care . These occur in physician offices , clinics , nursing homes , schools , home visits , and other places close to patients . About 90% of medical visits can be treated by the primary care provider . These include treatment of acute and chronic illnesses , preventive care and health education for all ages and both sexes . Secondary care medical services are provided by medical specialists in their offices or clinics or at local community hospitals for a patient referred by a primary care provider who first diagnosed or treated the patient . Referrals are made for those patients who required the expertise or procedures performed by specialists . These include both ambulatory care and inpatient services , emergency rooms , intensive care medicine , surgery services , physical therapy , labor and delivery , endoscopy units , diagnostic laboratory and medical imaging services , hospice centers , etc . Some primary care providers may also take care of hospitalized patients and deliver babies in a secondary care setting . Tertiary care medical services are provided by specialist hospitals or regional centers equipped with diagnostic and treatment facilities not generally available at local hospitals . These include trauma centers , burn treatment centers , advanced neonatology unit services , organ transplants , high-risk pregnancy , radiation oncology , etc . Modern medical care also depends on information still delivered in many health care settings on paper records , but increasingly nowadays by electronic means . In low-income countries , modern healthcare is often too expensive for the average person . International healthcare policy researchers have advocated that user fees be removed in these areas to ensure access , although even after removal , significant costs and barriers remain . # Branches # Working together as an interdisciplinary team , many highly trained health professionals besides medical practitioners are involved in the delivery of modern health care . Examples include : nurses , emergency medical technicians and paramedics , laboratory scientists , pharmacists , podiatrists physiotherapists , respiratory therapists , speech therapists , occupational therapists , radiographers , dietitians , and bioengineers . The scope and sciences underpinning human medicine overlap many other fields . Dentistry , while considered by some a separate discipline from medicine , is a medical field . A patient admitted to hospital is usually under the care of a specific team based on their main presenting problem , e.g. , the Cardiology team , who then may interact with other specialties , e.g. , surgical , radiology , to help diagnose or treat the main problem or any subsequent *26;1584;TOOLONG . Physicians have many specializations and subspecializations into certain branches of medicine , which are listed below . There are variations from country to country regarding which specialties certain subspecialties are in . The main branches of medicine are :  Basic sciences of medicine ; this is what every physician is educated in , and some return to in biomedical research  Medical specialties  Interdisciplinary fields , where different medical specialties are mixed to function in certain occasions . # Basic sciences #  ' ' Anatomy ' ' is the study of the physical structure of organisms . In contrast to ' ' macroscopic ' ' or ' ' gross anatomy ' ' , ' ' cytology ' ' and ' ' histology ' ' are concerned with microscopic structures .  ' ' Biochemistry ' ' is the study of the chemistry taking place in living organisms , especially the structure and function of their chemical components .  ' ' Biomechanics ' ' is the study of the structure and function of biological systems by means of the methods of Mechanics .  ' ' Biostatistics ' ' is the application of statistics to biological fields in the broadest sense . A knowledge of biostatistics is essential in the planning , evaluation , and interpretation of medical research . It is also fundamental to epidemiology and evidence-based medicine .  ' ' Biophysics ' ' is an interdisciplinary science that uses the methods of physics and physical chemistry to study biological systems .  ' ' Cytology ' ' is the microscopic study of individual cells .  ' ' Embryology ' ' is the study of the early development of organisms .  ' ' Endocrinology ' ' is the study of hormones and their effect throughout the body of animals .  ' ' Epidemiology ' ' is the study of the demographics of disease processes , and includes , but is not limited to , the study of epidemics .  ' ' Genetics ' ' is the study of genes , and their role in biological inheritance .  ' ' Histology ' ' is the study of the structures of biological tissues by light microscopy , electron microscopy and immunohistochemistry.  ' ' Immunology ' ' is the study of the immune system , which includes the innate and adaptive immune system in humans , for example .  ' ' Medical physics ' ' is the study of the applications of physics principles in medicine .  ' ' Microbiology ' ' is the study of microorganisms , including protozoa , bacteria , fungi , and viruses .  ' ' Molecular biology ' ' is the study of molecular underpinnings of the process of replication , transcription and translation of the genetic material .  ' ' Neuroscience ' ' includes those disciplines of science that are related to the study of the nervous system . A main focus of neuroscience is the biology and physiology of the human brain and spinal cord . Some related clinical specialties include neurology , neurosurgery and psychiatry.  ' ' Nutrition science ' ' ( theoretical focus ) and ' ' dietetics ' ' ( practical focus ) is the study of the relationship of food and drink to health and disease , especially in determining an optimal diet . Medical nutrition therapy is done by dietitians and is prescribed for diabetes , cardiovascular diseases , weight and eating disorders , allergies , malnutrition , and neoplastic diseases .  ' ' Pathology as a science ' ' is the study of diseasethe causes , course , progression and resolution thereof .  ' ' Pharmacology ' ' is the study of drugs and their actions .  ' ' Photobiology ' ' is the study of the interactions between non-ionizing radiation and living organisms .  ' ' Physiology ' ' is the study of the normal functioning of the body and the underlying regulatory mechanisms .  ' ' Radiobiology ' ' is the study of the interactions between ionizing radiation and living organisms .  ' ' Toxicology ' ' is the study of hazardous effects of drugs and poisons . # Specialties # In the broadest meaning of medicine , there are many different specialties . In the UK , most specialities have their own body or college , which have its own entrance examination . These are collectively known as the Royal Colleges , although not all currently use the term Royal . The development of a speciality is often driven by new technology ( such as the development of effective anaesthetics ) or ways of working ( such as emergency departments ) ; the new specialty leads to the formation a unifying body of doctors and the prestige of administering their own examination . Within medical circles , specialities usually fit into one of two broad categories : Medicine and Surgery . Medicine refers to the practice of non-operative medicine , and most of its subspecialties require preliminary training in Internal Medicine . In the UK , this was traditionally evidenced by passing the examination for the Membership of the Royal College of Physicians ( MRCP ) or the equivalent college in Scotland or Ireland . Surgery refers to the practice of operative medicine , and most subspecialties in this area require preliminary training in General Surgery , which in the UK leads to membership of the Royal College of Surgeons of England ( MRCS ) . At present , some specialties of medicine do not fit easily into either of these categories , such as radiology , pathology , or anesthesia . Most of these have branched from one or other of the two camps above ; for example anaesthesia developed first as a faculty of the Royal College of Surgeons ( for which MRCS/FRCS would have been required ) before becoming the Royal College of Anaesthetists and membership of the college is attained by sitting the examination of the Fellowship of the Royal College of Anesthetists ( FRCA ) . # #Surgery# # ' ' Surgical specialties ' ' employ operative treatment . In addition , surgeons must decide when an operation is necessary , and also treat many non-surgical issues , particularly in the surgical intensive care unit ( SICU ) , where a variety of critical issues arise . Surgeons must also manage pre-operative , post-operative , and potential surgical candidates on the hospital wards . Surgery has many sub-specialties , including ' ' general surgery , cardiovascular surgery , colorectal surgery , neurosurgery , oral and maxillofacial surgery , oncologic surgery , orthopedic surgery , otolaryngology , plastic surgery , podiatric surgery , transplant surgery , trauma surgery , urology , vascular surgery , and pediatric surgery . ' ' In some centers , anesthesiology is part of the division of surgery ( for historical and logistical reasons ) , although it is not a surgical discipline . Other medical specialties may employ surgical procedures , such as ophthalmology and dermatology , but are not considered surgical sub-specialties per se . Surgical training in the U.S. requires a minimum of five years of residency after medical school . Sub-specialties of surgery often require seven or more years . In addition , fellowships can last an additional one to three years . Because post-residency fellowships can be competitive , many trainees devote two additional years to research . Thus in some cases surgical training will not finish until more than a decade after medical school . Furthermore , surgical training can be very difficult and time consuming . # #'Medicine ' as a specialty# # Internal medicine is the medical specialty concerned with the diagnosis , management and nonsurgical treatment of unusual or serious diseases , either of one particular organ system or of the body as a whole . According to some sources , an emphasis on internal structures is implied . In North America , specialists in internal medicine are commonly called internists . Elsewhere , especially in Commonwealth nations , such specialists are often called physicians . These terms , ' ' internist ' ' or ' ' physician ' ' ( in the narrow sense , common outside North America ) , generally exclude practitioners of gynecology and obstetrics , pathology , psychiatry , and especially surgery and its subspecialities . Because their patients are often seriously ill or require complex investigations , internists do much of their work in hospitals . Formerly , many internists were not subspecialized ; such ' ' general physicians ' ' would see any complex nonsurgical problem ; this style of practice has become much less common . In modern urban practice , most internists are subspecialists : that is , they generally limit their medical practice to problems of one organ system or to one particular area of medical knowledge . For example , gastroenterologists and nephrologists specialize respectively in diseases of the gut and the kidneys.  ' ' Travel medicine ' ' or ' ' emporiatrics ' ' deals with health problems of international travelers or travelers across highly different environments .  ' ' Tropical medicine ' ' deals with the prevention and treatment of tropical diseases . It is studied separately in temperate climates where those diseases are quite unfamiliar to medical practitioners and their local clinical needs .  ' ' Urgent care ' ' focuses on delivery of unscheduled , walk-in care outside of the hospital emergency department for injuries and illnesses that are not severe enough to require care in an emergency department . In some jurisdictions this function is combined with the emergency room . Veterinary medicine ; veterinarians apply similar techniques as physicians to the care of animals .  ' ' Wilderness medicine ' ' entails the practice of medicine in the wild , where conventional medical facilities may not be available . Many other health science fields , e.g. dietetics # Education # Medical education and training varies around the world . It typically involves entry level education at a university medical school , followed by a period of supervised practice or internship , and/or residency . This can be followed by postgraduate vocational training . A variety of teaching methods have been employed in medical education , still itself a focus of active research . In Canada and the United States of America , a Doctor of Medicine degree , often abbreviated M.D. or a Doctor of Osteopathic Medicine degree , often abbreviated as D.O . and unique to the United States , must be completed in a recognized university . Since knowledge , techniques , and medical technology continue to evolve at a rapid rate , many regulatory authorities require continuing medical education . Medical practitioners upgrade their knowledge in various ways , including medical journals , seminars , conferences and online programs . # Medical ethics # Medical ethics is a system of moral principles that apply values and judgments to the practice of medicine . As a scholarly discipline , medical ethics encompasses its practical application in clinical settings as well as work on its history , philosophy , theology , and sociology . Six of the values that commonly apply to medical ethics discussions are :  autonomy - the patient has the right to refuse or choose their treatment . ( ' ' Voluntas aegroti suprema lex ' ' . )  beneficence - a practitioner should act in the best interest of the patient . ( ' ' Salus aegroti suprema lex ' ' . )  justice - concerns the distribution of scarce health resources , and the decision of who gets what treatment ( fairness and equality ) .  non-maleficence - first , do no harm ( ' ' primum non nocere ' ' ) .  respect for persons - the patient ( and the person treating the patient ) have the right to be treated with dignity .  truthfulness and honesty - the concept of informed consent has increased in importance since the historical events of the Doctors ' Trial of the Nuremberg trials , Tuskegee syphilis experiment , and others . Values such as these do not give answers as to how to handle a particular situation , but provide a useful framework for understanding conflicts . When moral values are in conflict , the result may be an ethical dilemma or crisis . Sometimes , no good solution to a dilemma in medical ethics exists , and occasionally , the values of the medical community ( i.e. , the hospital and its staff ) conflict with the values of the individual patient , family , or larger non-medical community . Conflicts can also arise between health care providers , or among family members . For example , some argue that the principles of autonomy and beneficence clash when patients refuse blood transfusions , considering them life-saving ; and truth-telling was not emphasized to a large extent before the HIV era. # Legal controls # In most countries , it is a legal requirement for a medical doctor to be licensed or registered . In general , this entails a medical degree from a university and accreditation by a medical board or an equivalent national organization , which may ask the applicant to pass exams . This restricts the considerable legal authority of the medical profession to physicians that are trained and qualified by national standards . It is also intended as an assurance to patients and as a safeguard against charlatans that practice inadequate medicine for personal gain . While the laws generally require medical doctors to be trained in evidence based , Western , or Hippocratic Medicine , they are not intended to discourage different paradigms of health . In the European Union , the profession of doctor of medicine is regulated . A profession is said to be regulated when access and exercise is subject to the possession of a specific professional qualification . The regulated professions database contains in the EU member states , EEA countries and Switzerland . This list is covered by the Directive 2005/36/EC . Doctors who are negligent or intentionally harmful in their care of patients can face charges of medical malpractice and be subject to civil , criminal , or professional sanctions . # Criticism of modern medicine # According to Paul Farmer , the main problem for modern medicine is lack of access in poor regions . There is an outcome gap between the rich and poor that is most noticeable with expensive-to-treat diseases like AIDS and tuberculosis . The majority of medical resources and therapies are concentrated in the rich , low-incidence regions such as the West . On the other hand , countries in the developing world have high rates of HIV but lack the necessary resources to treat them . Medical errors and overmedication and other forms of iatrogenesis ( harms caused by medical treatment ) are also the focus of complaints and negative coverage . Practitioners of human factors engineering believe that there is much that medicine may usefully gain by emulating concepts in aviation safety , where it is recognized that it is dangerous to place too much responsibility on one superhuman individual and expect him or her not to make errors . Reporting systems and checking mechanisms are becoming more common in identifying sources of error and improving practice . Clinical versus statistical , algorithmic diagnostic methods were famously examined in psychiatric practice in a 1954 book by Paul E. Meehl , which found statistical methods superior . A 2000 meta-analysis comparing these methods in both psychology and medicine found that statistical or mechanical diagnostic methods were , in general , although not always , superior . Disparities in quality of care given among local demographics are often an additional cause of controversy . For example , elderly mentally ill patients received poorer care during hospitalization in a 2008 study . Rural poor African-American men were used in an infamous study of syphilis that denied them basic medical care . # Honors and awards # The highest honor awarded in medicine is the Nobel Prize in Physiology or Medicine , awarded since 1901 by the Nobel Assembly at Karolinska Institutet. # History # # Ancient world # Prehistoric medicine incorporated plants ( herbalism ) , animal parts and minerals . In many cases these materials were used ritually as magical substances by priests , shamans , or medicine men . Well-known spiritual systems include animism ( the notion of inanimate objects having spirits ) , spiritualism ( an appeal to gods or communion with ancestor spirits ) ; shamanism ( the vesting of an individual with mystic powers ) ; and divination ( magically obtaining the truth ) . The field of medical anthropology examines the ways in which culture and society are organized around or impacted by issues of health , health care and related issues . Early records on medicine have been discovered from ancient Egyptian medicine , Babylonian medicine , Ayurvedic medicine ( in the Indian subcontinent ) , classical Chinese medicine ( predecessor to the modern traditional Chinese Medicine ) , and ancient Greek medicine and Roman medicine . In Egypt , Imhotep ( 3rd millennium BC ) is the first physician in history known by name . The oldest Egyptian medical text is the ' ' Kahun Gynaecological Papyrus ' ' from around 2000 BCE , which describes gynaecological diseases . The ' ' Edwin Smith Papyrus ' ' dating back to 1600 BCE is an early work on surgery , while the ' ' Ebers Papyrus ' ' dating back to 1500 BCE is akin to a textbook on medicine . In China , archaeological evidence of medicine in Chinese dates back to the Bronze Age Shang Dynasty , based on seeds for herbalism and tools presumed to have been used for surgery . The ' ' Huangdi Neijing ' ' , the progenitor of Chinese medicine , is a medical text written beginning in the 2nd century BCE and compiled in the 3rd century . In India , the surgeon Sushruta described numerous surgical operations , including the earliest forms of plastic surgery . Earliest records of dedicated hospitals come from Mihintale in Sri Lanka where evidence of dedicated medicinal treatment facilities for patients are found . In Greece , the Greek physician Hippocrates , the father of medicine , laid the foundation for a rational approach to medicine . Hippocrates introduced the Hippocratic Oath for physicians , which is still relevant and in use today , and was the first to categorize illnesses as acute , chronic , endemic and epidemic , and use terms such as , exacerbation , relapse , resolution , crisis , paroxysm , peak , and convalescence . The Greek physician Galen was also one of the greatest surgeons of the ancient world and performed many audacious operations , including brain and eye surgeries . After the fall of the Western Roman Empire and the onset of the Early Middle Ages , the Greek tradition of medicine went into decline in Western Europe , although it continued uninterrupted in the Eastern Roman ( Byzantine ) Empire . Most of our knowledge of ancient Hebrew medicine during the 1st millennium BC comes from the Torah , i.e. the Five Books of Moses , which contain various health related laws and rituals . The Hebrew contribution to the development of modern medicine started in the Byzantine Era , with the physician Asaph the Jew . # Middle ages # After 750 CE , the Muslim world had the works of Hippocrates , Galen and Sushruta translated into Arabic , and Islamic physicians engaged in some significant medical research . Notable Islamic medical pioneers include the polymath , Avicenna , who , along with Imhotep and Hippocrates , has also been called the father of medicine . He wrote ' ' The Canon of Medicine ' ' , considered one of the most famous books in the history of medicine . Others include Abulcasis , Avenzoar , Ibn al-Nafis , and Averroes . Rhazes was one of first to question the Greek theory of humorism , which nevertheless remained influential in both medieval Western and medieval Islamic medicine . Al-Risalah al-Dhahabiah by Ali al-Ridha is revered as the most precious Islamic literature in the Science of Medicine . The Islamic Bimaristan hospitals were an early example of public hospitals . In Europe , Charlemagne decreed that a hospital should be attached to each cathedral and monastery and the historian Geoffrey Blainey likened the activities of the Catholic Church in health care during the Middle Ages to an early version of a welfare state : It conducted hospitals for the old and orphanages for the young ; hospices for the sick of all ages ; places for the lepers ; and hostels or inns where pilgrims could buy a cheap bed and meal . It supplied food to the population during famine and distributed food to the poor . This welfare system the church funded through collecting taxes on a large scale and possessing large farmlands and estates . The Benedictine order was noted for setting up hospitals and infirmaries in their monasteries , growing medical herbs and becoming the chief medical care givers of their districts , as at the great Abbey of Cluny . The Church also established a network of cathedral schools and universities where medicine was studied . The Schola Medica Salernitana in Salerno , looking to the learning of Greek and Arab physicians , grew to be the finest medical school in Medieval Europe . However , the fourteenth and fifteenth century Black Death devastated both the Middle East and Europe , and it has even been argued that Western Europe was generally more effective in recovering from the pandemic than the Middle East . In the early modern period , important early figures in medicine and anatomy emerged in Europe , including Gabriele Falloppio and William Harvey . The major shift in medical thinking was the gradual rejection , especially during the Black Death in the 14th and 15th centuries , of what may be called the ' traditional authority ' approach to science and medicine . This was the notion that because some prominent person in the past said something must be so , then that was the way it was , and anything one observed to the contrary was an anomaly ( which was paralleled by a similar shift in European society in general see Copernicus 's rejection of Ptolemy 's theories on astronomy ) . Physicians like Vesalius improved upon or disproved some of the theories from the past . The main tomes used both by medicine students and expert physicians were Materia Medica and Pharmacopoeia . Andreas Vesalius was the author of ' ' De humani corporis fabrica ' ' , an important book on human anatomy . Bacteria and microorganisms were first observed with a microscope by Antonie van Leeuwenhoek in 1676 , initiating the scientific field microbiology . Independently from Ibn al-Nafis , Michael Servetus rediscovered the pulmonary circulation , but this discovery did not reach the public because it was written down for the first time in the Manuscript of Paris in 1546 , and later published in the theological work for which he paid with his life in 1553 . Later this was described by Renaldus Columbus and Andrea Cesalpino . Herman Boerhaave is sometimes referred to as a father of physiology due to his exemplary teaching in Leiden and textbook ' Institutiones medicae ' ( 1708 ) . Pierre Fauchard has been called the father of modern dentistry . # Modern # Veterinary medicine was , for the first time , truly separated from human medicine in 1761 , when the French veterinarian Claude Bourgelat founded the world 's first veterinary school in Lyon , France . Before this , medical doctors treated both humans and other animals . Modern scientific biomedical research ( where results are testable and reproducible ) began to replace early Western traditions based on herbalism , the Greek four humours and other such pre-modern notions . The modern era really began with Edward Jenner 's discovery of the smallpox vaccine at the end of the 18th century ( inspired by the method of inoculation earlier practiced in Asia ) , Robert Koch 's discoveries around 1880 of the transmission of disease by bacteria , and then the discovery of antibiotics around 1900 . The post-18th century modernity period brought more groundbreaking researchers from Europe . From Germany and Austria , doctors Rudolf Virchow , Wilhelm Conrad Rntgen , Karl Landsteiner and Otto Loewi made notable contributions . In the United Kingdom , Alexander Fleming , Joseph Lister , Francis Crick and Florence Nightingale are considered important . Spanish doctor Santiago Ramn y Cajal is considered the father of modern neuroscience . From New Zealand and Australia came Maurice Wilkins , Howard Florey , and Frank Macfarlane Burnet . In the United States , William Williams Keen , William Coley , James D. Watson , Italy ( Salvador Luria ) , Switzerland ( Alexandre Yersin ) , Japan ( Kitasato Shibasabur ) , and France ( Jean-Martin Charcot , Claude Bernard , Paul Broca and others did significant work ) . Russian Nikolai Korotkov also did significant work , as did Sir William Osler and Harvey Cushing . As science and technology developed , medicine became more reliant upon medications . Throughout history and in Europe right until the late 18th century , not only animal and plant products were used as medicine , but also human body parts and fluids . Pharmacology developed from herbalism and many drugs are still derived from plants ( atropine , ephedrine , warfarin , aspirin , digoxin , vinca alkaloids , taxol , hyoscine , etc . ) . Vaccines were discovered by Edward Jenner and Louis Pasteur . The first antibiotic was arsphenamine / Salvarsan discovered by Paul Ehrlich in 1908 after he observed that bacteria took up toxic dyes that human cells did not . The first major class of antibiotics was the sulfa drugs , derived by German chemists originally from azo dyes . Pharmacology has become increasingly sophisticated ; modern biotechnology allows drugs targeted towards specific physiological processes to be developed , sometimes designed for compatibility with the body to reduce side-effects . Genomics and knowledge of human genetics is having some influence on medicine , as the causative genes of most monogenic genetic disorders have now been identified , and the development of techniques in molecular biology and genetics are influencing medical technology , practice and decision-making . Evidence-based medicine is a contemporary movement to establish the most effective algorithms of practice ( ways of doing things ) through the use of systematic reviews and meta-analysis . The movement is facilitated by modern global information science , which allows as much of the available evidence as possible to be collected and analyzed according to standard protocols that are then disseminated to healthcare providers . The Cochrane Collaboration leads this movement . A 2001 review of 160 Cochrane systematic reviews revealed that , according to two readers , 21.3% of the reviews concluded insufficient evidence , 20% concluded evidence of no effect , and 22.5% concluded positive effect . # Patron saints # There are a number of patron saints for physicians , the most important of whom are Saint Luke the Evangelist the physician and disciple of Christ , Saints Cosmas and Damian ( 3rd-century physicians from Syria ) , and Saint Pantaleon ( 4th-century physician from Nicomedia ) . Archangel Raphael is also considered a patron saint of physicians . In India and in Hinduism , Dhanavantari , a form of Lord Vishnu and Vaidyanatha meaning ' Lord of Medicine ' , a form of Lord Shiva are the patron deities of medicine . The patron saints for surgeons are Saint Luke the Evangelist , the physician and disciple of Christ , Saints Cosmas and Damian ( 3rd-century physicians from Syria ) , Saint Quentin ( 3rd-century saint from France ) , Saint Foillan ( 7th-century saint from Ireland ) , and Saint Roch ( 14th-century saint from France ) . 
@@20401 A medicine man or medicine woman is a traditional healer and spiritual leader among American Indians , or Native Americans in the United States and First Nations in Canada . # The medicine man and woman in North America # # Role in native society # The primary function of these medicine elders is to secure the help of the spirit world , including the Great Spirit ( Wakan Tanka in the language of the Lakota people ) , for the benefit of the entire community . Sometimes the help sought may be for the sake of healing disease , sometimes it may be for the sake of healing the psyche , sometimes the goal is to promote harmony between human groups or between humans &amp; nature . So the term medicine man/woman is not entirely inappropriate , but it greatly oversimplifies and also skews the depiction of the people whose role in society complements that of the chief . These people are not the Native American equivalent of the Chinese barefoot doctors , herbalists , nor of the emergency medical technicians who ride rescue vehicles . To be recognized as the one who performs this function of bridging between the natural world and the spiritual world for the benefit of the community , an individual must be validated in his role by that community . Medicine men and women study through a medicine society or from a single teacher . # Cultural context # The term medicine people is commonly used in Native American communities , for example , when Arwen Nuttall ( Cherokee ) of the National Museum of the American Indian writes , The knowledge possessed by medicine people is privileged , and it often remains in particular families . Native Americans tend to be quite reluctant to discuss issues about medicine or medicine people with non-Indians . In some cultures , the people will not even discuss these matters with Indians from other tribes . In most tribes medicine elders are not expected to advertise or introduce themselves as such . As Nuttall writes , An inquiry to a Native person about religious beliefs or ceremonies is often viewed with suspicion . One example of this was the Apache medicine cord or ' ' Izze-kloth ' ' , whose purpose and use by Apache medicine elders was a mystery to nineteenth century ethnologists because ' ' the Apache look upon these cords as so sacred that strangers are not allowed to see them , much less handle them or talk about them ' ' . The 1954 version of ' ' Webster 's New World Dictionary of the American Language , ' ' reflects the poorly grounded perceptions of the people whose use of the term effectively defined it for the people of that time : a man supposed to have supernatural powers of curing disease and controlling spirits . In effect , such definitions were not explanations of what these medicine people were to their own communities , but instead reported on the consensus of socially and psychologically remote observers when they tried to categorize these individuals . The term medicine man/woman , like the term shaman , has been criticized by Native Americans , as well as other specialists in the fields of religion and anthropology . The term medicine man/woman was also frequently used by Europeans to refer to African traditional healers , also known as witch doctors or fetish men/women . While anthropologists sometimes use the term shaman , for Indigenous healers , shaman is the specific name for a spiritual mediator from the Tungusic peoples of Siberia , and is not used in Native American or First Nations communities . # Effectiveness # Some people believe native American healing can be used to treat a variety of human ailments including heart disease , diabetes and cancer . However , according to the American Cancer Society while its supportive community aspects might improve general well-being , available scientific evidence does not support claims that Native American healing can cure cancer or any other disease . <ref> cite web # See also #  Cultural appropriation  Curandero  Ethnobotany  Herbalism  Keewaydinoquay Peschel  Kallawaya  List of ineffective cancer treatments  Midewiwin  Native American religion  Plastic shaman  Prehistoric medicine  Quesalid  Trance  Kennekuk  Witch doctor # Notes # 
@@32654 Veterinary medicine is the branch of science that deals with the prevention , diagnosis and treatment of disease , disorder and injury in animals . The scope of veterinary medicine is wide , covering all animal species , both domesticated and wild , with a wide range of conditions which can affect different species . Veterinary medicine is widely practiced , both with and without professional supervision . Professional care is most often led by a veterinary physician ( also known as a vet , veterinary surgeon or veterinarian ) , but also by paraveterinary workers such as veterinary nurses or technicians . This can be augmented by other paraprofessionals with specific specialisms such as animal physiotherapy or dentistry , and species relevant roles such as farriers . Veterinary science helps human health through the monitoring and control of zoonotic disease ( infectious disease transmitted from non-human animals to humans ) and veterinary scientists often collaborate with epidemiologists. # History # # Premodern era # The Egyptian ' ' Papyrus of Kahun ' ' ( 1900 BCE ) and Vedic literature in ancient India offer one of the first written records of veterinary medicine . ( See also Shalihotra ) ( Buddhism ) First Buddhist Emperor of India edicts of Asoka reads : Everywhere King Piyadasi ( Asoka ) made two kinds of medicine ( ) available , medicine for people and medicine for animals . Where there were no healing herbs for people and animals , he ordered that they be bought and planted . Asoka The first attempts to organize and regulate the practice of treating animals tended to focus on horses because of their economic significance . In the Middle Ages from around 475 CE , farriers combined their work in horseshoeing with the more general task of horse doctoring . In 1356 , the Lord Mayor of London , concerned at the poor standard of care given to horses in the city , requested that all farriers operating within a seven mile radius of the City of London form a fellowship to regulate and improve their practices . This ultimately led to the establishment of the Worshipful Company of Farriers in 1674 . Meanwhile , Carlo Ruini 's book ' ' Anatomia del Cavallo , ' ' ( ' ' Anatomy of the Horse ' ' ) was published in 1598 . It was the first comprehensive treatise on the anatomy of a non-human species . # Establishment of profession # The first veterinary college was founded in Lyon , France in 1762 by Claude Bourgelat . According to Lupton , after observing the devastation being caused by cattle plague to the French herds , Bourgelat devoted his time to seeking out a remedy . This resulted in his founding a veterinary college in Lyon in 1761 , from which establishment he dispatched students to combat the disease ; in a short time , the plague was stayed and the health of stock restored , through the assistance rendered to agriculture by veterinary science and art . The Odiham Agricultural Society was founded in 1783 in England to promote agriculture and industry , and played an important role in the foundation of the veterinary profession in Britain . A founding member , Thomas Burgess , began to take up the cause of animal welfare and campaign for the more humane treatment of sick animals . A 1785 Society meeting resolved to promote the study of Farriery upon rational scientific principles . The physician James Clark wrote a treatise entitled ' ' Prevention of Disease ' ' in which he argued for the professionalization of the veterinary trade , and the establishment of veterinary colleges . This was finally achieved in 1790 , through the campaigning of Granville Penn , who persuaded the Frenchman , Benoit Vial de St. Bel to accept the professorship of the newly established Veterinary College in London . The Royal College of Veterinary Surgeons was established by royal charter in 1844 . Veterinary science came of age in the late 19th century , with notable contributions from Sir John McFadyean , credited by many as having been the founder of modern Veterinary research . In the United States , the first schools were established in the early 19th century in Boston , New York and Philadelphia . In 1879 , Iowa Agricultural College became the first land grant college to establish a school of veterinary medicine . # Veterinary workers # # Veterinary physicians # Veterinary care is usually led by a veterinary physician ( usually called a vet , veterinary surgeon or veterinarian ) . This role is the equivalent of a doctor in human medicine , and usually involves post-graduate study and qualification . In many countries , the local nomenclature for a vet is a protected term , meaning that people without the prerequisite qualifications and/or registration are not able to use the title , and in many cases , the activities that may be undertaken by a vet ( such as animal treatment or surgery ) are restricted only to those people who are registered as vet . For instance , in the United Kingdom , as in other jurisdictions , animal treatment may only be performed by registered vets ( with a few designated exceptions , such as paraveterinary workers ) , and it is illegal for any person who is not registered to call themselves a vet or perform any treatment . Most vets work in clinical settings , treating animals directly . These vets may be involved in a general practice , treating animals of all types ; may be specialized in a specific group of animals such as companion animals , livestock , laboratory animals , zoo animals or horses ; or may specialize in a narrow medical discipline such as surgery , dermatology , laboratory animal medicine , or internal medicine . As with healthcare professionals , vets face ethical decisions about the care of their patients . Current debates within the profession include the ethics of purely cosmetic procedures on animals , such as declawing of cats , docking of tails , cropping of ears and debarking on dogs . # Paraveterinary workers # Paraveterinary workers , including veterinary nurses , technicians and assistants , either assist vets in their work , or may work within their own scope of practice , depending on skills and qualifications , including in some cases , performing minor surgery . The role of paraveterinary workers is less homogeneous globally than that of a vet , and qualification levels , and the associated skill mix , vary widely . # Allied professions # A number of professions exist within the scope of veterinary medicine , but which may not necessarily be performed by vets or veterinary nurses . This includes those performing roles which are also found in human medicine , such as practitioners dealing with musculoskeletal disorders , including osteopaths , chiropractors and physiotherapists . There are also roles which are specific to animals , but which have parallels in human society , such as animal grooming and animal massage . Some roles are specific to a species or group of animals , such as farriers , who are involved in the shoeing of horses , and in many cases have a major role to play in ensuring the medical fitness of the horse . 
@@33583 image = Flag of WHO.svg parent = United Nations Economic and Social Council ( ECOSOC ) The World Health Organization ( WHO ) is a specialized agency of the United Nations ( UN ) that is concerned with international public health . It was established on 7 April 1948 , headquartered in Geneva , Switzerland . WHO is a member of the United Nations Development Group . Its predecessor , the Health Organization , was an agency of the League of Nations . The main responsibility was to help anybody in need of medical assistance . The constitution of the World Health Organization had been signed by all 69 countries of the United Nations by 22 July 1946 , with the first meeting of the World Health Assembly finishing on 24 July 1948 . It incorporated the ' ' Office International d'Hygine Publique ' ' and the League of Nations Health Organization . Since its creation , it has played a leading role in the eradication of smallpox . Its current priorities include communicable diseases , in particular , HIV/AIDS , malaria and tuberculosis ; the mitigation of the effects of non-communicable diseases ; sexual and reproductive health , development , and aging ; nutrition , food security and healthy eating ; occupational health ; substance abuse ; and drive the development of reporting , publications , and networking . WHO is responsible for the World Health Report , a leading international publication on health , the worldwide World Health Survey , and World Health Day ( 7 April of every year ) . Its links with the International Atomic Energy Agency and distribution of contraception have both proved controversial , as have guidelines on healthy eating and the 2009 flu pandemic. # History # # Establishment # The use of the word world , rather than international , emphasized the truly global nature of what the organization was seeking to achieve . The constitution of the World Health Organization had been signed by all 61 countries of the United Nations by 22 July 1946 . It thus became the first specialised agency of the United Nations to which every member subscribed . Its constitution formally came into force on the first World Health Day on 7 April 1948 , when it was ratified by the 26th member state . The first meeting of the World Health Assembly finished on 24 July 1948 , having secured a budget of US$5 million ( then GBP1,250,000 ) for the 1949 year . Andrija Stampar was the Assembly 's first president , and G. Brock Chisholm was appointed Director-General of WHO , having served as Executive Secretary during the planning stages . Its first priorities were to control the spread of malaria , tuberculosis and sexually transmitted infections , and to improve maternal and child health , nutrition and environmental hygiene . Its first legislative act was concerning the compilation of accurate statistics on the spread and morbidity of disease . The logo of the World Health Organization features the Rod of Asclepius as a symbol for healing . # Operational history # WHO established an epidemiological information service via telex in 1947 , and by 1950 a mass tuberculosis inoculation drive ( using the BCG vaccine ) was under way . In 1955 , the malaria eradication programme was launched , although it was later altered in objective . 1965 saw the first report on diabetes mellitus and the creation of the International Agency for Research on Cancer . WHO moved into its headquarters building in 1966 . The Expanded Programme on Immunization was started in 1974 , as was the control programme into onchocerciasis an important partnership between the Food and Agriculture Organization ( FAO ) , the United Nations Development Programme ( UNDP ) , and World Bank . In the following year , the Special Programme for Research and Training in Tropical Diseases was also launched . In 1976 , the World Health Assembly voted to enact a resolution on Disability Prevention and Rehabilitation , with a focus on community-driven care . The first list of essential medicines was drawn up in 1977 , and a year later the ambitious goal of health for all was declared . In 1986 , WHO started its global programme on the growing problem of HIV/AIDS , followed two years later by additional attention on preventing discrimination against sufferers and UNAIDS was formed in 1996 . The Global Polio Eradication Initiative was established in 1988 . In 1958 , Viktor Zhdanov , Deputy Minister of Health for the USSR , called on the World Health Assembly to undertake a global initiative to eradicate smallpox , resulting in Resolution WHA11.54 . At this point , 2 million people were dying from smallpox every year . In 1967 , the World Health Organization intensified the global smallpox eradication by contributing $2.4 million annually to the effort and adopted a new disease surveillance method . The initial problem the WHO team faced was inadequate reporting of smallpox cases . WHO established a network of consultants who assisted countries in setting up surveillance and containment activities . The WHO also helped contain the last European outbreak in Yugoslavia in 1972 . After over two decades of fighting smallpox , the WHO declared in 1979 that the disease had been eradicated the first disease in history to be eliminated by human effort . In 1998 , WHO 's Director General highlighted gains in child survival , reduced infant mortality , raised life expectancy and reduced rates of scourges such as smallpox and polio on the fiftieth anniversary of WHO 's founding . He , did , however , accept that more had to be done to assist maternal health and that progress in this area had been slow . Cholera and malaria have remained problems since WHO 's founding , although in decline for a large part of that period . In the twenty-first century , the Stop TB Partnership was created in 2000 , along with the UN 's formulation of the Millennium Development Goals . The Measles initiative was formed in 2001 , and credited with reducing global deaths from the disease by 68% by 2007 . In 2002 , The Global Fund to Fight AIDS , Tuberculosis and Malaria was drawn up to improve the resources available . In 2006 , the organization endorsed the world 's first official HIV/AIDS Toolkit for Zimbabwe , which formed the basis for a global prevention , treatment and support plan to fight the AIDS pandemic. # Overall focus # The WHO 's Constitution states that its objective is the attainment by all people of the highest possible level of health . WHO fulfils its objective through its functions as defined in its Constitution : ( a ) to act as the directing and co-ordinating authority on international health work ; ( b ) to establish and maintain effective collaboration with the United Nations , specialized agencies , governmental health administrations , professional groups and such other organizations as may be deemed appropriate ; ( c ) to assist Governments , upon request , in strengthening health services ; ( d ) to furnish appropriate technical assistance and , in emergencies , necessary aid upon the request or acceptance of Governments ; ( e ) to provide or assist in providing , upon the request of the United Nations , health services and facilities to special groups , such as the peoples of trust territories ; ( f ) to establish and maintain such administrative and technical services as may be required , including epidemiological and statistical services ; ( g ) to stimulate and advance work to eradicate epidemic , endemic and other diseases ; ( h ) to promote , in co-operation with other specialized agencies where necessary , the prevention of accidental injuries ; ( i ) to promote , in co-operation with other specialized agencies where necessary , the improvement of nutrition , housing , sanitation , recreation , economic or working conditions and other aspects of environmental hygiene ; ( j ) to promote co-operation among scientific and professional groups which contribute to the advancement of health ; ( k ) to propose conventions , agreements and regulations , and make recommendations with respect to international health matters and to perform . WHO currently defines its role in public health as follows :  providing leadership on matters critical to health and engaging in partnerships where joint action is needed ;  shaping the research agenda and stimulating the generation , translation and dissemination of valuable knowledge ;  setting norms and standards and promoting and monitoring their implementation ;  articulating ethical and evidence-based policy options ;  providing technical support , catalyzing change , and building sustainable institutional capacity ; and  monitoring the health situation and assessing health trends . # Communicable diseases # The 20122013 WHO budget identified 13 areas among which funding was distributed . Two of those thirteen areas related to communicable diseases : the first , to reduce the health , social and economic burden of communicable diseases in general ; the second to combat HIV/AIDS , malaria and tuberculosis in particular . In terms of HIV/AIDS , WHO works within the UNAIDS network and considers it important that it works in alignment with UNAIDS objectives and strategies . It also strives to involve sections of society other than health to help deal with the economic and social effects of the disease . In line with UNAIDS , WHO has set itself the interim task between 2009 and 2015 of reducing the number of those aged 1524 years who are infected by 50% ; reducing new HIV infections in children by 90% ; and reducing HIV-related deaths by 25% . Although WHO dropped its commitment to a global malaria eradication campaign in the 1970s as too ambitious , it retains a strong commitment to malaria control . WHO 's Global Malaria Programme works to keep track of malaria cases , and future problems in malaria control schemes . WHO is to report , likely in 2015 , as to whether RTS , S/AS01 , currently in research , is a viable malaria vaccine . For the time being , insecticide-treated mosquito nets and insecticide sprays are used to prevent the spread of malaria , as are antimalarial drugs particularly to vulnerable people such as pregnant women and young children . WHO 's help has contributed to a 40% fall in the number of deaths from tuberculosis between 1990 and 2010 , and since 2005 , it claims that over 46 million people have been treated and an estimated 7 million lives saved through practices advocated by WHO . These include engaging national governments and their financing , early diagnosis , standardising treatment , monitoring of the spread and impact of tuberculosis and stabilising the drug supply . It has also recognised the vulnerability of victims of HIV/AIDS to tuberculosis . WHO aims to eradicate polio . It has also been successful in helping to reduce cases by 99% since the Global Polio Eradication Initiative was launched in 1988 , which partnered WHO with Rotary International , the US Centers for Disease Control and Prevention ( CDC ) and the United Nations Children 's Fund ( UNICEF ) , as well as smaller organizations . It works to immunize young children and prevent the re-emergence of cases in countries declared polio-free . # Non-communicable diseases , mental health and injuries # Another of the thirteen WHO priority areas is aimed at the prevention and reduction of disease , disability and premature from chronic noncommunicable diseases , mental disorders , violence and injuries , and visual impairment . For example , the WHO promotes road safety as a means to reduce traffic-related injuries . WHO has also worked on global initiatives in surgery , including emergency and essential surgical care , trauma care , and safe surgery . The WHO Surgical Safety Checklist is in current use worldwide in the effort to improve patient safety . # Life course and life style # WHO works to reduce morbidity and mortality and improve health during key stages of life , including pregnancy , childbirth , the neonatal period , childhood and adolescence , and improve sexual and reproductive health and promote active and healthy aging for all individuals . It also tries to prevent or reduce risk factors for health conditions associated with use of tobacco , alcohol , drugs and other psychoactive substances , unhealthy diets and physical inactivity and unsafe sex . WHO works to improve nutrition , food safety and food security and to ensure this has a positive effect on public health and sustainable development . # Emergency work # When any sort of disaster or emergency occurs , it is WHO 's stated objective to reduce any consequences the event may have on world health and its social and economic implications . On 5 May 2014 , WHO announced that the spread of polio is a world health emergency - outbreaks of the disease in Asia , Africa and the Middle East are considered extraordinary . On 8 August 2014 , WHO declared that the spread of Ebola is a public health emergency ; an outbreak which is believed to have started in Guinea , has spread to spread to other nearby countries such as Liberia and Sierra Leone . The situation in West Africa is considered very serious . # Health policy # WHO addresses government health policy with two aims : firstly , to address the underlying social and economic determinants of health through policies and programmes that enhance health equity and integrate pro-poor , gender-responsive , and human rights-based approaches and secondly to promote a healthier environment , intensify primary prevention and influence public policies in all sectors so as to address the root causes of environmental threats to health . The organization develops and promotes the use of evidence-based tools , norms and standards to support member states to inform health policy options . It oversees the implementation of the International Health Regulations , and publishes a series of medical classifications ; of these , three are overreaching reference classifications : the International Statistical Classification of Diseases ( ICD ) , the International Classification of Functioning , Disability and Health ( ICF ) and the International Classification of Health Interventions ( ICHI ) . Other international policy frameworks produced by WHO include the International Code of Marketing of Breast-milk Substitutes ( adopted in 1981 ) , Framework Convention on Tobacco Control ( adopted in 2003 ) and the Global Code of Practice on the International Recruitment of Health Personnel ( adopted in 2010 ) . In terms of health services , WHO looks to improve governance , financing , staffing and management and the availability and quality of evidence and research to guide policy making . It also strives to ensure improved access , quality and use of medical products and technologies . # Governance and support # The remaining two of WHO 's thirteen identified policy areas relate to the role of WHO itself :  to provide leadership , strengthen governance and foster partnership and collaboration with countries , the United Nations system , and other stakeholders in order to fulfill the mandate of WHO in advancing the global health agenda ; and  to develop and sustain WHO as a flexible , learning organization , enabling it to carry out its mandate more efficiently and effectively . # #Partnerships# # The WHO along with the World Bank constitute the core team responsible for administering the International Health Partnership ( IHP+ ) . The IHP+ is a group of partner governments , development agencies , civil society and others committed to improving the health of citizens in developing countries . Partners work together to put international principles for aid effectiveness and development cooperation into practice in the health sector . The organization relies on contributions from renowned scientists and professionals to inform its work , such as the WHO Expert Committee on Biological Standardization , the WHO Expert Committee on Leprosy , and the Interprofessional education#WHO Study Group on Interprofessional Education &amp; Collaborative PracticeWHO Study Group on Interprofessional Education &amp; Collaborative Practice . WHO runs the Alliance for Health Policy and Systems Research , targeted at improving health policy and systems . WHO also aims to improve access to health research and literature in developing countries such as through the HINARI network . # #Public health education and action# # Each year , the organization marks World Health Day and other observances focusing on a specific health promotion topic . World Health Day falls on April 7 each year , timed to match the anniversary of WHO 's founding . Recent themes have been vector-borne diseases ( 2014 ) , healthy ageing ( 2012 ) and drug resistance ( 2011 ) . The other official global public health campaigns marked by WHO are World Tuberculosis Day , World Immunization Week , World Malaria Day , World No Tobacco Day , World Blood Donor Day , World Hepatitis Day , and World AIDS Day . As part of the United Nations , the World Health Organization supports work towards the Millennium Development Goals . Of the eight Millennium Development Goals , three reducing child mortality by two-thirds , to reduce maternal deaths by three-quarters , and to halt and begin to reduce the spread of HIV/AIDS relate directly to WHO 's scope ; the other five inter-relate and have an impact on world health . # Data handling and publications # The World Health Organization works to provide the needed health and well-being evidence through a variety of data collection platforms , including the World Health Survey covering almost 400,000 respondents from 70 countries , and the ' ' Study on Global Ageing and Adult Health ' ' ( SAGE ) covering over 50,000 persons over 50 years old in 23 countries . The Country Health Intelligence Portal ( CHIP ) , has also been developed to provide an access point to information about the health services that are available in different countries . The information gathered in this portal is utilized by the countries to set priorities for future strategies or plans , implement , monitor , and evaluate it . The WHO has published various tools for measuring and monitoring the capacity of national health systems and health workforces . The Global Health Observatory ( GHO ) has been the WHO 's main portal which provides access to data and analyses for key health themes by monitoring health situations around the globe . The ' ' WHO Assessment Instrument for Mental Health Systems ' ' ( WHO-AIMS ) , the ' ' WHO Quality of Life Instrument ' ' ( WHOQOL ) , and the ' ' Service Availability and Readiness Assessment ' ' ( SARA ) provide guidance for data collection . Collaborative efforts between WHO and other agencies , such as through the Health Metrics Network , also aim to provide sufficient high-quality information to assist governmental decision making . WHO promotes the development of capacities in member states to use and produce research that addresses their national needs , including through the Evidence-Informed Policy Network ( EVIPNet ) . The Pan American Health Organization ( PAHO/AMRO ) became the first region to develop and pass a policy on research for health approved in September 2009 . On December 10 , 2013 , a new WHO database , known as MiNDbank , went online . The database was launched on Human Rights Day , and is part of WHOs QualityRights initiative , which aims to end human rights violations against people with mental health conditions . The new database presents a great deal of information about mental health , substance abuse , disability , human rights , and the different policies , strategies , laws , and service standards being implemented in different countries . It also contains important international documents and information . The database allows visitors to access the health information of WHO member states and other partners . Users can review policies , laws , and strategies and search for the best practices and success stories in the field of mental health . The WHO regularly publishes a ' ' World Health Report ' ' , its leading publication , including an expert assessment of a specific global health topic . Other publications of WHO include the ' ' Bulletin of the World Health Organization ' ' , the ' ' Eastern Mediterranean Health Journal ' ' ( overseen by EMRO ) , the ' ' Human Resources for Health ' ' ( published in collaboration with BioMed Central ) , and the ' ' Pan American Journal of Public Health ' ' ( overseen by PAHO/AMRO ) . # Structure # The World Health Organization is a member of the United Nations Development Group . # Membership # , the WHO has 194 member states : all Member States of the United Nations except Liechtenstein , as well as the Cook Islands and Niue . ( A state becomes a full member of WHO by ratifying the treaty known as the Constitution of the World Health Organization. ) , it also had two associate members , Puerto Rico and Tokelau . Several other entities have been granted observer status . Palestine is an observer as a national liberation movement recognised by the League of Arab States under United Nations Resolution 3118 . The Holy See also attends as an observer , as does the Order of Malta . In 2010 , Taiwan was invited under the name of Chinese Taipei . WHO Member States appoint delegations to the World Health Assembly , WHO 's supreme decision-making body . All UN Member States are eligible for WHO membership , and , according to the WHO web site , other countries may be admitted as members when their application has been approved by a simple majority vote of the World Health Assembly . In addition , the UN observer organizations International Committee of the Red Cross and International Federation of Red Cross and Red Crescent Societies have entered into official relations with WHO and are invited as observers . In the World Health Assembly they are seated along the other NGOs. # Assembly and Executive Board # The World Health Assembly is the legislative and supreme body of WHO . Based in Geneva , it typically meets yearly in May . It appoints the Director-General every five years , and votes on matters of policy and finance of WHO , including the proposed budget . It also reviews reports of the Executive Board and decides whether there are areas of work requiring further examination . The Assembly elects 34 members , technically qualified in the field of health , to the Executive Board for three-year terms . The main functions of the Board are to carry out the decisions and policies of the Assembly , to advise it and to facilitate its work . # Regional offices # The regional divisions of WHO were created between 1949 and 1952 , and are based on article 44 of WHO 's constitution , which allowed the WHA to establish a single regional organization to meet the special needs of each defined area . Many decisions are made at regional level , including important discussions over WHO 's budget , and in deciding the members of the next assembly , which are designated by the regions . Each region has a Regional Committee , which generally meets once a year , normally in the autumn . Representatives attend from each member or associative member in each region , including those states that are not fully recognised . For example , Palestine attends meetings of the Eastern Mediterranean Regional office . Each region also has a regional office . Each Regional Office is headed by a Regional Director , who is elected by the Regional Committee . The Board must approve such appointments , although as of 2004 , it had never overruled the preference of a regional committee . The exact role of the board in the process has been a subject of debate , but the practical effect has always been small . Since 1999 , Regional Directors serve for a once-renewable five-year term . Each Regional Committee of the WHO consists of all the Health Department heads , in all the governments of the countries that constitute the Region . Aside from electing the Regional Director , the Regional Committee is also in charge of setting the guidelines for the implementation , within the region , of the health and other policies adopted by the World Health Assembly . The Regional Committee also serves as a progress review board for the actions of WHO within the Region . The Regional Director is effectively the head of WHO for his or her Region . The RD manages and/or supervises a staff of health and other experts at the regional offices and in specialized centers . The RD is also the direct supervising authorityconcomitantly with the WHO Director-Generalof all the heads of WHO country offices , known as WHO Representatives , within the Region . # People # class= wikitable style= float:right ; margin-left:10px ; width:30% ; ! Name ! Years of tenure The head of the organization is the Director-General , elected by the World Health Assembly . The current Director-General is Margaret Chan , who was first appointed on 9 November 2006 and confirmed for a second term until the end of June 2017 . WHO employs 8,500 people in 147 countries . In support of the principle of a tobacco-free work environment the WHO does not recruit cigarette smokers . The organization has previously instigated the Framework Convention on Tobacco Control in 2003 . The WHO operates Goodwill Ambassadors , members of the arts , sport or other fields of public life aimed at drawing attention to WHO 's initiatives and projects . There are currently five Goodwill Ambassadors ( Jet Li , Nancy Brinker , Peng Liyuan , Yohei Sasakawa and the Vienna Philharmonic Orchestra ) and a further ambassador associated with a partnership project ( Craig David ) . # Country and liaison offices # The World Health Organization operates 147 country offices in all its regions . It also operates several liaison offices , including those with the European Union , United Nations and a single office covering the World Bank and International Monetary Fund . It also operates the International Agency for Research on Cancer in Lyon , France , and the WHO Centre for Health Development in Kobe , Japan . Additional offices include those in Pristina ; the West Bank and Gaza ; the US-Mexico Border Field Office in El Paso ; the Office of the Caribbean Program Coordination in Barbados ; and Northern Micronesia office . There will generally be one WHO country office in the capital , occasionally accompanied by satellite-offices in the provinces or sub-regions of the country in question . The country office is headed by a WHO Representative ( WR ) . , the only WHO Representative outside Europe to be a national of that country was for the Libyan Arab Jamahiriya ( Libya ) ; all other staff were international . Those in the Region for the Americas , they are referred to as PAHO/WHO Representatives . In Europe , WHO Representatives also serve as Head of Country Office , and are nationals with the exception of Serbia ; there are also Heads of Country Office in Albania , the Russian Federation , Tajikistan , Turkey , and Uzbekistan . The WR is member of the UN system country team which is coordinated by the UN System Resident Coordinator . The country office consists of the WR , and several health and other experts , both foreign and local , as well as the necessary support staff . The main functions of WHO country offices include being the primary adviser of that country 's government in matters of health and pharmaceutical policies . # Financing and partnerships # The WHO is financed by contributions from member states and outside donors . , the largest annual assessed contributions from member states came from the United States ( $110 million ) , Japan ( $58 million ) , Germany ( $37 million ) , United Kingdom ( $31 million ) and France ( $31 million ) . The combined 20122013 budget has proposed a total expenditure of $3,959 million , of which $944 million ( 24% ) will come from assessed contributions . This represented a significant fall in outlay compared to the previous 20092010 budget , adjusting to take account of previous underspends . Assessed contributions were kept the same . Voluntary contributions will account for $3,015 million ( 76% ) , of which $800 million is regarded as highly or moderately flexible funding , with the remainder tied to particular programmes or objectives . In recent years , the WHO 's work has involved increasing collaboration with external bodies . , a total of 473 NGOs had some form of partnership with WHO . There were 189 partnerships with international non-governmental organization ( NGO ) in formal official relations the rest being considered informal in character . Partners include the Bill and Melinda Gates Foundation and the Rockefeller Foundation . # Controversies # # IAEA Agreement WHA 1240 # In 1959 , the WHO signed Agreement WHA 1240 with the International Atomic Energy Agency ( IAEA ) . The agreement states that the WHO recognises the IAEA as having responsibility for peaceful nuclear energy without prejudice to the roles of the WHO of promoting health . However , the following paragraph adds : whenever either organization proposes to initiate a programme or activity on a subject in which the other organization has or may have a substantial interest , the first party shall consult the other with a view to adjusting the matter by mutual agreement . The nature of this statement has led some pressure groups and activists ( including Women in Europe for a Common Future ) to believe that the WHO is restricted in its ability to investigate the effects on human health of radiation caused by the use of nuclear power and the continuing effects of nuclear disasters in Chernobyl and Fukushima . They believe WHO must regain what they see as independence . # Roman Catholic Church and AIDS # In 2003 , the WHO denounced the Roman Curia 's health department 's opposition to the use of condoms , saying : These incorrect statements about condoms and HIV are dangerous when we are facing a global pandemic which has already killed more than 20 million people , and currently affects at least 42 million . , the Catholic Church remains opposed to increasing the use of contraception to combat HIV/AIDS . At the time , the World Health Assembly President , Guyana 's Health Minister Leslie Ramsammy , condemned Pope Benedict 's opposition to contraception , saying he was trying to create confusion and impede proven strategies in the battle against the disease . # Intermittent preventive therapy # The aggressive support of the Bill &amp; Melinda Gates Foundation for intermittent preventive therapy of malaria triggered a memo from the former WHO malaria chief Akira Kochi. # Diet and sugar intake # Some of the research undertaken or supported by WHO to determine how people 's lifestyles and environments are influencing whether they live in better or worse health can be controversial , as illustrated by a 2003 joint WHO/FAO report on nutrition and the prevention of chronic non-communicable disease , which recommended that sugar should form no more than 10% of a healthy diet . This report led to lobbying by the sugar industry against the recommendation , to which the WHO/FAO responded by including in the report the statement The Consultation recognized that a population goal for free sugars of less than 10% of total energy is controversial , but also stood by its recommendation based upon its own analysis of scientific studies . In 2014 , WHO reduced recommended sugar levels by half , saying that sugar should make up no more than 5% of a healthy diet . # 2009 influenza pandemic # In 2007 , the WHO organized work on pandemic influenza vaccine development through clinical trials in collaboration with many experts . A pandemic involving the H1N1 influenza virus was declared by Director-General Margaret Chan in April 2009 . By the post-pandemic period critics claimed the WHO had exaggerated the danger , spreading fear and confusion rather than immediate information . Industry experts countered that the 2009 pandemic had led to unprecedented collaboration between global health authorities , scientists and manufacturers , resulting in the most comprehensive pandemic response ever undertaken , with a number of vaccines approved for use three months after the pandemic declaration . This response was only possible because of the extensive preparations undertaken in during the last decade . # World headquarters # The seat of the organization is in Geneva , Switzerland . It was dedicated and opened in 1966. # Early views # # Views 2013 # 
@@44279 formation = August 3 , 1979 The United States Secretary of Health and Human Services is the head of the United States Department of Health and Human Services , concerned with health matters . The Secretary is a member of the President 's Cabinet . The office was formerly Secretary of Health , Education , and Welfare . In 1979 , the Department of Health , Education , and Welfare was renamed the Department of Health and Human Services , and its education functions transferred to the new Department of Education . Patricia Roberts Harris headed the department before and after it was renamed . Nominations to the office of Secretary of HHS are referred to the Health , Education , Labor and Pensions Committee and the Finance Committee , which has jurisdiction over Medicare and Medicaid , before confirmation is considered by the full United States Senate . Under the Patient Protection and Affordable Care Act the role of the Secretary has been greatly expanded . Sylvia Mathews Burwell was nominated by President Obama on April 11 , 2014 , to be the next Secretary of Health and Human Services after the resignation of Kathleen Sebelius . She was confirmed on June 5 , 2014 and sworn in on June 9 , 2014. # Duties # The duties of the secretary revolve around human conditions and concerns in the United States . This includes advising the president on matters of health , welfare , and income security programs . It strives to administer the Department of Health and Human Services to carry out approved programs and make the public aware of the objectives of the department . Since the attacks of 9/11 and the subsequent anthrax attacks , the position has held a unique significance in the War on Terrorism . Upon his departure , then-Secretary Tommy Thompson remarked I , for the life of me , can not understand why the terrorists have not attacked our food supply , because it is so easy to do .. Scholars concur , arguing that an attack on food ( particularly milk ) could affect approximately 100,000 people . The Department of Health and Human Services oversees 11 agencies including the Food and Drug Administration ( FDA ) , Center for Disease Control ( CDC ) , National Institutes of Health ( NIH ) , Administration for Children and Families ( ACF ) and Centers for Medicare &amp; Medicaid Services ( CMS ) . # List of secretaries # ; Parties # Living former secretaries # # Health , education , and welfare #  F. David Mathews  Joseph A. Califano , Jr . # Health and human services #  Richard S. Schweiker  Margaret M. Heckler  Louis W. Sullivan  Donna Shalala  Tommy G. Thompson  Michael O. Leavitt Kathleen Sebelius 
@@46174 employees = The National Institutes of Health ( NIH ) is a biomedical research facility primarily located in Bethesda , Maryland , USA . An agency of the United States Department of Health and Human Services , it is the primary agency of the United States government responsible for biomedical and health-related research . The NIH both conducts its own scientific research through its Intramural Research Program ( IRP ) and provides major biomedical research funding to non-NIH research facilities through its Extramural Research Program . With 1,200 principal investigators and more than 4,000 postdoctoral fellows in basic , translational , and clinical research , the IRP is the largest biomedical research institution on Earth , while , as of 2003 , the extramural arm provided 28% of biomedical research funding spent annually in the US , or about US$26.4 billion . The NIH comprises 27 separate institutes and centers that conduct research in different disciplines of biomedical science . The IRP is responsible for many scientific accomplishments , including the discovery of fluoride to prevent tooth decay , the use of lithium to manage bipolar disorder , and the creation of vaccines against hepatitis , ' ' Haemophilus influenzae ' ' ( HIB ) and human papillomavirus. # History # NIH 's roots extend back to a Marine Hospital Service in the late 1790s that provided medical relief to sick and disabled men in the U.S. Navy . By 1870 , a network of marine hospitals had developed and was placed under the charge of a medical officer within the Bureau of the Treasury Department . In the late 1870s , Congress allocated funds to investigate the causes of epidemics like cholera and yellow fever , and it created the National Board of Health , making medical research an official government initiative . In 1887 , a laboratory for the study of bacteria , the Hygienic Laboratory , was established at the Marine Hospital in New York . In the early 1900s , Congress began appropriating funds for the Marine Hospital Service . By 1922 , this organization changed its name to Public Health Services and established a Special Cancer Investigations laboratory at Harvard Medical School . This marked the beginning of a partnership with universities . In 1930 , the Hygienic Laboratory was re-designated as the National Institutes of Health by the Ransdell Act and was given $750,000 to construct two NIH buildings . Over the next few decades , Congress would increase its funding tremendously to the NIH , and various institutes and centers within the NIH were created for specific research programs . In 1967 , the was created to administer grants for research for heart disease , cancer , and strokes . That same year , the NIH director lobbied the White House for increased federal funding in order to increase research and the speed with which health benefits could be brought to the people . An advisory committee was formed to oversee further development of the NIH and its research programs . By 1971 , cancer research was in full force and President Nixon signed the National Cancer Act , initiating a National Cancer Program , President 's Cancer Panel , National Cancer Advisory Board , and 15 new research , training , and demonstration centers . The funding of NIH has often been a source of contention in Congress , serving as a proxy for the political currents of the time . This contention was seen most dramatically during the 1980s , when President Reagan repeatedly tried to cut funding for research , only to see Congress partly restore funding . The political contention over NIH funding slowed the nations 's response to the AIDS epidemic ; while AIDS was reported in newspaper articles from 1981 , no funding was provided for research on the disease . In 1984 , National Cancer Institute scientists found implications that variants of a human cancer virus called HTLV-III are the primary cause of acquired immunodeficiency syndrome ( AIDS ) , a new epidemic that gripped the nation . But it was not until July 1987 , as NIH celebrated its 100th anniversary , that President Reagan announced a committee to research the HIV epidemic . By the 1990s , the focus of the NIH committee had shifted to DNA research , and the Human Genome Project was launched . In 2009 , President Obama reinstated federally funded stem-cell research , revoking the ban imposed by President Bush in 2001 . From logistical restructuring , to funding increases , to research prioritization , to government expansion and political influence , the history of the National Institutes of Health is extensive and full of change . The NIH has grown to encompass nearly 1 percent of the federal government 's operating budget . The NIH now controls more than 50 percent of all funding for health research , and 85 percent of all funding for health studies in universities . # Locations and campuses # Intramural research is primarily conducted at the main campus in Bethesda , Maryland , and the surrounding communities . The National Institute on Aging and the National Institute on Drug Abuse are located in Baltimore , Maryland , and the National Institute of Environmental Health Sciences is located in the Research Triangle region of North Carolina . The National Institute of Allergy and Infectious Diseases maintains its Rocky Mountain Labs in Hamilton , Montana , with an emphasis on BSL3 and BSL4 laboratory work . # Research # NIH devotes 10% of its funding to research within its own facilities ( intramural research ) . The institution gives 80% of its funding in research grants to extramural ( outside ) researchers . Of this extramural funding , a certain percentage ( 2.8% in 2014 ) must be granted to small businesses under the SBIR/STTR program . The extramural funding consists of about 50,000 grants to more than 325,000 researchers at more than 3000 institutions . , NIH spent ( not including temporary funding from the American Recovery and Reinvestment Act of 2009 ) on clinical research , on genetics-related research , on prevention research , on cancer , and on biotechnology . # Public Access Policy # In 2008 , a Congressional mandate called for investigators funded by the NIH to submit an electronic version of their final manuscripts to the National Library of Medicine 's research repository , PubMed Central ( PMC ) , no later than 12 months after the official date of publication . The NIH Public Access Policy was the first public access mandate for a U.S. public funding agency . # NIH Interagency Pain Research Coordinating Committee # February 13 , 2012 the National Institutes of Health ( NIH ) announced a new group of individuals assigned to research pain . This committee is composed of researchers from different organizations and will focus to coordinate pain research activities across the federal government with the goals of stimulating pain research collaboration and providing an important avenue for public involvement ( Members of new , 2012 ) . With a committee such as this research will not be conducted by each individual organization or person but instead a collaborating group which will increase the information available . With this hopefully more pain management will be available including techniques for arthritis sufferers . # NIH Toolbox # In September 2006 , a contract for the NIH Toolbox for the Assessment of Neurological and Behavioral Function ( ) was initiated by the NIH Blueprint for Neuroscience Research ( *33;1588417;TOOLONG ) to develop a set of state-of-the-art measurement tools to enhance collection of data in large cohort studies and to advance the biomedical research enterprise . The NIH Toolbox was officially rolled out to the research community on September 1011 , 2012 at a public conference Unveiling the NIH Toolbox held in Bethesda , Maryland and Washington , D.C. Scientists from more than 100 institutions nationwide contributed to the development of the NIH Toolbox . The construction of NIH Toolbox assessments is based , where possible , on Item Response Theory and adapted for testing by computer . # Economic impact # In 2000 , a report from a Joint Economic Committee of Congress outlined the benefits of NIH research . It noted that some econometric studies had given its research , which was funded at $16 billion a year in 2000 , a rate of return of 25 to 40 percent per year . It also found that of the 21 drugs with the highest therapeutic impact on society introduced between 1965 and 1992 , public funding was instrumental for 15. # Funding # To allocate funds , the NIH must first obtain its budget from Congress . This process begins with institute and center ( IC ) leaders collaborating with scientists to determine the most important and promising research areas within their fields . IC leaders discuss research areas with NIH management who then develops a budget request for continuing projects , new research proposals , and new initiatives from the Director . NIH submits its budget request to HHS , and HHS considers this request within the parameters of its overall budget . Many adjustments and appeals occur between NIH and HHS before the agency submits NIH 's budget request to the Office of Management and Budget ( OMB ) . OMB determines what amounts and research areas are approved for incorporation into the President 's final budget . The President then sends NIH 's budget request to Congress in February for the next fiscal year 's allocations . The House and Senate Appropriations Subcommittees deliberate and by fall , Congress usually appropriates funding . This process takes approximately 18 months before the NIH can allocate any actual funds . NIH employs five broad decision criteria in its funding policy . First , ensure the highest quality of scientific research by employing an arduous peer review process . Second , seize opportunities that have the greatest potential to yield new knowledge and that will lead to better prevention and treatment of disease . Third , maintain a diverse research portfolio in order to capitalize on major discoveries in a variety of fields such as cell biology , genetics , physics , engineering , and computer science . Fourth , address public health needs according to the disease burden ( e.g. , prevalence and mortality ) . And fifth , construct and support the scientific infrastructure ( e.g. , well-equipped laboratories and safe research facilities ) necessary to conduct research . In 2007 the director of the agency stated responsibilities for identifying .. FCOIs ( financial conflict of interest ) must remain with grantee institutions but institutions that administer grants have no interest to identify grantee 's conflicts of interest . The NIH issued dozens of waivers for NIH 's advisory committee members up to 2012 . Such waivers exempt a conflicted government employee from ethics laws . Since 2005 the US Office of Government Ethics had documented only three times where the NIH consulted with the office as required by law , and none of the waivers in question had to do with a member of an advisory committee . Advisory committee members advise the Institute on policy and procedures affecting the external research programs and provide a second level of review for all grant and cooperative agreement applications considered by the Institute for funding . # Recent changes # The NIH funding policy has changed in several significant ways over time . First , the amount of money given to the NIH has increased in hard dollars , although in relation to inflation and the increased expense of doing science , the funding levels are currently down . Most scientists know that in the history of the NIH , it is more difficult now to get R01 grant funding than ever before , let alone have them renewed . The scientific community concerns the low funding to be a crisis in America , and wonder how China can busily recruit our scientists who can not stay funded given the lowered NIH funding levels without American realizing the great cost to this nation of not funding research . R01 Grants scored even in the top 20% are not being funded nowadaysand that 20% is after fifty percent of the grants are first triaged . So only five percent of grants are getting funded . And grants can not be submitted more than two times . However in hard dollars , the funding appears to have gone up . For example , in 1999 , Congress increased the NIH 's budget by $2.3 billion . ( to $17.2 billion in 2000 ) In 2009 Congress again increased the NIH budget to $31 billion in 2010 . Second , with the creation of the various ICs , the responsibility to allocate funding to researchers has shifted from the OD and Advisory Committee to the individual ICs . Additionally , Congress increasingly sets apart funding for particular causes . In the 1970s , Congress began to earmark funds specifically for cancer research and in the 1980s there was a significant amount allocated for AIDS/HIV research . Congress has continued to play an active role in allotting funds for specified research . These are some of the most significant changes in NIH funding policy over the last century . A few of the key issues in evaluating NIH funding policy were previously mentioned in the paper as the five criteria the NIH has established . Three of the criteria are particularly relevant . First , is the NIH ensuring the highest quality of research by fairly implementing their peer review process and allocating extramural research funds ? Second , is the NIH maximizing opportunities to produce research that yields new knowledge that will lead to better disease prevention and treatment ? Next , are public health needs being addressed according to the public disease burden ; in other words , are the most important needs of society being met rather than those of special interest groups ? These are the most important issues in evaluating NIH funding policy . When a government shutdown occurs , the NIH continues to treat people who are already enrolled in clinical trials , but does not start any new clinical trials and does not admit new patients who are not already enrolled in a clinical trial , except for the most critically ill , as determined by the NIH Director . In 2014 , it was announced that the NIH is directing scientists to perform their experiments with both female and male animals , or cells derived from females as well as males if they are studying cell cultures , and that the NIH would take the balance of each study design into consideration when awarding grants . However , the announcement also stated that this rule would probably not apply when studying sex-specific diseases ( for example , ovarian or testicular cancer. ) # Grant allocation bias controversy # In 2011 , a paper published in ' ' Science ' ' found that black researchers were 10% less likely to win NIH R01 grants ( the oldest and most widely used ) than white researchers , after controlling for educational background , country of origin , training , previous research awards , publication record , and employer characteristics . It also found that black researchers are significantly less likely to resubmit an unapproved grant than white researchers . The study lead and economist Donna Grant said that grant reviewers do not have access to the applicant race , but may infer it from biographies or names . She also speculated that the decreased re-submission rate may be due to lack of mentoring . The study , which was commissioned by the NIH , included in its analysis 83,000 grant applications , made between 2000 and 2006 . Dr. Otis W. Brawley , chief medical officer at the American Cancer Society and a black man , commented on the cause of the disparity as one unrelated to racism per se , but rather to the reviewers ' unconscious tendency to more likely give the benefit of the doubt to someone they are familiar with , in a scientific world where black researchers tend to keep a lower profile than other groups . The study did not reveal similar difficulties for members of other races and ethnic groups ( e.g. , Hispanics ) . # Stakeholders # Many groups are highly invested in NIH funding . # General Public # One of the goals of the NIH is to expand the base in medical and associated sciences in order to ensure a continued high return on the public investment in research . Taxpayer dollars funding NIH are from the taxpayers , making them the primary beneficiaries of advances in research . Thus , the general public is a key stakeholder in the decisions resulting from the NIH funding policy . Congress theoretically represents the public interest as the NIH Advisory Committee allocates to the NIH , and the funds to the Director . However , many in the general public do not feel their interests are being accurately represented . As a result , individuals have formed patient advocacy groups to represent their own interests . Patient advocacy groups tend to focus on specific aspects of health care or diseases . Advocates get involved in many different areas such as organizing awareness campaigns , promoting patients ' rights , and enhancing health policy initiatives . Most importantly , patient advocacy groups are often involved with advisory panels to ensure that current projects and those projects being considered for funding will directly impact patients ' lives , improve delivery of care , and provide support for tertiary care . Advocacy groups strive to promote a health care system that is beneficial for all parties involved . Through congressional representation , NIH Advisory Committee efforts , and patient advocacy groups , the public is able to influence funding allocation as well as the policy itself . # Extramural Researchers and Scientists # Other important stakeholders of the NIH funding policy are the researchers and scientists themselves . Extramural researchers differ from intramural researchers in that they are not employed by the NIH but must apply for funding . Throughout the history of the NIH , the amount of funding received has increased , but the proportion to each IC remains relatively constant . The individual ICs then decide who will receive the grant money and how much will be allotted . Research funding is important to extramural researchers for multiple reasons . Without the help of an NIH grant ( or a similar type of funding ) , researchers and scientists are unable to pursue their own research interests but are obliged to follow the agenda of the company or university for which they work . This could potentially hinder discoveries in novel research areas . In 2000 , Brian Jacobs and Lars Lefgren researched extensively the impact of NIH grants on basic research and development , and the careers of grant recipients . For the period of 19802000 , they reviewed all postdoctoral research grants and standard research grants for those who received funding and those who did not . Jacobs and Lefgren found that scientists who received postdoctoral research grants were 20 percent more likely to be published within the first five years after receiving the grant . They also found that scientists who received grants were 11 percent more likely to have one publication and 23 percent more likely to have five publications . Due to the ' publish or perish ' standard that many researchers face , NIH funding can have a great impact on researchers ' careers . Receiving a standard research grant also has a significant impact on researchers . Young scientists who receive a first-time grant ( R01 ) usually produce more than one additional publication in the five-year period after they receive the grant . Those who receive an NIH grant will typically receive $252,000 more in NIH funding in the following six to ten years , and a statistically significant relationship exists between scientists receiving NIH grants and their research productivity throughout their careers . Policy changes on who receives funding also significantly affect researchers . For example , the NIH has recently attempted to approve more first-time NIH R01 applicants , or the research grant applications of young scientists . To encourage the participation of young scientists who potentially think outside the box , the application process has been shortened and made easier . In addition , first-time applicants are being offered more funding for their research grants than those who have received grants in the past . Although this change provides greater opportunities for young scientists , it also places older , more experienced scientists at a funding disadvantage . # Commercial partnerships # In 2011 and 2012 , the Department of Health and Human Services Office of Inspector General published a series of audit reports revealing that throughout the fiscal years 20002010 , institutes under the aegis of the NIH , did not comply with the time and amount requirements specified in appropriations statutes , in awarding federal contracts to commercial partners , committing the federal government to tens of millions of dollars of expenditure ahead of appropriation of funds from Congress . # Institutes and Centers # The NIH is composed of 27 separate institutes and centers ( ICs ) that conduct and coordinate research across different disciplines of biomedical science . These are :  National Cancer Institute  National Eye Institute  National Heart , Lung , and Blood Institute  National Human Genome Research Institute  National Institute on Aging  National Institute on Alcohol Abuse and Alcoholism  National Institute of Allergy and Infectious Diseases  National Institute of Arthritis and Musculoskeletal and Skin Diseases  National Institute of Biomedical Imaging and Bioengineering  National Institute of Child Health and Human Development  National Institute on Deafness and Other Communication Disorders  National Institute of Dental and Craniofacial Research  National Institute of Diabetes and Digestive and Kidney Diseases  National Institute on Drug Abuse  National Institute of Environmental Health Sciences  National Institute of General Medical Sciences  National Institute of Mental Health  National Institute on Minority Health and Health Disparities  National Institute of Neurological Disorders and Stroke  National Institute of Nursing Research  National Library of Medicine  Center for Information Technology  Center for Scientific Review  Fogarty International Center  National Center for Advancing Translational Sciences  National Center for Complementary and Alternative Medicine  NIH Clinical Center In addition , the National Center for Research Resources operated from April 13 , 1962 to December 23 , 2011. 
@@47878 ICDO = MeshID = D006816 Huntington 's disease ( HD ) is a neurodegenerative genetic disorder that affects muscle coordination and leads to cognitive decline and behavioral symptoms . It typically becomes noticeable in mid-adult life . HD is the most common genetic cause of abnormal involuntary writhing movements called chorea , which is why the disease used to be called Huntington 's chorea . It is much more common in people of Western European descent than in those of Asian or African ancestry . The disease can affect both men and women . The disease is caused by an autosomal dominant mutation in either of an individual 's two copies of a gene called Huntingtin , which means any child of an affected person typically has a 50% chance of inheriting the disease . Physical symptoms of Huntington 's disease can begin at any age from infancy to old age , but usually begin between 35 and 44 years of age . Through genetic anticipation , the disease may develop earlier in life in each successive generation . About 6% of cases start before the age of 21 years with an akinetic-rigid syndrome ; they progress faster and vary slightly . The variant is classified as juvenile , akinetic-rigid or Westphal variant HD . The ' ' Huntingtin ' ' gene provides the genetic information for a protein that is also called huntingtin . Expansion of a CAG ( cytosine-adenine-guanine ) triplet repeat stretch within the ' ' Huntingtin ' ' gene results in a different ( mutant ) form of the protein , which gradually damages cells in the brain , through mechanisms that are not fully understood . The genetic basis of HD was discovered in 1993 by an international collaborative effort spearheaded by the Hereditary Disease Foundation . Genetic testing can be performed at any stage of development , even before the onset of symptoms . This fact raises several ethical debates : the age at which an individual is considered mature enough to choose testing ; whether parents have the right to have their children tested ; and managing confidentiality and disclosure of test results . Genetic counseling has developed to inform and aid individuals considering genetic testing and has become a model for other genetically dominant diseases . Symptoms of the disease can vary between individuals and even among affected members of the same family , but usually progress predictably . The earliest symptoms are often subtle problems with mood or cognition . A general lack of coordination and an unsteady gait often follows . As the disease advances , uncoordinated , jerky body movements become more apparent , along with a decline in mental abilities and behavioral symptoms . Physical abilities are gradually impeded until coordinated movement becomes very difficult . Mental abilities generally decline into dementia . Complications such as pneumonia , heart disease , and physical injury from falls reduce life expectancy to around twenty years from the point at which symptoms begin . There is no cure for HD , and full-time care is required in the later stages of the disease . Existing pharmaceutical and non-drug treatments can relieve many of its symptoms . Research and support organizations , first founded in the 1960s and increasing in number , work to increase public awareness , to provide support for individuals and their families , and to promote and facilitate research . Many new research discoveries have been made and understanding of the disease is improving . Current research directions include determining the exact mechanism of the disease , improving animal models to expedite research , clinical trials of pharmaceuticals to treat symptoms or slow the progression of the disease , and studying procedures such as stem cell therapy with the goal of repairing damage caused by the disease . # Signs and symptoms # Symptoms of Huntington 's disease commonly become noticeable between the ages of 35 and 44 years , but they can begin at any age from infancy to old age . In the early stages , there are subtle changes in personality , cognition , and physical skills . The physical symptoms are usually the first to be noticed , as cognitive and behavioral symptoms are generally not severe enough to be recognized on their own at the earlier stages . Almost everyone with Huntington 's disease eventually exhibits similar physical symptoms , but the onset , progression and extent of cognitive and behavioral symptoms vary significantly between individuals . The most characteristic initial physical symptoms are jerky , random , and uncontrollable movements called chorea . Chorea may be initially exhibited as general restlessness , small unintentionally initiated or uncompleted motions , lack of coordination , or slowed saccadic eye movements . These minor motor abnormalities usually precede more obvious signs of motor dysfunction by at least three years . The clear appearance of symptoms such as rigidity , writhing motions or abnormal posturing appear as the disorder progresses . These are signs that the system in the brain that is responsible for movement has been affected . Psychomotor functions become increasingly impaired , such that any action that requires muscle control is affected . Common consequences are physical instability , abnormal facial expression , and difficulties chewing , swallowing , and speaking . Eating difficulties commonly cause weight loss and may lead to malnutrition . Sleep disturbances are also associated symptoms . Juvenile HD differs from these symptoms in that it generally progresses faster and chorea is exhibited briefly , if at all , with rigidity being the dominant symptom . Seizures are also a common symptom of this form of HD. align= right border= 2 class= wikitable style= text-align:center ; margin-left:15px Cognitive abilities are progressively impaired . Especially affected are executive functions which include planning , cognitive flexibility , abstract thinking , rule acquisition , initiation of appropriate actions , and inhibition of inappropriate actions . As the disease progresses , memory deficits tend to appear . Reported impairments range from short-term memory deficits to long-term memory difficulties , including deficits in episodic ( memory of one 's life ) , procedural ( memory of the body of how to perform an activity ) and working memory . Cognitive problems tend to worsen over time , ultimately leading to dementia . This pattern of deficits has been called a subcortical dementia syndrome to distinguish it from the typical effects of cortical dementias e.g. Alzheimer 's disease . Reported neuropsychiatric manifestations are anxiety , depression , a reduced display of emotions ( blunted affect ) , egocentrism , aggression , and compulsive behavior , the latter of which can cause or worsen addictions , including alcoholism , gambling , and hypersexuality . Difficulties in recognizing other people 's negative expressions have also been observed . The prevalence of these symptoms is highly variable between studies , with estimated rates for lifetime prevalence of psychiatric disorders between 33% and 76% . For many sufferers and their families , these symptoms are among the most distressing aspects of the disease , often affecting daily functioning and constituting reason for institutionalization . Suicidal thoughts and suicide attempts are more common than in the general population . Often individuals have reduced awareness of chorea , cognitive and emotional impairments . Mutant Huntingtin is expressed throughout the body and associated with abnormalities in peripheral tissues that are directly caused by such expression outside the brain . These abnormalities include muscle atrophy , cardiac failure , impaired glucose tolerance , weight loss , osteoporosis , and testicular atrophy. # Genetics # All humans have two copies of the Huntingtin gene ( ' ' HTT ' ' ) , which codes for the protein Huntingtin ( Htt ) . The gene is also called ' ' HD ' ' and ' ' IT15 ' ' , which stands for ' interesting transcript 15 ' . Part of this gene is a repeated section called a trinucleotide repeat , which varies in length between individuals and may change length between generations . If the repeat is present in a healthy gene , a dynamic mutation may increase the repeat count and result in a defective gene . When the length of this repeated section reaches a certain threshold , it produces an altered form of the protein , called mutant Huntingtin protein ( mHtt ) . The differing functions of these proteins are the cause of pathological changes which in turn cause the disease symptoms . The Huntington 's disease mutation is genetically dominant and almost fully penetrant : mutation of either of a person 's ' ' HTT ' ' genes causes the disease . It is not inherited according to sex , but the length of the repeated section of the gene and hence its severity can be influenced by the sex of the affected parent . # Genetic mutation # HD is one of several trinucleotide repeat disorders which are caused by the length of a repeated section of a gene exceeding a normal range . The ' ' HTT ' ' gene is located on the short arm of chromosome 4 at 4p16.3 . ' ' HTT ' ' contains a sequence of three DNA *29;379;TOOLONG ( CAG ) repeated multiple times ( i.e. .. CAGCAGCAG ... ) , known as a trinucleotide repeat . CAG is the 3-letter genetic code ( codon ) for the amino acid glutamine , so a series of them results in the production of a chain of glutamine known as a polyglutamine tract ( or polyQ tract ) , and the repeated part of the gene , the ' ' PolyQ region ' ' . Generally , people have fewer than 36 repeated glutamines in the polyQ region which results in production of the cytoplasmic protein Huntingtin . However , a sequence of 36 or more glutamines results in the production of a protein which has different characteristics . This altered form , called mHtt ( mutant Htt ) , increases the decay rate of certain types of neurons . Regions of the brain have differing amounts and reliance on these type of neurons , and are affected accordingly . Generally , the number of CAG repeats is related to how much this process is affected , and accounts for about 60% of the variation of the age of the onset of symptoms . The remaining variation is attributed to environment and other genes that modify the mechanism of HD. 3639 repeats result in a reduced-penetrance form of the disease , with a much later onset and slower progression of symptoms . In some cases the onset may be so late that symptoms are never noticed . With very large repeat counts , HD has full penetrance and can occur under the age of 20 , when it is then referred to as juvenile HD , akinetic-rigid , or Westphal variant HD . This accounts for about 7% of HD carriers . # Inheritance # Huntington 's disease has autosomal dominant inheritance , meaning that an affected individual typically inherits one copy of the gene with an expanded trinucleotide repeat ( the mutant allele ) from an affected parent . Since penetrance of the mutation is very high , those who have a mutated copy of the gene will have the disease . In this type of inheritance pattern , each offspring of an affected individual has a 50% risk of inheriting the mutant allele and therefore being affected with the disorder ( see figure ) . This probability is sex-independent . Trinucleotide CAG repeats over 28 are unstable during replication and this instability increases with the number of repeats present . This usually leads to new expansions as generations pass ( dynamic mutations ) instead of reproducing an exact copy of the trinucleotide repeat . This causes the number of repeats to change in successive generations , such that an unaffected parent with an intermediate number of repeats ( 2835 ) , or reduced penetrance ( 3640 ) , may pass on a copy of the gene with an increase in the number of repeats that produces fully penetrant HD . Such increases in the number of repeats ( and hence earlier age of onset and severity of disease ) in successive generations is known as genetic anticipation . Instability is greater in spermatogenesis than oogenesis ; maternally inherited alleles are usually of a similar repeat length , whereas paternally inherited ones have a higher chance of increasing in length . It is rare for Huntington 's disease to be caused by a new mutation , where neither parent has over 36 CAG repeats . In the rare situations where both parents have an expanded HD gene , the risk increases to 75% , and when either parent has two expanded copies , the risk is 100% ( all children will be affected ) . Individuals with both genes affected are rare . For some time HD was thought to be the only disease for which possession of a second mutated gene did not affect symptoms and progression , but it has since been found that it can affect the phenotype and the rate of progression . # Mechanism # The Htt protein interacts with over 100 other proteins , and appears to have multiple biological functions . The behavior of this mutated protein is not completely understood , but it is toxic to certain cell types , particularly in the brain . Early damage is most evident in the striatum , but as the disease progresses , other areas of the brain are also more conspicuously affected . Early symptoms are attributable to functions of the striatum and its cortical connectionsnamely control over movement , mood and higher cognitive function . # Htt function # Htt is expressed in all mammalian cells . The highest concentrations are found in the brain and testes , with moderate amounts in the liver , heart , and lungs . The function of Htt in humans is unclear . It interacts with proteins which are involved in transcription , cell signaling and intracellular transporting . In animals genetically modified to exhibit HD , several functions of Htt have been found . In these animals , Htt is important for embryonic development , as its absence is related to embryonic death . Caspase , an enzyme which plays a role in catalyzing apoptosis , is thought to be activated by the mutated gene through damaging the ubiquitin-protease system . It also acts as an anti-apoptotic agent preventing programmed cell death and controls the production of brain-derived neurotrophic factor , a protein which protects neurons and regulates their creation during neurogenesis . Htt also facilitates vesicular transport and synaptic transmission and controls neuronal gene transcription . If the expression of Htt is increased and more Htt produced , brain cell survival is improved and the effects of mHtt are reduced , whereas when the expression of Htt is reduced , the resulting characteristics are more typical of the presence of mHtt . In humans the disruption of the normal gene does not cause the disease . It is thought that the disease is not caused by inadequate production of Htt , but by a gain of toxic function of mHtt. # Cellular changes due to mHtt # There are multiple cellular changes through which the toxic function of mHtt may manifest and produce the HD pathology . During the biological process of posttranslational modification of mHtt , cleavage of the protein can leave behind shorter fragments constituted of parts of the polyglutamine expansion . The polar nature of glutamine causes interactions with other proteins when it is overabundant in unmodified Htt proteins or the Htt fragments created from Htt cleavage . Thus , the mHtt molecule strands will form hydrogen bonds with one another , forming a protein aggregate rather than folding into functional proteins . Over time , the aggregates accumulate , ultimately interfering with neuron function because these fragments can then misfold and coalesce , in a process called protein aggregation , to form inclusion bodies within cells . Rhes was found to induce sumoylation of mHtt , which causes the protein clumps to disaggregatestudies in cell culture showed that the clumps were much less toxic than the disaggregated form . An additional theory that explains another way cell function may be disrupted by HD proposes that damage to mitochondria in striatal cells ( numerous accounts of mitochondrial metabolism deficiency have been found ) and the interactions of the altered huntingtin protein with numerous proteins in neurons leads to an increased vulnerability of glutamine , which , in large amounts , has been found to be an excitotoxin . Excitotoxins may cause damage to numerous cellular structures . Although glutamine is not found in excessively high amounts , it has been postulated that because of the increased vulnerability , even normal amounts glutamine can cause excitotoxins to be expressed . # Macroscopic changes due to mHtt # HD affects the whole brain , but certain areas are more vulnerable than others . The most prominent early effects are in a part of the basal ganglia called the neostriatum , which is composed of the caudate nucleus and putamen . Other areas affected include the substantia nigra , layers 3 , 5 and 6 of the cerebral cortex , the hippocampus , purkinje cells in the cerebellum , lateral tuberal nuclei of the hypothalamus and parts of the thalamus . These areas are affected according to their structure and the types of neurons they contain , reducing in size as they lose cells . Striatal spiny neurons are the most vulnerable , particularly ones with projections towards the external globus pallidus , with interneurons and spiny cells projecting to the internal pallidum being less affected . HD also causes an abnormal increase in astrocytes and activation of the brain 's immune cells , microglia . The basal gangliathe part of the brain most prominently affected in early HDplay a key role in movement and behavior control . Their functions are not fully understood , but current theories propose that they are part of the cognitive executive system The basal ganglia ordinarily inhibit a large number of circuits that generate specific movements . To initiate a particular movement , the cerebral cortex sends a signal to the basal ganglia that causes the inhibition to be released . Damage to the basal ganglia can cause the release or reinstatement of the inhibitions to be erratic and uncontrolled , which results in an awkward start to motion or motions to be unintentionally initiated , or a motion to be halted before , or beyond , its intended completion . The accumulating damage to this area causes the characteristic erratic movements associated with HD. # Transcriptional dysregulation # CREB-binding protein ( CBP ) , a transcriptional coregulator , is essential for cell function because as a coactivator at a significant number of promoters , it activates the transcription of genes for survival pathways . Specifically , CBP contains an acetyltransferase domain to which Htt binds through its polyglutamine-containing domain . Autopsied brains of those who had Huntington 's disease also have been found to have incredibly reduced amounts of CBP . A physical examination , sometimes combined with a psychological examination , can determine whether the onset of the disease has begun . Excessive unintentional movements of any part of the body are often the reason for seeking medical consultation . If these are abrupt and have random timing and distribution , they suggest a diagnosis of HD . Cognitive or behavioral symptoms are rarely the first symptoms diagnosed ; they are usually only recognized in hindsight or when they develop further . How far the disease has progressed can be measured using the ' ' unified Huntington 's disease rating scale ' ' , which provides an overall rating system based on motor , behavioral , cognitive , and functional assessments . Medical imaging , such as computerized tomography ( CT ) and magnetic resonance imaging ( MRI ) , can show atrophy of the caudate nuclei early in the disease , as seen in the illustration to the right , but these changes are not , by themselves , diagnostic of HD . Cerebral atrophy can be seen in the advanced stages of the disease . Functional neuroimaging techniques , such as functional magnetic resonance imaging ( fMRI ) and positron emission tomography ( PET ) , can show changes in brain activity before the onset of physical symptoms , but they are experimental tools , and are not used clinically. # Predictive genetic testing # Because HD follows an autosomal dominant pattern of inheritance , there is a strong motivation for individuals who are at risk of inheriting it to seek a diagnosis . The genetic test for HD consists of a blood test which counts the numbers of CAG repeats in each of the ' ' HTT ' ' alleles . Cutoffs are given as follows : 40 or more CAG repeats : ' ' full penetrance allele ' ' ( FPA ) . A positive test or positive result generally refers to this case . A positive result is not considered a diagnosis , since it may be obtained decades before the symptoms begin . However , a negative test means that the individual does not carry the expanded copy of the gene and will not develop HD . The test will tell a person who originally had a 50 percent chance of inheriting the disease if their risk goes up to 100 percent or is eliminated . A person who tests positive for the disease will develop HD sometime within their lifetime , provided he or she lives long enough for the disease to appear . 36 to 39 repeats : ' ' incomplete ' ' or ' ' reduced penetrance allele ' ' ( RPA ) . It may cause symptoms , usually later in the adult life . There is a maximum risk of 60% that a person with an RPA will be symptomatic at the age of 65 years , and a 70% risk of being symptomatic at the age of 75 years . 27 to 35 repeats : ' ' intermediate allele ' ' ( IA ) , or ' ' large normal allele ' ' . It is not associated with symptomatic disease in the tested individual , but may expand upon further inheritance to give symptoms in offspring . 26 or less repeats : Not associated with HD . A pre-symptomatic test is a life-changing event and a very personal decision . The main reason given for choosing testing for HD is to aid in career and family decisions . Before 1993 there was not an available test for individuals to learn if they carried the Huntington 's gene . At that time surveys indicated that 5070% of at-risk individuals would have been interested in receiving testing , but since predictive testing has been offered far fewer choose to be tested . Over 95% of individuals at risk of inheriting HD do not proceed with testing , mostly because there is no treatment . A key issue is the anxiety an individual experiences about not knowing whether they will eventually develop HD , compared to the impact of a positive result . Irrespective of the result , stress levels have been found to be lower two years after being tested , but the risk of suicide is increased after a positive test result . Individuals found to have not inherited the disorder may experience survivor guilt with regard to family members who are affected . Other factors taken into account when considering testing include the possibility of discrimination and the implications of a positive result , which usually means a parent has an affected gene and that the individual 's siblings will be at risk of inheriting it . In one study genetic discrimination was found in 46% of individuals at risk for Huntington 's disease . It occurred at higher rates within personal relationships than health insurance or employment relations . Genetic counseling in HD can provide information , advice and support for initial decision-making , and then , if chosen , throughout all stages of the testing process . Because of the implications of this test , patients who wish to undergo testing must complete three counseling sessions which provide information about Huntington 's . Counseling and guidelines on the use of genetic testing for HD have become models for other genetic disorders , such as autosomal dominant cerebellar ataxias . Presymptomatic testing for HD has also influenced testing for other illnesses with genetic variants such as polycystic kidney disease , familial Alzheimer 's disease and breast cancer . The European Molecular Genetics Quality Network have published yearly external quality assessment scheme for molecular genetic testing for this disease and have developed best practice guidelines for genetic testing for HD to assist in testing and reporting of results . # Preimplantation genetic diagnosis # Embryos produced using in vitro fertilization may be genetically tested for HD using preimplantation genetic diagnosis ( PGD ) . This technique , where one or two cells are extracted from a typically 4 to 8 cell embryo and then tested for the genetic abnormality , can then be used to ensure embryos affected with HD genes are not implanted , and therefore any offspring will not inherit the disease . Some forms of preimplantation genetic diagnosisnon-disclosure or exclusion testingallow at-risk people to have HD-free offspring ' ' without ' ' revealing their own parental genotype , giving no information about whether they themselves are destined to develop HD . In exclusion testing , the embryos ' DNA is compared with that of the parents and grandparents to avoid inheritance of the chromosomal region containing the HD gene from the affected grandparent . In non-disclosure testing , only disease-free embryos are replaced in the uterus while the parental genotype and hence parental risk for HD are never disclosed . # Prenatal testing # It is also possible to obtain a prenatal diagnosis for an embryo or fetus in the womb , using fetal genetic material acquired through chorionic villus sampling . An amniocentesis can be performed if the pregnancy is further along , within 1418 weeks . This procedure looks at the amniotic fluid surrounding the baby for indicators of the HD mutation . This , too , can be paired with exclusion testing to avoid disclosure of parental genotype . Prenatal testing can be done when a parent has been diagnosed with HD , when they have had genetic testing showing the expansion of the HTT gene , or when they have a 50% chance of inheriting the disease . The parents can be counseled on their options , which include termination of pregnancy , and on the difficulties of a child with the identified gene . In addition , in at-risk pregnancies due to an affected male partner , non-invasive prenatal diagnosis can be performed by analyzing cell-free fetal DNA taken by venipuncture on the mother between 6 and 12 weeks of pregnancy . It has no procedure-related risk of miscarriage. # Differential diagnosis # About 99% of HD diagnoses based on the typical symptoms and a family history of the disease are confirmed by genetic testing to have the expanded trinucleotide repeat that causes HD . Most of the remaining are called HD-like disorders . Most of these other disorders are collectively labelled HD-like ( HDL ) . The cause of most HDL diseases is unknown , but those with known causes are due to mutations in the prion protein gene ( HDL1 ) , the junctophilin 3 gene ( HDL2 ) , a recessively inherited ' ' HTT ' ' gene ( HDL3only found in one family and poorly understood ) , and the gene encoding the TATA box-binding protein ( HDL4/SCA17 ) . Other autosomal dominant diseases that can be misdiagnosed as HD are *28;410;TOOLONG atrophy and neuroferritinopathy . There are also autosomal recessive disorders that resemble sporadic cases of HD . Main examples are chorea acanthocytosis , pantothenate kinase-associated neurodegeneration and X-linked McLeod syndrome . # Management # There is no cure for HD , but there are treatments available to reduce the severity of some of its symptoms . For many of these treatments , comprehensive clinical trials to confirm their effectiveness in treating symptoms of HD specifically are incomplete . As the disease progresses the ability to care for oneself declines and carefully managed multidisciplinary caregiving becomes increasingly necessary . Although there have been relatively few studies of exercises and therapies that help rehabilitate cognitive symptoms of HD , there is some evidence for the usefulness of physical therapy , occupational therapy , and speech therapy . Tetrabenazine was approved in 2008 for treatment of chorea in Huntington 's disease in the US . Other drugs that help to reduce chorea include neuroleptics and benzodiazepines . Compounds such as amantadine or remacemide are still under investigation but have shown preliminary positive results . Hypokinesia and rigidity , especially in juvenile cases , can be treated with antiparkinsonian drugs , and myoclonic hyperkinesia can be treated with valproic acid . Psychiatric symptoms can be treated with medications similar to those used in the general population . Selective serotonin reuptake inhibitors and mirtazapine have been recommended for depression , while atypical antipsychotic drugs are recommended for psychosis and behavioral problems . Specialist neuropsychiatric input is recommended as patients may require long-term treatment with multiple medications in combination . Weight loss and eating difficulties due to dysphagia and other muscle discoordination are common , making nutrition management increasingly important as the disease advances . Thickening agents can be added to liquids as thicker fluids are easier and safer to swallow . Reminding the patient to eat slowly and to take smaller pieces of food into the mouth may also be of use to prevent choking . If eating becomes too hazardous or uncomfortable , the option of using a percutaneous endoscopic gastrostomy is available . This is a feeding tube , permanently attached through the abdomen into the stomach , which reduces the risk of aspirating food and provides better nutritional management . Assessment and management by speech and language therapists with experience in Huntington 's disease is recommended . Patients with Huntington 's disease may see a physical therapist for non-invasive and non-medication-based ways of managing the physical symptoms . Physical therapists may implement fall risk assessment and prevention , as well as strengthening , stretching , and cardiovascular exercises . Walking aids may be prescribed as appropriate . Physical therapists also prescribe breathing exercises and airway clearance techniques with the development of respiratory problems . Consensus guidelines on physiotherapy in Huntington 's disease have been produced by the European HD Network . Goals of early rehabilitation interventions are prevention of loss of function . Participation in rehabilitation programs during early to middle stage of the disease may be beneficial as it translates into long term maintenance of motor and functional performance . Rehabilitation during the late stage aims to compensate for motor and functional losses . For long-term independent management , the therapist may develop home exercise programs for appropriate patients . The families of individuals who have inherited or are at risk of inheriting HD , have generations of experience of HD which may be outdated and lack knowledge of recent breakthroughs and improvements in genetic testing , family planning choices , care management , and other considerations . Genetic counseling benefits these individuals by updating their knowledge , dispelling any myths they may have and helping them consider their future options and plans . # Prognosis # The length of the trinucleotide repeat accounts for 60% of the variation in the age symptoms appear and the rate they progress . A longer repeat results in an earlier age of onset and a faster progression of symptoms . Individuals with more than sixty repeats often develop the disease before age 20 , while those with fewer than 40 repeats may not ever develop noticeable symptoms . The remaining variation is due to environmental factors and other genes that influence the mechanism of the disease . Life expectancy in HD is generally around 20 years following the onset of visible symptoms . Most life-threatening complications result from muscle coordination and , to a lesser extent , behavioral changes induced by declining cognitive function . The largest risk is pneumonia , which causes death in one third of those with HD . As the ability to synchronize movements deteriorates , difficulty clearing the lungs and an increased risk of aspirating food or drink both increase the risk of contracting pneumonia . The second greatest risk is heart disease , which causes almost a quarter of fatalities of those with HD . Suicide is the third greatest cause of fatalities , with 7.3% of those with HD taking their own lives and up to 27% attempting to do so . It is unclear to what extent suicidal thoughts are influenced by behavioral symptoms , as they signify sufferers ' desires to avoid the later stages of the disease . Other associated risks include choking , physical injury from falls , and malnutrition . # Epidemiology # The late onset of Huntington 's disease means it does not usually affect reproduction . The worldwide prevalence of HD is 510 cases per 100,000 persons , but varies greatly geographically as a result of ethnicity , local migration and past immigration patterns . Prevalence is similar for men and women . The rate of occurrence is highest in peoples of Western European descent , averaging around 7 per 100,000 people , and is lower in the rest of the world , e.g. one per million people of Asian and African descent . A 2013 epidemiological study of the prevalence of Huntington 's disease in the UK between 1990 and 2010 found that the average prevalence for the UK was 12.3 per 100,000 . Additionally , some localized areas have a much higher prevalence than their regional average . One of the highest prevalences is in the isolated populations of the Lake Maracaibo region of Venezuela , where HD affects up to 700 per 100,000 persons . Other areas of high localization have been found in Tasmania and specific regions of Scotland , Wales and Sweden . Increased prevalence in some cases occurs due to a local founder effect , a historical migration of carriers into an area of geographic isolation . Some of these carriers have been traced back hundreds of years using genealogical studies . Genetic haplotypes can also give clues for the geographic variations of prevalence . Until the discovery of a genetic test , statistics could only include clinical diagnosis based on physical symptoms and a family history of HD , excluding those who died of other causes before diagnosis . These cases can now be included in statistics and as the test becomes more widely available , estimates of the prevalence and incidence of the disorder are likely to increase . # History # Although Huntington 's has been recognized as a disorder since at least the Middle Ages , the cause has been unknown until fairly recently . Huntington 's was given different names throughout this history as understanding of the disease changed . Originally called simply ' chorea ' for the jerky dancelike movements associated with the disease , HD has also been called hereditary chorea and chronic progressive chorea . The first definite mention of HD was in a letter by Charles Oscar Waters , published in the first edition of Robley Dunglison 's ' ' Practice of Medicine ' ' in 1842 . Waters described a form of chorea , vulgarly called magrums , including accurate descriptions of the chorea , its progression , and the strong heredity of the disease . In 1846 Charles Gorman observed how higher prevalence seemed to occur in localized regions . Independently of Gorman and Waters , both students of Dunglison at Jefferson Medical College in Philadelphia , Johan Christian Lund also produced an early description in 1860 . He specifically noted that in Setesdalen , a secluded mountain valley in Norway , there was a high prevalence of dementia associated with a pattern of jerking movement disorders that ran in families . The first thorough description of the disease was by George Huntington in 1872 . Examining the combined medical history of several generations of a family exhibiting similar symptoms , he realized their conditions must be linked ; he presented his detailed and accurate definition of the disease as his first paper . Huntington described the exact pattern of inheritance of autosomal dominant disease years before the rediscovery by scientists of Mendelian inheritance . # Of its hereditary nature . When either or both the parents have shown manifestations of the disease ... , one or more of the offspring almost invariably suffer from the disease .. But if by any chance these children go through life without it , the thread is broken and the grandchildren and great-grandchildren of the original shakers may rest assured that they are free from the disease . . # Sir William Osler was interested in the disorder and chorea in general , and was impressed with Huntington 's paper , stating that In the history of medicine , there are few instances in which a disease has been more accurately , more graphically or more briefly described . Osler 's continued interest in HD , combined with his influence in the field of medicine , helped to rapidly spread awareness and knowledge of the disorder throughout the medical community . Great interest was shown by scientists in Europe , including Louis Thophile Joseph Landouzy , Dsir-Magloire Bourneville , Camillo Golgi , and Joseph Jules Dejerine , and until the end of the century , much of the research into HD was European in origin . By the end of the 19th century , research and reports on HD had been published in many countries and the disease was recognized as a worldwide condition . During the rediscovery of Mendelian inheritance at the turn of the 20th century , HD was used tentatively as an example of autosomal dominant inheritance . The English biologist William Bateson used the pedigrees of affected families to establish that HD had an autosomal dominant inheritance pattern . The strong inheritance pattern prompted several researchers , including Smith Ely Jelliffe , to attempt to trace and connect family members of previous studies . Jelliffe collected information from across New York State and published several articles regarding the genealogy of HD in New England . Jelliffe 's research roused the interest of his college friend , Charles Davenport , who commissioned Elizabeth Muncey to produce the first field study on the East Coast of the United States of families with HD and to construct their pedigrees . Davenport used this information to document the variable age of onset and range of symptoms of HD ; he claimed that most cases of HD in the USA could be traced back to a handful of individuals . This research was further embellished in 1932 by P. R. Vessie , who popularized the idea that three brothers who left England in 1630 bound for Boston were the progenitors of HD in the USA . The claim that the earliest progenitors had been established and eugenic bias of Muncey 's , Davenport , and Vessie 's work contributed to misunderstandings and prejudice about HD . Muncey and Davenport also popularized the idea that in the past some HD sufferers may have been thought to be possessed by spirits or victims of witchcraft , and were sometimes shunned or exiled by society . This idea has not been proven . Researchers have found contrary evidence ; for instance , the community of the family studied by George Huntington openly accommodated those who exhibited symptoms of HD . The search for the cause of this condition was enhanced considerably in 1968 when the Hereditary Disease Foundation ( HDF ) was created by Milton Wexler , a psychoanalyst based in Los Angeles , California whose wife Leonore Sabin had been diagnosed earlier that year with Huntington 's disease . The three brothers of Wexler 's wife also suffered from this disease . The foundation was involved in the recruitment of over 100 scientists in the Huntington 's Disease Collaborative Research Project who over a 10-year period worked to locate the responsible gene . Thanks to the HDF , the ongoing US-Venezuela Huntington 's Disease Collaborative Research Project was started in 1979 , and reported a major breakthrough in 1983 with the discovery of the approximate location of a causal gene . This was the result of an extensive study focusing on the populations of two isolated Venezuelan villages , Barranquitas and Lagunetas , where there was an unusually high prevalence of the disease . It involved over 18,000 peoplemostly from a single extended family . Among other innovations , the project developed DNA-marking methods which were an important step in making the Human Genome Project possible . In 1993 , the research group isolated the precise causal gene at 4p16.3 , making this the first autosomal disease locus found using genetic linkage analysis . In the same time frame , key discoveries concerning the mechanisms of the disorder were being made , including the findings by Anita Harding 's research group on the effects of the gene 's length . Modelling the disease in various types of animals , such as the transgenic mouse developed in 1996 , enabled larger scale experiments . As these animals have faster metabolisms and much shorter lifespans than humans , results from experiments are received sooner , speeding research . The 1997 discovery that mHtt fragments misfold led to the discovery of the nuclear inclusions they cause . These advances have led to increasingly extensive research into the proteins involved with the disease , potential drug treatments , care methods , and the gene itself . The condition was formerly called ' Huntington 's chorea ' , but this term has been replaced by ' Huntington 's disease ' , because not all patients develop chorea , and because of the importance of cognitive and behavioral problems . # Society and culture # # Ethics # Huntington 's disease , particularly the application of the genetic test for the disease , has raised several ethical issues . The issues for genetic testing include defining how mature an individual should be before being considered eligible for testing , ensuring the confidentiality of results , and whether companies should be allowed to use test results for decisions on employment , life insurance or other financial matters . There was controversy when Charles Davenport proposed in 1910 that compulsory sterilization and immigration control be used for people with certain diseases , including HD , as part of the eugenics movement . In vitro fertilization has some issues regarding its use of embryos . Some HD research has ethical issues due to its use of animal testing and embryonic stem cells . The development of an accurate diagnostic test for Huntington 's disease has caused social , legal , and ethical concerns over access to and use of a person 's results . Many guidelines and testing procedures have strict procedures for disclosure and confidentiality to allow individuals to decide when and how to receive their results and also to whom the results are made available . Financial institutions and businesses are faced with the question of whether to use genetic test results when assessing an individual , such as for life insurance or employment . Although the United Kingdom 's insurance companies have agreed that until 2014 they will not use genetic information when writing most insurance policies , Huntington 's is explicitly excluded from this agreement . As with other untreatable genetic conditions with a later onset , it is ethically questionable to perform pre-symptomatic testing on a child or adolescent , as there would be no medical benefit for that individual . There is consensus for testing only individuals who are considered cognitively mature , although there is a counter-argument that parents have a right to make the decision on their child 's behalf . With the lack of an effective treatment , testing a person under legal age who is not judged to be competent is considered unethical in most cases . There are ethical concerns related to prenatal genetic testing or preimplantation genetic diagnosis to ensure a child is not born with a given disease . For example , prenatal testing raises the issue of selective abortion , a choice considered unacceptable by some . As it is a dominant disease , there are difficulties in situations in which a parent does not want to know his or her own diagnosis . This would require parts of the process to be kept secret from the parent . # Support organizations # In 1968 , after experiencing HD in his wife 's family , Dr. Milton Wexler was inspired to start the Hereditary Disease Foundation ( HDF ) , with the aim of curing genetic illnesses by coordinating and supporting research . The foundation and Dr. Wexler 's daughter , Nancy Wexler , were key parts of the research team in Venezuela which discovered the HD gene . At roughly the same time as the HDF formed , Marjorie Guthrie helped to found the Committee to Combat Huntington 's Disease ( now the Huntington 's Disease Society of America ) , after her husband Woody Guthrie died from complications of HD . Since then , support and research organizations have formed in many countries around the world and have helped to increase public awareness of HD . A number of these collaborate in umbrella organizations , like the International Huntington Association and the European HD network . Many support organizations hold an annual HD awareness event , some of which have been endorsed by their respective governments . For example , 6 June is designated National Huntington 's Disease Awareness Day by the US Senate . The largest funder of Huntington 's disease research globally , in terms of financial expenditure , is the CHDI Foundation , a US non-profit biomedical foundation that aims to rapidly discover and develop drugs that delay or slow Huntington 's disease . CHDI was formerly known as the High Q Foundation . In 2006 , it spent $50 million on Huntington 's disease research . CHDI collaborates with many academic and commercial laboratories globally and engages in oversight and management of research projects as well as funding . Many organizations exist to support and inform those affected by HD. # Research directions # Research into the mechanism of HD has focused on identifying the functioning of Htt , how mHtt differs or interferes with it , and the brain pathology that the disease produces . Research is conducted using ' ' in vitro ' ' methods , animal models and human volunteers . Animal models are critical for understanding the fundamental mechanisms causing the disease and for supporting the early stages of drug development . Animals with chemically induced brain injury exhibit HD-like symptoms and were initially used , but they did not mimic the progressive features of the disease . The identification of the causative gene has enabled the development of many transgenic animal models including nematode worms , ' ' Drosophila ' ' fruit flies , mice , rats , sheep , pigs and monkeys that express mutant huntingtin and develop progressive neurodegeneration and HD-like symptoms . Three broad approaches are under study to attempt to slow the progression of Huntington 's disease : reducing production of the mutant protein , improving cells ' ability to survive its diverse harmful effects , and replacing lost neurons. # Reducing huntingtin production # Gene silencing aims to reduce the production of the mutant protein , since HD is caused by a single dominant gene encoding a toxic protein . Gene silencing experiments in mouse models have shown that when the expression of mHtt is reduced , symptoms improve . Safety of gene silencing has now been demonstrated in the large , human-like brains of primates. # Improving cell survival # Among the approaches aimed at improving cell survival in the presence of mutant huntingtin are correction of transcriptional regulation using histone deacetylase inhibitors , modulating aggregation of huntingtin , improving metabolism and mitochondrial function and restoring dysfunction of synapses. # Neuronal replacement # Stem cell therapy is the replacement of damaged neurons by transplantation of stem cells into affected regions of the brain . Experiments have yielded mixed results using this technique in animal models and preliminary human clinical trials . Whatever their future therapeutic potential , stem cells are already a valuable tool for studying HD in the laboratory . # Clinical trials # Numerous drugs have been reported to produce benefits in animals , including creatine , coenzyme Q10 and the antibiotic minocycline . Some of these have then been tested by humans in clinical trials , with more underway , but as yet none has proven effective . In 2010 , minocycline was found to be ineffective for humans in a multi-center trial . Large observational studies involving human volunteers have revealed insights into the pathobiology of HD and supplied outcome measures for future clinical trials . 
@@52502 The Nobel Prize in Physiology or Medicine ( ) administered by the Nobel Foundation , is awarded once a year for outstanding discoveries in the fields of life sciences and medicine . It is one of five Nobel Prizes established in 1895 by Swedish chemist Alfred Nobel , the inventor of dynamite , in his will . Nobel was personally interested in experimental physiology and wanted to establish a prize for progress through scientific discoveries in laboratories . The Nobel prize is presented to the recipient(s) at an annual ceremony on 10 December , the anniversary of Nobel 's death , along with a diploma and a certificate for the monetary award . The front side of the medal provides the same profile of Alfred Nobel as depicted on the medals for Physics , Chemistry , and Literature ; its reverse side is unique to this medal . As of 2011 , 102 Nobel Prizes in Physiology or Medicine have been awarded to 199 men and 10 women . The first Nobel Prize in Physiology or Medicine was awarded in 1901 to the German physiologist Emil Adolf von Behring , for his work on serum therapy and the development of a vaccine against diphtheria . The first woman to receive the Nobel Prize in Physiology or Medicine , Gerty Cori , received it in 1947 for her role in elucidating the metabolism of glucose , important in many aspects of medicine , including treatment of diabetes . In 2011 , the prize was awarded to Bruce Beutler of the United States and Jules A. Hoffmann of France for their discoveries concerning the activation of innate immunity and to Ralph M. Steinman of Canada for his discovery of the dendritic cell and its role in adaptive immunity . Some awards have been controversial . This includes one to Antnio Egas Moniz in 1949 for the prefrontal leucotomy , bestowed despite protests from the medical establishment . Other controversies resulted from disagreements over who was included in the award . The 1952 prize to Selman Waksman was litigated in court , and half the patent rights awarded to his co-discoverer Albert Schatz who was not recognized by the prize . The 1962 prize awarded to James D. Watson , Francis Crick and Maurice Wilkins for their work on DNA structure and properties did not acknowledge the contributing work from others , such as Oswald Avery and Rosalind Franklin who had died by the time of the nomination . Since the Nobel Prize rules forbid nominations of the deceased , longevity is an asset , one prize being awarded as long as 50 years after the discovery . Also forbidden is awarding any one prize to more than three recipients , and since in the last half century there has been an increasing tendency for scientists to work as teams , this rule has resulted in controversial exclusions . # Background # Alfred Nobel was born on 21 October 1833 in Stockholm , Sweden into a family of engineers . He was a chemist , engineer and inventor who amassed a fortune during his lifetime , most of it from his 355 inventions of which dynamite is the most famous . He was interested in experimental physiology and set up his own labs in France and Italy to conduct experiments in blood transfusions . Keeping abreast of scientific findings , he was generous in his donations to Ivan Pavlov 's laboratory in Russia , and was optimistic about the progress resulting from scientific discoveries made in laboratories . In 1888 , Nobel was surprised to read his own obituary , titled ' ' The merchant of death is dead ' ' , in a French newspaper . As it happened , it was Nobel 's brother Ludvig who had died , but Nobel , unhappy with the content of the obituary and concerned that his legacy would reflect poorly on him , was inspired to change his will . In his last will , Nobel requested that his money be used to create a series of prizes for those who confer the greatest benefit on mankind in physics , chemistry , peace , physiology or medicine , and literature . Though Nobel wrote several wills during his lifetime , the last was written a little over a year before he died at the age of 63 . Because his will was contested , it was not approved by the Storting ( Norwegian Parliament ) until 26 April 1897 . After Nobel 's death , the Nobel Foundation was set up to manage the assets of the bequest . In 1900 , the Nobel Foundation 's newly created statutes were promulgated by Swedish King Oscar II . According to Nobel 's will , the Karolinska Institutet in Sweden , a medical school and research center , is responsible for the Prize in Physiology or Medicine . Today the prize is commonly referred to as the Nobel Prize in Medicine . # Nomination and selection # It was important to Nobel that the prize be awarded for a discovery and that it was of greatest benefit on mankind . Per the provisions of the will , only select persons are eligible to nominate individuals for the award . These include members of academies around the world , professors of medicine in Sweden , Denmark , Norway , Iceland and Finland , as well as professors of selected universities and research institutions in other lands . Past Nobel laureates may also nominate . Until 1977 , all professors of Karolinska Institutet together decided on the Nobel Prize in Physiology or Medicine . That year , changes in Swedish law forced the Institute to make any documents pertaining to the Nobel Prize public and it was considered necessary to establish a legally independent body for the Prize work . Therefore , the Nobel Assembly was constituted , consisting of 50 professors at Karolinska Institutet . It elects the Nobel Committee with 5 members who evaluate the nominees , the Secretary who is in charge of the organization , and each year 10 adjunct members to assist in the evaluation of candidates . In 1968 , a provision was added that no more than three persons may share a Nobel prize . True to its mandate , the Committee has selected researchers working in the basic sciences over those who have made applied contributions . Harvey Cushing , a pioneering American neurosurgeon who identified Cushing 's syndrome never was awarded the prize , nor was Sigmund Freud , as his psychoanalysis lacks hypotheses that can be tested experimentally . The public expected Jonas Salk or Albert Sabin to receive the prize for their development of the polio vaccines , but instead the award went to John Enders , Thomas Weller , and Frederick Robbins whose basic discovery that the polio virus could reproduce in monkey cells in laboratory preparations was a fundamental finding that led to the elimination of the disease of polio . Through the 1930s , there were frequent prize laureates in classical physiology , but after that the field began dissolving into specialties . The last classical physiology laureates were John Eccles , Alan Hodgkin and Andrew Huxley in 1963 for their findings regarding unitary electrical events in the central and peripheral nervous system . # Prizes # A Medicine or Physiology Nobel Prize laureate , earns a gold medal , a diploma bearing a citation , and a sum of money . These are awarded at the Nobel Banquet . # Medals # The Nobel Prize medals , minted by Myntverket in Sweden are registered trademarks of the Nobel Foundation . Each medal features an image of Alfred Nobel in left profile on the obverse ( front side of the medal ) . The Nobel Prize medals for Physics , Chemistry , Physiology or Medicine , and Literature have identical obverses , showing the image of Alfred Nobel and the years of his birth and death ( 18331896 ) . Before 1980 , the medals were made of 23K gold ; since then the medals are of 18K green gold , plated with 23K gold . The medal awarded by the Karolinska Institute displays an image of the Genius of Medicine holding an open book in her lap , collecting the water pouring out from a rock in order to quench a sick girl 's thirst . The medal is inscribed with words taken from Virgil 's Aeneid and reads : ' ' Inventas vitam juvat excoluisse per artes ' ' , which translates to inventions enhance life which is beautified through art . # Diplomas # Nobel laureates receive a Diploma directly from the King of Sweden . Each Diploma is uniquely designed by the prize-awarding institutions for the laureate that receives it . In the case of the Nobel Prize in Physiology or Medicine , that is the Nobel Assembly at Karolinska Institute . Well-known artists and calligraphers from Sweden are commissioned to create it . The Diploma contains a picture and text which states the name of the laureate and a citation as to why they received the prize . # Award money # The amount of prize money fluctuates depending on how much money the Nobel Foundation can award that year , and is awarded in Swedish kronor ( SEK ) . The first award in 1901 was for 150,782 kronor ( 7,872,648 kronor in 2009 value ) . In 2009 , the prize money totaled 10,000,000 kronor . Due to budget cuts , in 2012 , the amount for each Nobel prize was 8 million Swedish Krona , or US$1.1 million . If there are two laureates in a particular category , the award grant is divided equally between the recipients . If there are three , the awarding committee has the option of dividing the grant equally , or awarding one-half to one recipient and one-quarter to each of the others . # Ceremony and banquet # The awards are bestowed at a gala ceremony followed by a banquet . The Nobel Banquet is an extravagant affair with the menu , planned months ahead of time , kept secret until the day of the event . The Nobel Foundation chooses the menu after tasting and testing selections submitted by selected chefs of international repute . Currently it is a three course dinner , although it was originally six courses when it began in 1901 . Every Nobel Prize laureate is allowed to bring up to 16 guests , and Sweden 's royal family is always there . Typically the Prime Minister and other members of the government attend as well as representatives of the Nobel family . # Laureates # The first Nobel Prize in Physiology or Medicine was awarded in 1901 to the German physiologist Emil Adolf von Behring . Behring 's discovery of serum therapy in the development of the diphtheria and tetanus vaccines put in the hands of the physician a victorious weapon against illness and deaths . In 1902 , the award went to Ronald Ross for his work on malaria , by which he has shown how it enters the organism and thereby has laid the foundation for successful research on this disease and methods of combating it . He identified the mosquito as the transmitter of malaria , and worked tirelessly on measures to prevent malaria worldwide . The 1903 prize was awarded to Niels Ryberg Finsen , the first Danish laureate , in recognition of his contribution to the treatment of diseases , especially lupus vulgaris , with concentrated light radiation , whereby he has opened a new avenue for medical science . He died within a year after receiving the prize at the age of 43 . Ivan Pavlov , whose work Nobel admired and supported , received the prize in 1904 for his work on the physiology of digestion . Subsequently , those selecting the recipients have exercised wide latitude in determining what falls under the umbrella of Physiology or Medicine . The awarding of the prize in 1973 to Nikolaas Tinbergen , Konrad Lorenz and Karl von Frisch for their observations of animal behavioral patterns could be considered a prize in the behavioral sciences rather than medicine or physiology . Tinbergen expressed surprise in his Nobel Prize acceptance speech at the unconventional decision of the Nobel Foundation to award this years prize for Physiology or Medicine to three men who had until recently been regarded as mere animal watchers . Laureates have been awarded the Nobel Prize in a wide range of fields that relate to physiology or medicine . , eight Prizes have been awarded for contributions in the field of signal transduction through G proteins and second messengers. 13 have been awarded for contributions in the field of neurobiology and 13 have been awarded for contributions in Intermediary metabolism . The 100 Nobel Prizes in Physiology or Medicine have been awarded to 195 individuals through 2009 . Ten women have received the prize : Gerty Cori ( 1947 ) , Rosalyn Yalow ( 1977 ) , Barbara McClintock ( 1983 ) , Rita Levi-Montalcini ( 1986 ) , Gertrude B. Elion ( 1988 ) , Christiane Nsslein-Volhard ( 1995 ) , Linda B. Buck ( 2004 ) , Franoise Barr-Sinoussi ( 2008 ) , Elizabeth H. Blackburn ( 2009 ) and Carol W. Greider ( 2009 ) . Only one woman , Barbara McClintock , has received an unshared prize in this category , for the discovery of genetic transposition . Mario Capecchi , Martin Evans and Oliver Smithies was awarded the prize in 2007 for the discovery of a gene targeting procedure ( a type of genetic recombination ) for introducing homologous recombination in mice , employing embryonic stem cells through the development of the knockout mouse . There have been 37 times when the Nobel Prize in Physiology or Medicine was awarded to a single individual , 31 times when it was shared by two , and 33 times there were three laureates ( the maximum allowed ) . In 2009 , the Nobel Prize was awarded to Elizabeth Blackburn , Carol W. Greider and Jack W. Szostak of the United States for discovering the process by which chromosomes are protected by telomeres ( regions of repetitive DNA at the ends of chromosomes ) and the enzyme telomerase ; they shared the prize of 10,000,000 SEK ( slightly more than 1 million , or US$1.4 million ) . Rita Levi-Montalcini , an Italian neurologist , who together with colleague Stanley Cohen , received the 1986 Nobel Prize in Physiology or Medicine for their discovery of Nerve growth factor ( NGF ) , was the first Nobel Laureate to reach the 100th birthday . # Time factor and death # Because of the length of time that may pass before the significance of a discovery becomes apparent , some prizes are awarded many years after the initial discovery . Barbara McClintock made her discoveries in 1944 , before the structure of the DNA molecule was known ; she was not awarded the prize until 1983 . Similarly , in 1916 Peyton Rous discovered the role of tumor viruses in chickens , but was not awarded the prize until 50 years later , in 1966 . Nobel laureate Carol Greider 's research leading to the prize was conducted over 20 years before . She noted that the passage of time is an advantage in the medical sciences , as it may take many years for the significance of a discovery to become apparent . The 2009 award in medicine was the first in the Nobel Prize 's history that more than one woman has been the recipient of the Nobel Prize in a single year . It is also the first time two women have been awarded the Physiology or Medicine prize . In 2011 , Canadian immunologist Ralph M. Steinman was awarded the prize ; however , unknown to the committee , he had died three days before the announcement . The committee decided that since the prize was awarded in good faith , it would be allowed to stand . # Controversial inclusions and exclusions # Some of the awards have been controversial . The person who was deserving of the 1923 prize for the discovery of insulin as a central hormone for controlling diabetes ( awarded only a year after its discovery ) has been heatedly debated . It was shared between Frederick Banting and John Macleod ; this infuriated Banting who regarded Macleod 's involvement as minimal . Macleod was the department head at the University of Toronto but otherwise was not directly involved in the findings . Banting thought his laboratory partner Charles Best , who had shared in the laboratory work of discovery , should have shared the prize with him as well . In fairness , he decided to give half of his prize money to Best . Macleod on his part felt the biochemist James Collip , who joined the laboratory team later , deserved to be included in the award and shared his prize money with him . Some maintain that Nicolae Paulescu , a Romanian professor of physiology at the University of Medicine and Pharmacy in Bucharest , was the first to isolate insulin , in 1916 , although his pancrein was an impure aqueous extract unfit for human treatment similar to the one used previously by Israel Kleiner . In the paper that brought him the Nobel , Paulescu already held a patent for his discovery ( 10 April 1922 , patent no. 6254 ( 8322 ) Pancreina i procedeul fabricaiei ei / Pancrein and the process of making it , from the Romanian Ministry of Industry and Trade ) . In 1949 , despite protests from the medical establishment , the Portuguese neurologist Antnio Egas Moniz received the Physiology or Medicine Prize for his development of the prefrontal leucotomy , which he promoted by declaring the procedure 's success just 10 days postoperative . Due largely to the publicity surrounding the award , it was prescribed without regard for modern medical ethics . Favorable results were reported by such publications as ' ' The New York Times ' ' . It is estimated that around 40,000 lobotomies were performed in the United States before the procedure 's popularity faded . Joseph Kennedy , the father of John Kennedy , subjected his daughter , Rosemary , to the procedure which incapacitated her to the degree that she needed to be institutionalized for the rest of her life . The 1952 prize , awarded solely to Selman Waksman for his discovery of streptomycin , omitted the recognition some felt due to his co-discoverer Albert Schatz . There was litigation brought by Schatz against Waksman over the details and credit of the streptomycin discovery ; Schatz was awarded a substantial settlement , and , together with Waksman , Schatz was to be officially recognized as a co-discoverer of streptomycin as concerned patent rights . However , he is not recognized as a Nobel Prize laureate . The 1962 Prize awarded to James D. Watson , Francis Crick and Maurice Wilkinsfor their work on DNA structure and propertiesdid not recognize contributing work from others , such as Alec Stokes and Herbert Wilson . In addition , Erwin Chargaff , Oswald Avery and Rosalind Franklin ( whose key DNA x-ray crystallography work was the most detailed yet least acknowledged among the three ) contributed directly to the ability of Watson and Crick to solve the structure of the DNA moleculebut Avery died in 1955 , and Franklin in 1958 and posthumous nominations for the Nobel Prize are not permitted . However , recently unsealed files of the Nobel Prize nominations reveal that no one ever nominated Franklin for the prize when she was alive . Wilkins ' only contribution was to show Rosalind Franklin 's key x-ray photos to Watson . As a result of Watson 's misrepresentations of Franklin and her role in the discovery of the double helix in his controversial book ' ' The Double Helix ' ' , Franklin has come to be portrayed as a classic victim of sexism in science . Chargaff , for his part , was not quiet about his exclusion from the prize , bitterly writing to other scientists about his disillusionment regarding the field of molecular biology . The 2008 award went to Harald zur Hausen in recognition of his discovery that human papillomavirus ( HPV ) can cause cervical cancer , and to Franoise Barr-Sinoussi and Luc Montagnier for discovering the Human immunodeficiency virus ( HIV ) . Whether Robert Gallo or Luc Montagnier deserved more credit for the discovery of the virus that causes AIDS has been a matter of considerable controversy . As it was , Gallo was left out and not awarded a prize . Additionally , there was scandal when it was learned that Harald zur Hausen was being investigated for having a financial interest in vaccines for the cervical cancer that HPV can cause . AstraZeneca , who with a stake in two lucrative HPV vaccines could benefit financially from the prize , had agreed to sponsor Nobel Media and Nobel Web . According to Times Online , two senior figures in the selection process that chose zur Hausen also had strong links with AstraZeneca. # Limits on number of awardees # The provision that restricts the maximum number of nominees to three for any one prize , introduced in 1968 , has caused considerable controversy . From the 1950s onward , there has been an increasing trend to award the Nobel Prize in Physiology or Medicine to more than one person . There were 59 people who received the prize in the first 50 years of the last century , while 113 individuals received it between 1951 and 2000 . This increase could be attributed to the rise of the international scientific community after World War II , resulting in more persons being responsible for the discovery , and nominated for , a particular prize . Also , current biomedical research is more often carried out by teams rather than by scientists working alone , making it unlikely that any one scientist , or even a few , is primarily responsible for a discovery ; this has meant that a prize nomination that would have to include more than three contributors is automatically excluded from consideration . Also , deserving contributors may not be nominated at all because the restriction results in a cut off point of three nominees per prize , leading to controversial exclusions . # Years without awards # There have been nine years in which the Nobel Prize in Physiology or Medicine was not awarded ( 19151918 , 1921 , 1925 , 19401942 ) . Most of these occurred during either World War I ( 19141918 ) or World War II ( 19391945 ) . In 1939 , Adolf Hitler 's Third Reich forbade Gerhard Domagk to accept his prize . He was later able to receive the diploma and medal but not the money . 
@@52974 Emergency medicine is a medical specialty involving care for adult and pediatric patients with acute illnesses or injuries that require immediate medical attention . While not usually providing long-term or continuing care , Emergency Medicine Physicians ( DOs/MDs ) diagnose a variety of illnesses and undertake acute interventions to resuscitate and stabilize patients . Emergency Medicine Physicians practice in hospital emergency departments , pre-hospital settings via emergency medical services , other locations where initial medical treatment of illness takes place , and recently the intensive-care unit . Just as clinicians operate by immediacy rules under large emergency systems , emergency practitioners aim to diagnose emergent conditions and stabilize the patient for definitive care . Physicians specializing in Emergency Medicine in the US and Canada can enter fellowships to receive credentials in subspecialties . These are palliative medicine , critical-care medicine , medical toxicology , wilderness medicine , pediatric Emergency Medicine , sports medicine , disaster medicine , ultrasound , emergency medical services , and undersea and hyperbaric medicine . # Scope # Emergency medicine has evolved to treat conditions that pose a threat to life , limb , or have a significant risk of morbidity . In the words of the International Federation for Emergency Medicine : Emergency medicine encompasses a large amount of general medicine and surgery including the surgical sub-specialties . Emergency physicians are tasked with seeing a large number of patients , treating their illnesses and arranging for dispositioneither admitting them to the hospital or releasing them after treatment as necessary . The emergency physician requires a broad field of knowledge and advanced procedural skills often including surgical procedures , trauma resuscitation , advanced cardiac life support and advanced airway management . Emergency Physicians must have the skills of many specialiststhe ability to resuscitate a patient ( critical care medicine ) , manage a difficult airway ( anesthesia ) , suture a complex laceration ( plastic surgery ) , reduce ( set ) a fractured bone or dislocated joint ( orthopedic surgery ) , treat a heart attack ( cardiology ) , work-up a pregnant patient with vaginal bleeding ( Obstetrics and Gynecology ) , stop a bad nosebleed ( ENT ) , place a chest tube ( cardiothoracic surgery ) , and to conduct and interpret x-rays and ultrasounds ( radiology ) . Emergency medicine is distinct from urgent care , which refers to immediate healthcare for non-emergency medical issues . In fact , urgent care has its roots in emergency medicine when in the 1970s , physicians extended hours of practice to focus on non-emergency issues . # History # During the French Revolution , after seeing the speed with which the carriages of the French flying artillery maneuvered across the battlefields , French military surgeon Dominique Jean Larrey applied the idea of ambulances , or flying carriages , for rapid transport of wounded soldiers to a central place where medical care was more accessible and effective . Larrey manned ambulances with trained crews of drivers , corpsmen and litter-bearers and had them bring the wounded to centralized field hospitals , effectively creating a forerunner of the modern MASH units . Dominique Jean Larrey is sometimes called the father of Emergency Medicine for his strategies during the French wars . Emergency Medicine ( EM ) as a medical specialty is relatively young . Prior to the 1960s and 1970s , in general hospital emergency departments were staffed by physicians on staff at the hospital on a rotating basis , among them general surgeons , internists , psychiatrists , and dermatologists . Physicians in training ( interns and residents ) , foreign medical graduates and sometimes nurses also staffed the Emergency Department ( ED ) . EM was born as a specialty in order to fill the time commitment required by physicians on staff to work in the increasingly chaotic emergency departments ( EDs ) of the time . During this period , groups of physicians began to emerge who had left their respective practices in order to devote their work completely to the ED . The first of such groups was headed by Dr. James DeWitt Mills who , along with four associate physicians ; Dr. Chalmers A. Loughridge , Dr. William Weaver , Dr. John McDade , and Dr. Steven Bednar at Alexandria Hospital , Virginia , established 24/7 year-round emergency care , which became known as the Alexandria Plan . It was not until the establishment of American College of Emergency Physicians ( ACEP ) , the recognition of Emergency Medicine training programs by the AMA and the AOA , and in 1979 a historical vote by the American Board of Medical Specialties that EM became a recognized medical specialty . The first Emergency Medicine residency program in the world was begun in 1970 at the University of Cincinnati and the first Department of Emergency Medicine at a U.S. medical school was founded in 1971 at the University of Southern California . # United Kingdom # Emergency medicine traces its development as a specialty in UK to 1952 when Mr Maurice Ellis was appointed as the first consultant in Emergency Medicine in the UK at Leeds General Infirmary . In 1967 , the Casualty Surgeons Association was established with Maurice Ellis as its first President . The name of the Association was changed twice , in 1990 , to the British Association for Accident and Emergency Medicine , and later on in 2004 , to British Association for Emergency Medicine ( BAEM ) . In 1993 , Intercollegiate Faculty of Accident and Emergency Medicine ( FAEM ) was formed at the Royal College of Surgeons of England , London . In 2005 , the BAEM and the FAEM were merged to form College of Emergency Medicine . The College of Emergency Medicine is the single authoritative body for Emergency Medicine in the UK . It conducts its fellowship and membership exams , publishes guidelines and standards for the practise of Emergency Medicine , and has its own journal , called the ' ' Emergency Medicine Journal ' ' ( EMJ ) . # Organizations around the world # # Argentina # In Argentina , the SAE ( Sociedad Argentina de Emergencias ) is the main organization of Emergency Medicine . There are a lot of residency programs . Also is possible to reach the certification with a two-year postgraduate university course after a few years of ED background . # Australia and New Zealand # In Australia and New Zealand , specialist training in Emergency Medicine is overseen by the Australasian College for Emergency Medicine ( ACEM ) . The ACEM also offers formal qualifications and continuing professional education for non-specialists who have Emergency Medicine responsibilities . # India # In India , many private hospitals and institutes have been providing Emergency Medicine training for doctors , nurses &amp; paramedics since 1994 . The certification programs varied from 6 months to 3 years . Emergency Medicine was recognized as a separate specialty by Medical Council of India ( MCI ) only from July 2009 . After this , many medical colleges are about to start postgraduate training , i.e. , MD in Emergency Medicine . It will be at least a few years until the specialty gets streamlined in India . 3 year Emergency medicine residency is also provided by Apollo hospitals at various sites ( Hyderabad , chennai , delhi , bangalore ) making the candodates eligible to appear for MCEM examinations . National board of examinations has announced that DNB emergency medicine would be started from the next academic session at various accredited hospitals/colleges in India . Emergency medicine is an upcoming branch in India , which is growing at a rapid pace . # Saudi Arabia # In Saudi Arabia , Certification of Emergency Medicine is done by taking the 4-year program Saudi Board of Emergency Medicine ( SBEM ) , which is accredited by Saudi Council for Health Specialties ( SCFHS ) . It requires passing the two-part exam : first part and final part ( written and oral ) to obtain the SBEM certificate , which is equivalent to Doctorate Degree . http : *46;96717;TOOLONG Saudi Society of Emergency Medicine SASEM is an organization that encompasses all emergency doctors in Saudi Arabia . # Canada # In Canada , there are two routes to certification in Emergency Medicine . The vast majority of full-time practicing ED physicians in Canada are certified via one of these routes . Most busy urban , sub-urban and larger rural hospitals are staffed primarily by full-time , certified career emergency physicians . Smaller rural and community hospitals may still be staffed by family physicians who work in the emergency department on a part-time rotating basis . Basic experience in Emergency Medicine is a core component of family medicine training in Canada . The general trend in Canadian emergency departments over the last decade has been the gradual replacement of part-time , non-certified physicians ( mostly family physicians ) by full-time certified Emergency Physicians . This trend was first noted in larger academic centers but has gradually evolved to include most busy emergency departments . The two routes to ED certification can be summarized as follows : Route 1 : A five-year residency leading to the designation of FRCP(EM) through the Royal College of Physicians and Surgeons of Canada ( Emergency Medicine Board Certification- Emergency Medicine Consultant ) . Route 2 : A 1-year Emergency Medicine fellowship after a two-year family medicine residency leading to the designation of CCFP(EM) through the College of Family Physicians of Canada ( Competency Certification ) . CCFP(EM) ED physicians outnumber FRCP(EM) physicians by about 3 to 1 , and tend to work primarily as clinicians with a smaller focus on academic activities such as teaching and research mostly run urgent care units . FRCP(EM) ED Emergency Medicine Board specialists tend to congregate in academic centers and tend to have more academically oriented careers , which emphasize administration , research , critical care , disaster medicine , teaching and tend to go for subspecialty in toxicology , critical care , pediatrics , and sports medicine . Furthermore the length of the FRCP(EM) residency allows more time for formal training in these areas . As a consequence of the above , most Canadian medical students wishing to pursue an academic Emergency Medicine career , and/or work primarily in a major academic center , choose the FRCP route of certification . On the other hand , those wishing to function primarily as clinical ED physicians choose the CCFP route of certification . Although many in the Emergency Medicine community in Canada feel that a unified training process would be beneficial to the current 2-stream schism , this has yet to happen for a variety of complex reasons . # China # There are only two academic societies in EM in China , Chinese Association of EM ( CAEM ) and Chinese College of Emergency Physicians ( CCEP , equivalent to ACEP in US ) . CAEM was established in 1986 , under the management of the China Medical Society ( CMS ) . However , CCEP was organized by the Ministry of Public Health in 2009 . Their primary missions and tasks are not yet clearly defined . As a matter of fact , there are some overlaps in terms of organization administrators and academic activities . # Malaysia # There are three universities ( Universiti Sains Malaysia USM , Universiti Kebangsaan Malaysia UKM , &amp; Universiti Malaya UM that offer Masters in Emergency Medicine . These post-graduate trainings consists of 4 years of various clinical trainings in the field relevant to Emergency Medicine ( EM ) practices . The certifications consists of clinical posting evaluations , year 1 and year 4 examinations and research projects ( dissertation ) with satisfactory completion is mandatory . The 1st batch of Emergency Physician ( EP ) trained locally had graduated in 2002 . The EM field in Malaysia has developed tremendously over the past 10 years . The College of Emergency Physician ( CEP ) was formed under the Academy of Medicine Malaysia ( AMM ) recently that strengthen further this fraternity. # United Kingdom and Ireland # In the United Kingdom and Ireland , the College of Emergency Medicine sets the examinations that trainees in Emergency Medicine take in order to become consultants ( fully trained Emergency Physicians ) . Physicians that have passed the fellowship examination of the college of Emergency Medicine are awarded the post nominals ' FCEM ' . # United States # In the United States , there are many member organizations for emergency clinicians :  The American Academy of Emergency Medicine ( AAEM ) restricts its membership to board certified specialists in Emergency Medicine , and as of 2009 has over 6000 members . It promotes the independence of Emergency Physicians and seeks to limit the interference of corporations and other outside groups in the doctor-patient relationship .  The American College of Emergency Physicians ( ACEP ) is the oldest and largest professional organization . Originally founded in 1968 , it now has over 25,000 members , although some became members before board certification in Emergency Medicine was required .  The American College of Osteopathic Emergency Physicians ( ACOEP ) was founded in 1975  The Emergency Department Practice Management Association ( EDPMA ) is a trade association that offers membership to Emergency Medicine Physician groups and their practice business partners , including billing companies and emergency department supporting organizations like EMR firms , consultants , and scribe companies . Founded in 1997 , EDPMA 's members make it their business to deliver quality care in the emergency department . The Emergency Medicine Residents ' Association ( EMRA ) is an organization that offers membership to Emergency Medicine Physicians in training ( residents and medical students ) and graduates of ACGME and AOA Emergency Medicine residency training programs . Originally founded in 1972 , EMRA represents the interests of Emergency Medicine physicians-in-training . As of 2014 EMRA has nearly 12,000 members . In the United States and Canada , there are five ways to become Board Certified in Emergency Medicine :  The American Board of Emergency Medicine ( ABEM ) is for MDs and DOs . The ABEM is under the authority of the American Board of Medical Specialties .  The American Osteopathic Board of Emergency Medicine ( AOBEM ) certifies only Emergency Physicians with a D.O . degree . It is under the authority of the American Osteopathic Association Bureau of Osteopathic Specialists .  The Royal College of Physicians and Surgeons of Canada .  The College of Family Physicians of Canada - Emergency Medicine Certification Examination  The Board of Certification in Emergency Medicine ( BCEM ) is the fifth designation - outside of the ABEM , AOBEM , RCPSC , or CFPC-EMCE exams . The BCEM is the only organization in the United States that will grant board certification in Emergency Medicine to a physician who has not completed an Emergency Medicine residency but have experience in another field . ( http : *52;96765;TOOLONG ) . BCEM allows physicians who were not initially residency-trained in Emergency Medicine , but that have completed a residency in other fields ( internists , family practitioners , pediatricians , general surgeons , and anesthesiologists ) , to become board-certified in Emergency Medicine . BCEM requires five years of full-time Emergency Medicine experience , preparation of case reports for review by the board , and passing both written and oral examinations before allowing a candidate to become board-certified in Emergency Medicine . Recertification is required every 8 years . BCEM is under the control of the American Association of Physician Specialists ( AAPS ) - an organization that allows both M.D.s and D.O.s to become members . # Turkey # In Turkey there are two associations for Emergency Physicians :  Emergency Medicine Association of Turkey ( EMAT ) is the oldest professional organization .  Emergency Physicians ' Association of Turkey ( EPAT ) is the second organization and refers to Emergency Medicine Specialists . # Iran # In Iran , was developed in 2002 . ISEM holds congress on Emergency Medicine annually . All Emergency Medicine specialists are members of this society in Iran . # Pakistan # In Pakistan , ) was established in 2009 . SEPP is relatively new society and is in the phase of growing , as the numbers of trainees are slowing increasing . # South Korea # In South Korea ( Republic of Korea ) , was established in 1989. # Education # # Australia and New Zealand # The specialist medical college responsible for Emergency Medicine in Australia and New Zealand is the Australasian College for Emergency Medicine ( ACEM ) . The training program is nominally seven years in duration , after which the trainee is awarded a Fellowship of ACEM , conditional upon passing all necessary assessments .  Basic Training ( 24 months ) : Pre-vocational hospital rotation experience , which usually consists of the PGY1 internship year and PGY2 year as a junior medical officer .  Provisional Training ( 12 months ) : 6 months of Emergency Medicine training , plus 6 months of elective experience . Trainees must pass the ACEM Primary Examination before the end of this period , which tests basic and clinical science knowledge of trainees .  Advanced Training ( 48 months ) : 30 months of Emergency Medicine training , 6 months of intensive care and/or anaesthesia training , and 18 months of elective training relevant to Emergency Medicine . Trainees must pass the ACEM Fellowship Examinations in order to qualify as an Emergency Medicine specialist at the end of this period . Dual fellowship programs also exist for Paediatric Medicine ( in conjunction with the Royal Australasian College of Physicians ) and Intensive Care Medicine ( in conjunction with the College of Intensive Care Medicine ) . These programs nominally add one or more years to the ACEM training program . For medical doctors not ( and not wishing to be ) specialists in Emergency Medicine but have a significant interest or workload in emergency departments , the ACEM provides non-specialist certificates and diplomas . The EM Certificate requires minimum three years of postgraduate experience as a medical doctor , completion of minimum six months supervised training in Emergency Medicine , and pass marks in formal examinations . The EM Diploma requires attainment of an EM Certificate ( or equivalent training and experience ) , completion of a further 12 months of supervised training in Emergency Medicine and 6 months supervised training in clinical anaesthesia or intensive care , and pass marks in examinations . # Canada # In Canada , there are a few different ways to become certified as an Emergency Physician . For all methods , one has to first complete a medical degree . The next most common step is to complete two years of family medicine residency offered by the College of Family Physicians Canada ( CFPC ) followed by a further one-year residency in Emergency Medicine . There is also a 5-year residency offer by the Royal College of Physicians and Surgeons of Canada that may be completed instead of the above . The CFPC also allows those having worked a minimum of 4 years at a minimum of 400 hours per year in Emergency Medicine to challenge the examination of special competence in Emergency Medicine and thus become specialized . # China # The current post-graduate Emergency Medicine training process is highly complex in China . The first EM post-graduate training took place in 1984 at the Peking Union Medical College Hospital . Because specialty certification in EM has not been established , formal training is not required to practice Emergency Medicine in China . For those physicians that do choose to obtain training in EM , several options are available . Graduates from medical school can apply directly to hospitals for staff physician-in-training positions , which eventually lead to a staff position at that same hospital . In addition , physicians from smaller hospitals can go to those larger academic centers for a 6 to 12-month post-graduate re-education . While these physicians may undergo the same training as the staff physicians , they will return to their own hospital once their training is completed . Finally , physicians having completed previous post-graduate training may choose to apply for fellowship positions for further training in Emergency Medicine . About one decade ago , Emergency Medicine residency training was centralized at the municipal levels , following the guidelines issued by The Ministry of Public Health . Residency programs in all hospitals are called residency training bases , which have to be approved by local health governments . These bases are hospital-based , but the residents are selected and managed by the municipal associations of medical education . These associations are also the authoritative body of setting up their residents ' training curriculum . All medical school graduates wanting to practice medicine have to go through 5 years of residency training at designated training bases , first 3 years of general rotation followed by 2 more years of specialty-centered training . # United States # Emergency Medicine is a popular field for medical school graduates to enter . Both Doctors of Medicine ( M.D ) and Doctors of Osteopathic Medicine ( D.O ) can be fully trained and licensed as an Emergency Physician . In addition to the didactic exposure , much of an Emergency Medicine residency involves rotating through emergency departments , intensive care units , pediatric and obstetric units , and other specialties . By the end of their training , Emergency Physicians are expected to handle a vast field of medical , surgical , and psychiatric emergencies , and are considered specialists in the stabilization and treatment of emergent conditions . A number of fellowships are available for Emergency Medicine graduates including pre-hospital medicine ( emergency medical services ) , critical care , hospice and palliative care , research , undersea and hyperbaric medicine , sports medicine , ultrasound , pediatric Emergency Medicine , disaster medicine , wilderness medicine , toxicology , and critical care medicine . # United Kingdom # Emergency medical trainees enter specialty training after five years of medical school and two years of foundation training . During the two-year core training programme ( Acute Care Common Stem ) , doctors complete training in anaesthesia , acute medicine , intensive care , and Emergency Medicine . In the third year , the trainee learns about Emergency Medicine ( paediatric focus ) and musculo-skeletal Emergency Medicine . They must also pass the Membership of the College of Emergency Medicine ( MCEM ) examination . Trainees will then go onto Higher Training , lasting a further 3 years . Before the end of higher training , the final examinationthe Fellowship of the College of Emergency Medicine ( FCEM ) must be passed . Upon completion of training the doctor will be eligible for entry on the GMC Specialist Register and allowed to apply for a post as a Consultant in Emergency Medicine . Emergency Medicine training in the UK is emerging . Historically , emergency specialists were drawn from anaesthesia , medicine , and surgery . Many established EM consultants were surgically trained ; some hold the Fellowship of Royal College of Surgeons of Edinburgh in Accident and EmergencyFRCSEd(A&amp;E) . Some of these consultants will be referred to as ' Mister ' , whilst others choose either not to change from ' Doctor ' or to change back to ' Doctor ' after passing the FCEM exam . Others used the MRCP or the FRCA as their primary examination ( now replaced by MCEM ) . Trainees in Emergency Medicine may dual accredit in Intensive-Care Medicine or seek sub-specialisation in Paediatric Emergency Medicine . # Turkey # The only way to become a certified Emergency Medicine Physician is via attending Medical Board Examination ( TUS ) to become a resident . After TUS , candidates are allocated to different residencies according to their score and choice . Emergency Medicine residency lasts for 4 years in Turkey . During the programme doctors complete 13 months of rotation on different specialties , including anesthesia , orthopedics , pulmonary medicine , internal medicine , pediatrics , general surgery , radiology , neurosurgery , neurology , and cardiology . Last year , they design and manage a clinical or animal research , and write their dissertations . At the end of their residency they attend two different exams three months apart : Dissertation Exam , Emergency Medicine Specialty Exam . Both exams are oral , and doctor is expected to answer all questions asked by the Exam Board . Exam Board consists of 5 members : 2-3 from Emergency Medicine , others from Internal Medicine , Surgery or Anesthesia faculty members . After the exam , doctor starts to hold the title of Emergency Medicine Specialist . However , all the doctors should attend a 2-year Obligatory Service in Turkey to be qualified to have their diploma . After this period , EM specialist can choose to work in private or governmental ED's. # Pakistan # Emergency Medicine training in Pakistan lasts for 5 years . The candidate enters the program by clearing part 1 of FCPS ( fellow of college of physicians and surgeons of Pakistan ) and passing the entry test of one of the institutions offering Emergency Medicine residency in Pakistan . The initial 2 years involve trainees to be sent to various sub-specialties including both medicine and surgery . Major rotations include , Internal Medicine , ICU , Anesthesia and Pediatrics . The residents enrolled in the program rotate for 3 months each of first two years . They work in the emergency Department for about six months . After the two years they appear in the exams called Intermediate Module ( IMM ) . In last three years trainee residents spend most of their time in emergency room as senior residents . Full-time faculty supervises the residents . The duration can vary from 6080 hours per week depending upon the rotation . There is an extensive curriculum that is covered over 5 years . Certain certificate courses include ACLS , PALS , ATLS , and research and dissertations are required for successful completion of the training . At the end of 5 years , candidates become eligible for sitting for FCPS part II exam . After completion of requirements and passing the exam , the physician is called Emergency Medicine specialist and they can use FCPS with their names . # Iran # First residency program in Iran started in 2002 at Iran University of Medical Sciences ( which merged with Tehran University of Medical Sciences later ) . There are now three-year standard residency programs running in Tehran , Tabriz , Mashhad , Isfahan , and some other universities . All these programs work under supervision of Emergency Medicine specialty board committee . There are now more than 200 ( and increasing ) board-certified Emergency Physicians in Iran . # Work # The employment arrangement of Emergency Physician practices are either private ( a democratic group of EPs staff an ED under contract ) , institutional ( EPs with an independent contractor relationship with the hospital ) , corporate ( EPs with an independent contractor relationship with a third-party staffing company that services multiple emergency departments ) , or governmental ( employed by the US armed forces , the US public health service , the Veteran 's Administration or other government agency ) . Most Emergency Physicians staff hospital emergency departments in shifts , a job structure necessitated by the 24/7 nature of the emergency department . In the United States , Emergency Medicine practitioners are expected to be competent in treating , diagnosing and managing a wide array of illnesses and conditions , both chronic and acute . Overall , more than half of Emergency Physicians report high levels of career satisfaction . Although career satisfaction has remained high among Emergency Physicians , concern about burnout is substantial . In the United Kingdom , all Consultants in Emergency Medicine work in the NHS . There is little scope for private emergency practice . In Australia and New Zealand , Emergency Medicine specialists are almost always salaried employees of government health departments and work in public hospitals , with pockets of employment in private or non-government aeromedical rescue or transport services , as well as some private hospitals with emergency departments . The emergency departments themselves are usually headed by a cadre of salaried Emergency Medicine specialists ( Fellows of ACEM ) , backed by non-specialist medical officers , and visiting general practitioners ( i.e. family physicians in US parlance ) . Rural emergency departments are usually headed by general practitioners , sometimes with non-specialist qualifications in Emergency Medicine . In Turkey , EM specialist may choose to work in private ( corporate hospitals ) , governmental ( all the hospitals under Ministry of Health ) or institutional ( University Hospitals ) EDs . However most of the EPs work in governmental or university hospitals . According to the American College of Emergency Physicians , the US will likely face a shortage of physicians in the near future , leading to increased employment opportunities . # Epidemiology # A U.S. government report found there were 119 million emergency department visits in 2006 , an increase of 36% from 1996 . During this same ten-year period of increased usage , the number of emergency departments decreased , from 4,019 to 3,833 and the rate of emergency department visits per 100 people in the U.S. rose from 34.2 to 40.5. 
@@58250 The United States Department of Health and Human Services ( HHS ) , also known as the Health Department , is a cabinet-level department of the U.S. federal government with the goal of protecting the health of all Americans and providing essential human services . Its motto is Improving the health , safety , and well-being of America . Before the separate federal Department of Education was created in 1979 , it was called the Department of Health , Education , and Welfare ( HEW ) . # History # # Federal Security Agency # The Federal Security Agency ( FSA ) was established on July 1 , 1939 , under the Reorganization Act of 1939 , P.L. 76-19 . The objective was to bring together in one agency all Federal programs in the fields of health , education , and social security . The first Federal Security Administrator was Paul V. McNutt . The new agency originally consisted of the following major components : #Office of the Administrator #Public Health Service ( PHS ) #Office of Education #Civilian Conservation Corps #Social Security Board # #Origins# # The origins of these components , however , could be traced back to the early days of the Republic . On July 16 , 1798 , President John Adams signed an act creating the Marine Hospital Service to furnish treatment to sick and disabled American merchant seamen . On April 29 , 1878 , the first Federal Quarantine Act enlarged the Service 's responsibilities to include prevention of epidemics from abroad . On August 14 , 1912 , the name was changed to the Public Health Service ( PHS ) . On May 26 , 1930 , the Hygienic Laboratory of the Service was redesignated the National Institute of Health ( NIH ) . PHS was transferred from the Treasury Department to the FSA in 1939. Even though the first steps toward public education were taken in 1647 by the Massachusetts Bay Colony and land was set aside for public schools by the Congress of the Confederation in 1785 , the idea of universal , free public schools did not become firmly established until the Civil War era . Even then , only half of the States had an efficient public school system . In 1867 , Congress established the Department of Education to promote the cause of education and collect and disseminate facts and statistics about education . Until it was transferred to the FSA , the Office of Education and its predecessor organization had been part of the Department of the Interior . The Civilian Conservation Corps ( CCC ) was born during the Great Depression to provide employment for American youth and advance conservation of the Nation 's natural resources . It operated from April 5 , 1933 until June 30 , 1942 . During that time , the CCC provided work training to 3 million men and advanced conservation by more than 25 years . It was an independent agency until it came to FSA . The Nation 's social security and public assistance programs also were born during the Depression with approval of the Social Security Act on August 14 , 1935 . The initial Act of 1935 established the Social Security Board to administer Titles I , II , III , IV , and X of the Act . It remained an independent organization until its transfer to FSA . The Social Security Act Amendments of 1939 revised and expanded basic provisions of the program and eligibility requirements and extended protection to aged wives , dependent children and certain survivors of insured workers . Organized in 1855 and incorporated by the Kentucky Legislature in 1858 , the American Printing House for the Blind was established to produce educational materials for the blind and since 1879 has received an allocation of Federal funds to help support this activity . Federal responsibility regarding the Printing House was transferred to FSA from the Treasury Department on July 1 , 1939. Established in 1935 to provide youth with work training , the National Youth Administration later trained young people for jobs in war industries . It was supervised by the Office of the Administrator from the time FSA was created in 1939 until 1942 , when it was transferred to the War Manpower Commission . # #Early years# #  Under a Reorganization Plan that became effective on June 30 , 1940 , the organization of the Federal Security Agency ( FSA ) was enlarged : #The Food and Drug Administration ( FDA ) was transferred from the Department of Agriculture ; and #Saint Elizabeth 's Hospital , Freedmen 's Hospital , and #Federal functions relating to Howard University and the Columbia Institution for the Deaf were transferred to FSA from the Department of the Interior * As a result of pressure for the Federal Government to control adulterated and misbranded foods and drugs , the Food and Drugs Act was enacted on June 30 , 1906 . These responsibilities were entrusted to the Bureau of Chemistry in the Department of Agriculture in 1907 and were organized into a Food , Drug and Insecticide Administration in 1927 , renamed the Food and Drug Administration ( FDA ) in 1931 . Transferred to FSA in 1940 , FDA also was responsible for administering the Tea Importation Act ( 1897 ) , the Filled Milk Act ( 1923 ) , the Caustic Poison Act ( 1927 ) , and the Food , Drug , and Cosmetic Act ( 1938 ) . * Saint Elizabeths Hospital , created by Act of Congress in 1852 as the Government Hospital for the Insane , received its first patients on January 15 , 1855 . Founder of Saint Elizabeth 's was Dorothea Dix , the most prominent humanitarian of the era . The name was changed by Act of Congress in 1916 . Freedmen 's Hospital was an outgrowth of the Bureau for the Relief of Freedmen and Refugees authorized by the Act of March 3 , 1865 . In 1871 , the hospital was transferred to the Department of the Interior . * ' Howard University ' was established by an act of March 2 , 1867 , to provide higher education for Negroes . Education for the deaf was made available in the District of Columbia through the Columbia Institution for the Deaf established by the Act of February 16 , 1857 . The name was changed to Gallaudet College in 1954.  The Vocational Rehabilitation Act Amendments of 1943 expanded functions relating to vocational rehabilitation and assigned them to the Federal Security Administrator , who established the Office of Vocational Rehabilitation on September 4 , 1943 , to carry out these functions . Since the original Vocational Rehabilitation Act of 1920 , certain vocational rehabilitation and vocational education activities had been a responsibility of the Office of Education , first when it was part of the Department of Interior , then after it became part of FSA in 1939. Impact Of World War II * World War II had a broad impact on the social programs of FSA . Between 1941 and 1947 , the Government recognized the need to maintain essential health and welfare services . The Federal Security Administrator also served as coordinator of the Office of Health , Welfare , and related Defense Activities , renamed the Office of Defense , Health , and Welfare Services in September 1941 , which provided health care , education , and related services necessitated by the war effort . It was responsible for adjusting the distribution of remaining professional personnel to meet the requirements of the population . In 1943 , the Office 's title was again changed to the Office of Community War Services , which was abolished on June 30 , 1947. * The FDA during the war was charged with maintaining food standards to insure delivery of properly tested foods and drugs to the military establishment . * The Public Health Service was in charge of protecting both the general population and military personnel against epidemics and carrying out medical research . # #Post WWII# # Organizational Changes When the war ended , President Truman moved to strengthen the arm of the Federal Government for better integration of services in the fields of health , education , and welfare .  1946 * Reorganization Plan No. 2 of 1946 , effective July 16 , 1946 , abolished the three-member Social Security Board , creating in its place , the Social Security Administration , headed by a Commissioner of Social Security . The plan transferred the Children 's Bureau ( created in 1912 ) , exclusive of its Industrial Division , from the Department of Labor to FSA , where it became part of the Social Security Administration ( SSA ) ; the US Employees Compensation Commission , formerly an independent organization , to the Office of the Administrator of FSA ; functions of the Department of Commerce regarding vital statistics to the FSA Administrator , who delegated them to the Surgeon General of the Public Health Service . * Legislation of major importance to the Agency also was passed in 1946 : the National Mental Health Act ; the Vocational Education Act ; the Federal Employees Health Act ; the 1946 Amendments to the Social Security Act ; and the Hospital Survey and Construction Act .  1947 . In 1947 , the Administrator directed the establishment of a central library , consolidating the resources of three independent libraries at the SSA , the Office of Education , and the Office of Vocational Rehabilitation . This library eventually became the central library of the Department of Health , Education , and Welfare .  1948 * By 1948 , the retail price of food had risen 114 percent over the 1935-39 base , yet the monthly benefits under Social Security had not changed since the 1939 amendments had established a base level . On October 1 , 1948 , increases in Social Security benefits were authorized . * Other key pieces of legislation passed in 1948 included bills creating the National Heart Institute and the National Institute of Dental Research . On June 16 , 1948 , the name of the National Institute of Health was changed to the National Institutes of Health . * On June 30 , 1948 , the President signed the Water Pollution Bill , delegating national water pollution responsibilities to the Public Health Service . * Also in 1948 , legislation authorized the transfer of the Federal Credit Union program from the Federal Deposit Insurance Corporation to the SSA .  1949 * The Federal Property and Administrative Services Act of 1949 gave the Federal Security Administrator authority to dispose of surplus Federal propel property to tax-supported or nonprofit educational institutions for health or educational purposes . * During 1949 , the Federal Security Agency began the establishment of 10 FSA regional offices to replace the 11 previously operated by the SSA and consolidated those being operated by other FSA constituents into one common regional office structure . Previous to the consolidation , constituent agencies were maintaining five and , in some cases , six independent regional offices in a single city .  1950 * On May 24 , 1950 , Reorganization Plan No. 19 of 1950 transferred from FSA to the Department of Labor the Bureau of Employees Compensation and the Employees Compensation Appeals Board . Then , the FSA abolished the Office of Special Services that had administered the two transferred units plus the Office of Vocational Rehabilitation ( OVR ) and the Food and Drug Administration . The effect of this action was to elevate OVR and FDA to agency status . * In 1950 , two important national conferences required months of staff work by FSA personnel . The Mid-century White House Conference on Children and Youth was held in Washington , D.C. in December 1950 . Nearly 6,000 representatives of 100,000 local and community groups throughout the country met to discuss the spiritual values , democractic practice , and the dignity and worth of the individual . In August of that year , a Conference on Aging was called by the FSA Administrator to study the needs and problems of the older segment of the population . * In September 1950 , Congress authorized the impacted aid program-to relieve the impact on local school facilities of a heavy influx of Federal civilian and military personnel-and in FY 1951 appropriated $96.5 million for school construction under P.L. 81-815 , September 23 , 1950 , and $23 million for school operating expenses under P.L. 81-874 , September 30 , 1950. * The Social Security Act Amendments of 1950 added to the social security rolls about 10 million persons who previously had been ineligible . These persons included agricultural workers and selfemployed small shop owners . Others who benefitted from the changes were the elderly and those who had job-related disabilities . This expansion of beneficiaries was made possible by revisions to the oldage and survivors insurance and long-term disability insurance sections of the original Act .  1951 . In May 1951 , a citizens committee , the National Mid-century Committee for Children and Youth , was established to provide national follow-up to the problems discussed at the White House Conference . Staff of the Children 's Bureau worked closely with the Committee until it was dissolved in 1953.  1952 . The year 1952 was a period of transition for FSA . Despite the contributions made by the Agency during and before the Korean War , most of the defense-related activities in FSA were being phased out . The FDA continued to study chemical and bacteriological warfare agents but other FSA components were mobilized to provide disaster relief and health care assistance to a number of foreign countries . Technical assistance , under the Federal Point IV and Mutual Security Agency programs , provided needed help to many underdeveloped countries . The Agency also furnished guidance for foreign representatives sent to this country to study American programs and methods in the fields of health and education . Later in the year , FSA accelerated its response to the Nation 's social needs .  1953 . FSA Becomes DHEW * By 1953 , the Federal Security Agency 's programs in health , education , and social security had grown to such importance that its annual budget exceeded the combined budgets of the Departments of Commerce , Justice , Labor and Interior and affected the lives of millions of people . * Consequently , in accordance with the Reorganization Act of 1949 , President Eisenhower submitted to the Congress on March 12 , 1953 , Reorganization Plan No. 1 of 1953 , which called for the dissolution of the Federal Security Agency and elevation of the agency to Cabinet status as the Department of Health , Education , and Welfare . All of the responsibilities of the Federal Security Administrator would be transferred to the Secretary of Health , Education , end Welfare and the components of FSA would be transferred to the Department . A major objective of the reorganization was to improve administration of the functions of the Federal Security Agency . The plan was approved April 1 , 1953 , and became effective on April 11 , 1953 . Unlike statutes authorizing the creation of other executive departments , the contents of Reorganization Plan No. 1 of 1953 were never properly codified within the United States Code , although Congress did codify a later statute ratifying the Plan . Today , the Plan is included as an appendix to Title 5 of the United States Code . The result is that HHS is the only executive department whose statutory foundation today rests on a confusing combination of several codified and uncodified statutes . # Department of Health , Education , and Welfare # The Department of Health , Education , and Welfare ( HEW ) was created on April 11 , 1953 , when Reorganization Plan No. 1 of 1953 became effective . HEW thus became the first new Cabinet-level department since the Department of Labor was created in 1913 . The Reorganization Plan abolished the FSA and transferred all of its functions to the Secretary of HEW and all components of the Agency to the Department . The first Secretary of HEW was Oveta Culp Hobby , a native of Texas , who had served as Commander of the Women 's Army Corps in World War II and was editor and publisher of the ' ' Houston Post ' ' . Sworn in on April 11 , 1953 , as Secretary , she had been FSA Administrator since January 21 , 1953. # Department of Health and Human Services # The Department of Health , Education , and Welfare was renamed the Department of Health and Human Services ( HHS ) in 1979 , when its education functions were transferred to the newly created United States Department of Education under the Department of Education Organization Act . HHS was left in charge of the Social Security Administration , agencies constituting the Public Health Service , and Family Support Administration . In 1995 , the Social Security Administration was removed from the Department of Health and Human Services , and established as an independent agency of the executive branch of the United States Government . HHS is administered by the Secretary of Health and Human Services , who is appointed by the President with the advice and consent of the Senate . The United States Public Health Service ( PHS ) is the main division of the HHS and is led by the Assistant Secretary for Health . The current Secretary , Kathleen Sebelius is the Vice-Chair of the United States Interagency Council on Homelessness , and the Department of Health and Human Services is a member of the Council , which is dedicated to preventing and ending homelessness in America . The United States Public Health Service Commissioned Corps , the uniformed service of the PHS , is led by the Surgeon General who is responsible for addressing matters concerning public health as authorized by the Secretary or by the Assistant Secretary of Health in addition to his or her primary mission of administering the Commissioned Corps . The Office of Inspector General ( OIG ) investigates criminal activity for HHS . The special agents who work for OIG have the same title series 1811 , training and authority as other federal criminal investigators , such as the FBI , ATF , DEA and Secret Service . However , OIG Special Agents have special skills in investigating white collar crime related to Medicare and Medicaid fraud and abuse . Organized crime has dominated the criminal activity relative to this type of fraud . HHS-OIG investigates tens of millions of dollars in Medicare fraud each year . In addition , OIG will continue its coverage of all 50 states and the District of Columbia by its multi-agency task forces ( PSOC Task Forces ) that identify , investigate , and prosecute individuals who willfully avoid payment of their child support obligations under the Child Support Recovery Act . HHS-OIG agents also provide protective services to the Secretary of HHS , and other department executives as necessary . In 2002 , the department released Healthy People 2010 , a national strategic initiative for improving the health of Americans . # Strengthening Communities Fund # In June 2010 the Department of Health and Human Services created the Strengthening Communities Fund as part of the American Recovery and Reinvestment Act . The fund was appropriated $50 million to be given as grants to organizations in the United States who were engaged in Capacity Building programs . The grants were given to two different types of capacity builders :  State , Local and Tribal governments engaged in capacity building : grants will go to state local and tribal governments to equip them with the capacity to more effectively partner with faith-based or non-faith based nonprofit organizations . : : Capacity building in this program will involve education and outreach that catalyzes more involvement of nonprofit organizations in economic recovery and building up nonprofit organization 's abilities to tackle economic problems . State , Local and Tribal governments can receive up to $250,000 in two year grants  Nonprofit Social Service Providers engaged in capacity building : they will make grants available to nonprofit organizations who can assist other nonprofit organizations in organizational development , program development , leadership , and evaluations . Nonprofits can receive up to $1 million in two year grants . # Organization # # Internal Structure # The Department of Health and Human Services is led by the United States Secretary of Health and Human Services , a member of the United States Cabinet appointed by the President of the United States with the consent of the United States Senate . The Secretary is assisted in managing the Department by the Deputy Secretary of Health and Human Services , who is also appointed by the President . The Secretary and Deputy Secretary are further assisted by seven Assistant Secretaries , who serve as top Departmental administrators . Secretary of Health and Human Services *Deputy Secretary **Assistant Secretary for Health ***Public Health Service ****Office of the Surgeon General ****Public Health Service Commissioned Corps **Assistant Secretary for Preparedness and Response ***Office of the Assistant Secretary for Preparedness and Response ****Biomedical Advanced Research and Development Authority **Assistant Secretary for Legislation **Assistant Secretary for Planning and Evaluation **Assistant Secretary for Administration **Assistant Secretary for Public Affairs **Assistant Secretary for Financial Resources **Office of the Inspector General Administration for Children and Families Administration on Aging Agency for Healthcare Research and Quality Agency for Toxic Substances and Disease Registry Centers for Disease Control and Prevention Centers for Medicare and Medicaid Services Food and Drug Administration Health Resources and Services Administration Indian Health Service National Institutes of Health Substance Abuse and Mental Health Services Administration Office of the General Counsel Several agencies within HHS are components of the Public Health Service ( PHS ) , including AHRQ , ASPR , ATSDR , CDC , FDA , HRSA , IHS , NIH , SAMHSA , OGHA , and OPHS. # Budget and finances # The Department of Health and Human Services was authorized a budget for Fiscal Year 2015 of $60.9 billion . The budget authorization is broken down as follows : cellpadding= 5 class= wikitable ! Program ! Funding ( in billions ) # Former operating divisions and agencies #  Social Security Administration , made independent in 1995.  Health Care Financing Administration , renamed to Centers for Medicare and Medicaid Services # Programs # The Department of Health and Human Services ' administers 115 programs across its 11 operating divisions . Some highlights include :  Health and social science research  Preventing disease , including immunization services  Assuring food and drug safety  Medicare ( health insurance for elderly and disabled Americans ) and Medicaid ( health insurance for low-income people )  Health information technology  Financial assistance and services for low-income families  Improving maternal and infant health , including a Nurse Home Visitation to support first-time mothers .  Head Start ( pre-school education and services )  Faith-based and community initiatives  Preventing child abuse and domestic violence  Substance abuse treatment and prevention  Services for older Americans , including home-delivered meals  Comprehensive health services for Native Americans  Medical preparedness for emergencies , including potential terrorism .  Child support enforcement # Health care reform # The 2010 United States federal budget establishes a reserve fund of more than $630 billion over 10 years to finance fundamental reform of the health care system . # Related legislation #  1946 : Hospital Survey and Construction Act ( Hill-Burton Act ) PL 79-725  1949 : Hospital Construction Act PL 81-380  1950 : Public Health Services Act Amendments PL 81-692  1955 : Poliomyelitis Vaccination Assistance Act PL 84-377  1956 : Health Research Facilities Act PL 84-835  1960 : Social Security Amendments ( Kerr-Mill aid ) PL 86-778  1961 : Community Health Services and Facilities Act PL 87-395  1962 : Public Health Service Act PL 87-838  1962 : Vaccination Assistance PL 87-868  1963 : Mental Retardation Facilities Construction Act/Community Mental Health Centers Act PL 88-164  1964 : Nurse Training Act PL 88-581  1965 : Community Health Services and Facilities Act PL 89-109  1965 : Medicare PL 89-97  1965 : Mental Health Centers Act Amendments PL 89-105  1965 : Heart Disease , Cancer , and Stroke Amendments PL 89-239  1966 : Comprehensive Health Planning and Service Act PL 89-749  1970 : Community Mental Health Service Act PL 91-211  1970 : Family Planning Services and Population Research Act PL 91-572  1970 : Lead-Based Paint Poisoning Prevention Act PL 91-695  1971 : National Cancer Act PL 92-218  1974 : Research on Aging Act PL 93-296  1974 : National Health Planning and Resources Development Act PL 93-641  1979 : Department of Education Organization Act ( removed education functions ) PL 96-88  1987 : Department of Transportation Appropriations Act PL 100-202  1988 : Medicare Catastrophic Coverage Act PL 100-360  1989 : Department of Transportation and Related Agencies Appropriations Act PL 101-164  1996 : Health Insurance Portability and Accountability Act PL 104-191  2000 : Child Abuse Reform and Enforcement Act P.L. 106-177  2010 : Patient Protection and Affordable Care Act PL 111-148 
@@60976 A health system , also sometimes referred to as health care system or healthcare system , is the organization of people , institutions , and resources that deliver health care services to meet the health needs of target populations . There is a wide variety of health systems around the world , with as many histories and organizational structures as there are nations . In some countries , health system planning is distributed among market participants . In others , there is a concerted effort among governments , trade unions , charities , religious organizations , or other co-ordinated bodies to deliver planned health care services targeted to the populations they serve . However , health care planning has been described as often evolutionary rather than revolutionary . # Goals # According to the World Health Organization , health care systems ' goals are good health for the citizens , responsiveness to the expectations of the population , and fair means of funding operations . Progress towards them depends on how systems carry out four vital functions : provision of health care services , resource generation , financing , and stewardship . Other dimensions for the evaluation of health systems include quality , efficiency , acceptability , and equity . They have also been described in the United States as the five C 's : Cost , Coverage , Consistency , Complexity , and Chronic Illness . Also , continuity of health care is a major goal . # Definitions # Often health system has been defined with a reductionist perspective , for example reducing it to health care system . In many publications , for example , both expressions are used interchangeably . Some authors have developed arguments to expand the concept of health systems , indicating additional dimensions that should be considered :  Health systems should not be expressed in terms of their components only , but also of their interrelationships ;  Health systems should include not only the institutional or supply side of the health system , but also the population ;  Health systems must be seen in terms of their goals , which include not only health improvement , but also equity , responsiveness to legitimate expectations , respect of dignity , and fair financing , among others ;  Health systems must also be defined in terms of their functions , including the direct provision of services , whether they are medical or public health services , but also other enabling functions , such as stewardship , financing , and resource generation , including what is probably the most complex of all challenges , the health workforce . # World Health Organization definition # The World Health Organization defines health systems as follows : # A health system consists of all organizations , people and actions whose primary intent is to promote , restore or maintain health . This includes efforts to influence determinants of health as well as more direct health-improving activities . A health system is therefore more than the pyramid of publicly owned facilities that deliver personal health services . It includes , for example , a mother caring for a sick child at home ; private providers ; behaviour change programmes ; vector-control campaigns ; health insurance organizations ; occupational health and safety legislation . It includes inter-sectoral action by health staff , for example , encouraging the ministry of education to promote female education , a well known determinant of better health . # # Providers # Health care providers are institutions or individuals providing health care services . Individuals including health professionals and allied health professions can be self-employed or working as an employee in a hospital , clinic , or other health care institution , whether government operated , private for-profit , or private not-for-profit ( e.g. non-governmental organization ) . They may also work outside of direct patient care such as in a government health department or other agency , medical laboratory , or health training institution . Examples of health workers are doctors , nurses , midwives , dietitians , paramedics , dentists , medical laboratory technologists , therapists , psychologists , pharmacists , chiropractors , optometrists , community health workers , traditional medicine practitioners , and others . # Financial resources # There are generally five primary methods of funding health systems : , World Health Organization . And . Retrieved August 18 , 2006. # general taxation to the state , county or municipality # social health insurance # voluntary or private health insurance # out-of-pocket payments # donations to charities Most countries ' systems feature a mix of all five models . One study based on data from the OECD concluded that all types of health care finance are compatible with an efficient health system . The study also found no relationship between financing and cost control . The term health insurance is generally used to describe a form of insurance that pays for medical expenses . It is sometimes used more broadly to include insurance covering disability or long-term nursing or custodial care needs . It may be provided through a social insurance program , or from private insurance companies . It may be obtained on a group basis ( e.g. , by a firm to cover its employees ) or purchased by individual consumers . In each case premiums or taxes protect the insured from high or unexpected health care expenses . By estimating the overall cost of health care expenses , a routine finance structure ( such as a monthly premium or annual tax ) can be developed , ensuring that money is available to pay for the health care benefits specified in the insurance agreement . The benefit is typically administered by a government agency , a non-profit health fund or a corporation operating seeking to make a profit . Many forms of commercial health insurance control their costs by restricting the benefits that are paid by through deductibles , co-payments , coinsurance , policy exclusions , and total coverage limits and will severely restrict or refuse coverage of pre-existing conditions . Many government schemes also have co-payment schemes but exclusions are rare because of political pressure . The larger insurance schemes may also negotiate fees with providers . Many forms of social insurance schemes control their costs by using the bargaining power of their community they represent to control costs in the health care delivery system . For example by negotiating drug prices directly with pharmaceutical companies , or negotiating standard fees with the medical profession . Social schemes sometimes feature contributions related to earnings as part of a scheme to deliver universal health care , which may or may not also involve the use of commercial and non-commercial insurers . Essentially the more wealthy pay proportionately more into the scheme to cover the needs of the relatively poor who therefore contribute proportionately less . There are usually caps on the contributions of the wealthy and minimum payments that must be made by the insured ( often in the form of a minimum contribution , similar to a deductible in commercial insurance models ) . In addition to these traditional health care financing methods , some lower income countries and development partners are also implementing non-traditional or innovative financing mechanisms for scaling up delivery and sustainability of health care , such as micro-contributions , public-private partnerships , and market-based financial transaction taxes . For example , as of June 2011 , UNITAID had collected more than one billion dollars from 29 member countries , including several from Africa , through an air ticket solidarity levy to expand access to care and treatment for HIV/AIDS , tuberculosis and malaria in 94 countries . # Payment models # In most countries , wage costs for health care practitioners are estimated to represent between 65% and 80% of renewable health system expenditures . There are three ways to pay medical practitioners : fee for service , capitation , and salary . There has been growing interest in blending elements of these systems . # #Fee-for-service# # ' ' Fee-for-service arrangements ' ' pay general practitioners ( GPs ) based on the service . They are even more widely used for specialists working in ambulatory care . There are two ways to set fee levels :  By individual practitioners .  Central negotiations ( as in Japan , Germany , Canada and in France ) or hybrid model ( such as in Australia , France 's sector 2 , and New Zealand ) where GPs can charge extra fees on top of standardized patient reimbursement rates . # #Capitation# # In ' ' capitation payment systems ' ' , GPs are paid for each patient on their list , usually with adjustments for factors such as age and gender . According to OECD , these systems are used in Italy ( with some fees ) , in all four countries of the United Kingdom ( with some fees and allowances for specific services ) , Austria ( with fees for specific services ) , Denmark ( one third of income with remainder fee for service ) , Ireland ( since 1989 ) , the Netherlands ( fee-for-service for privately insured patients and public employees ) and Sweden ( from 1994 ) . Capitation payments have become more frequent in managed care environments in the United States . According to OECD , Capitation systems allow funders to control the overall level of primary health expenditures , and the allocation of funding among GPs is determined by patient registrations . However , under this approach , GPs may register too many patients and under-serve them , select the better risks and refer on patients who could have been treated by the GP directly . Freedom of consumer choice over doctors , coupled with the principle of money following the patient may moderate some of these risks . Aside from selection , these problems are likely to be less marked than under salary-type arrangements . # #Salary arrangements# # In several OECD countries , general practitioners ( GPs ) are employed on ' ' salaries ' ' for the government . According to OECD , Salary arrangements allow funders to control primary care costs directly ; however , they may lead to under-provision of services ( to ease workloads ) , excessive referrals to secondary providers and lack of attention to the preferences of patients . # Information resources # Sound information plays an increasingly critical role in the delivery of modern health care and efficiency of health systems . Health informatics the intersection of information science , medicine and health care deals with the resources , devices , and methods required to optimize the acquisition and use of information in health and biomedicine . Necessary tools for proper health information coding and management include clinical guidelines , formal medical terminologies , and computers and other information and communication technologies . The kinds of data processed may include patients ' medical records , hospital administration and clinical functions , and human resources information . The use of health information lies at the root of evidence-based policy and evidence-based management in health care . Increasingly , information and communication technologies are being utilised to improve health systems in developing countries through : the standardisation of health information ; computer-aided diagnosis and treatment monitoring ; informing population groups on health and treatment . # Management # The management of any health system is typically directed through a set of policies and plans adopted by government , private sector business and other groups in areas such as personal health care delivery and financing , pharmaceuticals , health human resources , and public health . Public health is concerned with threats to the overall health of a community based on population health analysis . The population in question can be as small as a handful of people , or as large as all the inhabitants of several continents ( for instance , in the case of a pandemic ) . Public health is typically divided into epidemiology , biostatistics and health services . Environmental , social , behavioral , and occupational health are also important subfields . Today , most governments recognize the importance of public health programs in reducing the incidence of disease , disability , the effects of ageing and health inequities , although public health generally receives significantly less government funding compared with medicine . For example , most countries have a vaccination policy , supporting public health programs in providing vaccinations to promote health . Vaccinations are voluntary in some countries and mandatory in some countries . Some governments pay all or part of the costs for vaccines in a national vaccination schedule . The rapid emergence of many chronic diseases , which require costly long-term care and treatment , is making many health managers and policy makers re-examine their health care delivery practices . An important health issue facing the world currently is HIV/AIDS . Another major public health concern is diabetes . In 2006 , according to the World Health Organization , at least 171 million people worldwide suffered from diabetes . Its incidence is increasing rapidly , and it is estimated that by the year 2030 , this number will double . A controversial aspect of public health is the control of tobacco smoking , linked to cancer and other chronic illnesses . Antibiotic resistance is another major concern , leading to the reemergence of diseases such as tuberculosis . The World Health Organization , for its World Health Day 2011 campaign , is calling for intensified global commitment to safeguard antibiotics and other antimicrobial medicines for future generations . # Health systems performance # Since 2000 , more and more initiatives have been taken at the international and national levels in order to strengthen national health systems as the core components of the global health system . Having this scope in mind , it is essential to have a clear , and unrestricted , vision of national health systems that might generate further progresses in global health . The elaboration and the selection of performance indicators are indeed both highly dependent on the conceptual framework adopted for the evaluation of the health systems performances . Like most social systems , health systems are complex adaptive systems where change does not necessarily follow rigid epidemiological models . In complex systems path dependency , emergent properties and other non-linear patterns are under-explored and unmeasured , which can lead to the development of inappropriate guidelines for developing responsive health systems . An increasing number of tools and guidelines are being published by international agencies and development partners to assist health system decision-makers to monitor and assess health systems strengthening including human resources development using standard definitions , indicators and measures . In response to a series of papers published in 2012 by members of the World Health Organization 's Task Force on Developing Health Systems Guidance , researchers from the Future Health Systems consortium argue that there is insufficient focus on the ' policy implementation gap ' . Recognizing the diversity of stakeholders and complexity of health systems is crucial to ensure that evidence-based guidelines are tested with requisite humility and without a rigid adherence to models dominated by a limited number of disciplines . Health Policy and Systems Research ( HPSR ) is an emerging multidisciplinary field that challenges ' disciplinary capture ' by dominant health research traditions , arguing that these traditions generate premature and inappropriately narrow definitions that impede rather than enhance health systems strengthening . HPSR focuses on low- and middle-income countries and draws on the relativist social science paradigm which recognises that all phenomena are constructed through human behaviour and interpretation . In using this approach , HPSR offers insight into health systems by generating a complex understanding of context in order to enhance health policy learning . HPSR calls for greater involvement of local actors , including policy makers , civil society and researchers , in decisions that are made around funding health policy research and health systems strengthening . # International comparisons # Health systems can vary substantially from country to country , and in the last few years , comparisons have been made on an international basis . The World Health Organization , in its ' ' World Health Report 2000 ' ' , provided a ranking of health systems around the world according to criteria of the overall level and distribution of health in the populations , and the responsiveness and fair financing of health care services . The goals for health systems , according to the WHO 's ' ' World Health Report 2000 Health systems : improving performance ' ' ( WHO , 2000 ) , are good health , responsiveness to the expectations of the population , and fair financial contribution . There have been several debates around the results of this WHO exercise , and especially based on the country ranking linked to it , insofar as it appeared to depend mostly on the choice of the retained indicators . Direct comparisons of health statistics across nations are complex . The Commonwealth Fund , in its annual survey , Mirror , Mirror on the Wall , compares the performance of the health systems in Australia , New Zealand , the United Kingdom , Germany , Canada and the U.S. Its 2007 study found that , although the U.S. system is the most expensive , it consistently underperforms compared to the other countries . A major difference between the U.S. and the other countries in the study is that the U.S. is the only country without universal health care . The OECD also collects comparative statistics , and has published brief country profiles . Health Consumer Powerhouse makes comparisons between both national health care systems in the Euro health consumer index and specific areas of health care such as diabetes <ref> cite web url= http : *36;165;TOOLONG ? *75;203;TOOLONG 
@@63522 ileal , ileocolic and colonic . ICDO = MeshID = D003424 Crohn 's disease , also known as Crohn syndrome and regional enteritis , is a type of inflammatory bowel disease ( IBD ) that may affect any part of the gastrointestinal tract from mouth to anus . Symptoms often include : abdominal pain , diarrhea ( which may be bloody if inflammation is severe ) , fever and weight loss . Other complications may occur outside the gastrointestinal tract and include : anemia , skin rashes , arthritis , inflammation of the eye , and tiredness . The skin rashes may be due to infections as well as pyoderma gangrenosum or erythema nodosum . Bowel obstruction also commonly occurs and those with the disease are at greater risk of bowel cancer . Crohn 's disease is caused by a combination of environmental , immune and bacterial factors in genetically susceptible individuals . It results in a chronic inflammatory disorder , in which the body 's immune system attacks the gastrointestinal tract possibly directed at microbial antigens . While Crohn 's is an immune related disease , it does not appear to be an autoimmune disease ( in that the immune system is not being triggered by the body itself ) . The exact underlying immune problem is not clear ; however , it may be an immunodeficiency state . About half of the overall risk is related to genetics with more than 70 genes found to be involved . Tobacco smokers are two times more likely to develop Crohn 's disease than nonsmokers . It also often begins after gastroenteritis . Diagnosis is based on a number of findings including : biopsy and appearance of the bowel wall , medical imaging and description of the disease . Other conditions that can present similarly include : irritable bowel syndrome and Behcet 's disease . There are no medications or surgical procedures that can cure Crohn 's disease . Treatment options help with symptoms , maintain remission , and prevent relapse . In those newly diagnosed a corticosteroid may be used for a brief period of time to quickly improve the disease with another medication such as either methotrexate or a thiopurine used to prevent recurrence . An important part of treatment is the stopping of smoking among those who do . One in five people with the disease are admitted to hospital each year , and half of those with the disease will require surgery for the disease at some point over a ten year period . While surgery should be used as little as possible , it is necessary to address some abscesses , certain bowel obstructions , and cancers . Checking for bowel cancer via colonoscopy is recommended every few years , starting eight years after the disease has begun . Crohn 's disease affects about 3.2 per 1,000 people in Europe and North America . It is less common in Asia and Africa . It has historically been more common in the developed world . Rates have ; however , been increasing particularly in the developing world since the 1970s . Inflammatory bowel disease resulted in 35,000 deaths in 2010 and those with Crohn 's disease have a slightly reduced life expectancy . It tends to start in the teens and twenties , although it can occur at any age . Males and females are equally affected . The disease was named after gastroenterologist Burrill Bernard Crohn , who , in 1932 , together with two other colleagues at Mount Sinai Hospital in New York , described a series of patients with inflammation of the terminal ileum of the small intestine , the area most commonly affected by the illness . # Signs and symptoms # # Gastrointestinal # Many people with Crohn 's disease have symptoms for years prior to the diagnosis . The usual onset is between 15 and 30 years of age , but can occur at any age . Because of the ' patchy ' nature of the gastrointestinal disease and the depth of tissue involvement , initial symptoms can be more subtle than those of ulcerative colitis . People with Crohn 's disease experience chronic recurring periods of flare-ups and remission . Abdominal pain may be the initial symptom of Crohn 's disease . It is often accompanied by diarrhea , especially in those who have had surgery . The diarrhea may or may not be bloody . The nature of the diarrhea in Crohn 's disease depends on the part of the small intestine or colon involved . Ileitis typically results in large-volume , watery feces . Colitis may result in a smaller volume of feces of higher frequency . Fecal consistency may range from solid to watery . In severe cases , an individual may have more than 20 bowel movements per day and may need to awaken at night to defecate . Visible bleeding in the feces is less common in Crohn 's disease than in ulcerative colitis , but may be seen in the setting of Crohn 's colitis . Bloody bowel movements typically come and go , and may be bright or dark red in color . In the setting of severe Crohn 's colitis , bleeding may be copious . Flatulence and bloating may also add to the intestinal discomfort . Symptoms caused by intestinal stenosis are also common in Crohn 's disease . Abdominal pain is often most severe in areas of the bowel with stenoses . Persistent vomiting and nausea may indicate stenosis from small bowel obstruction or disease involving the stomach , pylorus , or duodenum . Although the association is greater in the context of ulcerative colitis , Crohn 's disease may also be associated with primary sclerosing cholangitis , a type of inflammation of the bile ducts . Perianal discomfort may also be prominent in Crohn 's disease . Itchiness or pain around the anus may be suggestive of inflammation , fistulization or abscess around the anal area or anal fissure . Perianal skin tags are also common in Crohn 's disease . Fecal incontinence may accompany perianal Crohn 's disease . At the opposite end of the gastrointestinal tract , the mouth may be affected by non-healing sores ( aphthous ulcers ) . Rarely , the esophagus , and stomach may be involved in Crohn 's disease . These can cause symptoms including difficulty swallowing ( dysphagia ) , upper abdominal pain , and vomiting. # Systemic # Crohn 's disease , like many other chronic , inflammatory diseases , can cause a variety of systemic symptoms . Among children , growth failure is common . Many children are first diagnosed with Crohn 's disease based on inability to maintain growth . As it may manifest at the time of the growth spurt in puberty , up to 30% of children with Crohn 's disease may have retardation of growth . Fever may also be present , though fevers greater than 38.5 C ( 101.3 F ) are uncommon unless there is a complication such as an abscess . Among older individuals , Crohn 's disease may manifest as weight loss , usually related to decreased food intake , since individuals with intestinal symptoms from Crohn 's disease often feel better when they do not eat and might lose their appetite . People with extensive small intestine disease may also have malabsorption of carbohydrates or lipids , which can further exacerbate weight loss . # Extraintestinal # In addition to systemic and gastrointestinal involvement , Crohn 's disease can affect many other organ systems . Inflammation of the interior portion of the eye , known as uveitis , can cause blurred vision and eye pain , especially when exposed to light ( photophobia ) . Inflammation may also involve the white part of the eye ( sclera ) , a condition called episcleritis . Both episcleritis and uveitis can lead to loss of vision if untreated . Crohn 's disease that affects the ileum may result in an increased risk for gallstones . This is due to a decrease in bile acid resorption in the ileum and the bile gets excreted in the stool . As a result , the cholesterol/bile ratio increases in the gallbladder , resulting in an increased risk for gallstones . Crohn 's disease is associated with a type of rheumatologic disease known as seronegative spondyloarthropathy . This group of diseases is characterized by inflammation of one or more joints ( arthritis ) or muscle insertions ( enthesitis ) . The arthritis in Crohn 's disease can be divided into two types . The first type affects larger weight-bearing joints such as the knee ( most common ) , hips , shoulders , wrists , or elbows . The second type symmetrically involves five or more of the small joints of the hands and feet . The arthritis may also involve the spine , leading to ankylosing spondylitis if the entire spine is involved or simply sacroiliitis if only the sacroiliac joint is involved . The symptoms of arthritis include painful , warm , swollen , stiff joints and loss of joint mobility or function . Crohn 's disease may also involve the skin , blood , and endocrine system . The most common type of skin manifestation , erythema nodosum , presents as raised , tender red nodules usually appearing on the shins . Erythema nodosum is due to inflammation of the underlying subcutaneous tissue , and is characterized by septal panniculitis . Another skin lesion , pyoderma gangrenosum , is typically a painful ulcerating nodule . Crohn 's disease also increases the risk of blood clots ; painful swelling of the lower legs can be a sign of deep venous thrombosis , while difficulty breathing may be a result of pulmonary embolism . Autoimmune hemolytic anemia , a condition in which the immune system attacks the red blood cells , is also more common in Crohn 's disease and may cause fatigue , a pale appearance , and other symptoms common in anemia . Clubbing , a deformity of the ends of the fingers , may also be a result of Crohn 's disease . Finally , Crohn 's disease increases the risk of osteoporosis , or thinning of the bones . Individuals with osteoporosis are at increased risk of bone fractures . People with Crohn 's disease often have anemia due to vitamin B12 , folate , iron deficiency , or due to anemia of chronic disease . from chronic blood loss , reduced dietary intake , and persistent inflammation leading to increased hepcidin levels , restricting iron absorption in the duodenum . As Crohn 's disease most commonly affects the terminal ileum where the vitamin B12/intrinsic factor complex is absorbed , B12 deficiency may be seen . This is particularly common after surgery to remove the ileum . Involvement of the duodenum and jejunum can impair the absorption of many other nutrients including folate . If Crohn 's disease affects the stomach , production of intrinsic factor can be reduced . Crohn 's disease can also cause neurological complications ( reportedly in up to 15% ) . The most common of these are seizures , stroke , myopathy , peripheral neuropathy , headache and depression . People with Crohn 's often also have issues with small bowel bacterial overgrowth syndrome , which has similar symptoms . In the oral cavity people with Crohn 's may develop cheilitis granulomatosa and other forms of orofacial granulomatosis , pyostomatitis vegetans , recurrent aphthous stomatitis , geographic tongue and migratory stomatitis in higher prevalence than the general population . # Cause # Crohn 's disease seems to be caused by a combination of environmental factors and genetic predisposition . Crohn 's is the first genetically complex disease in which the relationship between genetic risk factors and the immune system is understood in considerable detail . Each individual risk mutation makes a small contribution to the overall risk of Crohn 's ( approximately 1:200 ) . The genetic data , and direct assessment of immunity , indicates a malfunction in the innate immune system . In this view , the chronic inflammation of Crohn 's is caused when the adaptive immune system tries to compensate for a deficient innate immune system . # Genetics # Crohn 's has a genetic component . Because of this , siblings of known people with Crohn 's are 30 times more likely to develop Crohn 's than the general population . The first mutation found to be associated with Crohn 's was a frameshift in the NOD2 gene ( also known as the CARD15 gene ) , followed by the discovery of point mutations . Over thirty genes have been associated with Crohn 's ; a biological function is known for most of them . For example , one association is with mutations in the XBP1 gene , which is involved in the unfolded protein response pathway of the endoplasmatic reticulum . There is considerable overlap between susceptibility loci for IBD and mycobacterial infections . # Immune system # There was a prevailing view that Crohn 's disease is a primary T cell autoimmune disorder , however a newer theory hypothesizes that Crohn 's results from an impaired innate immunity . The later hypothesis describes impaired cytokine secretion by macrophages , which contributes to impaired innate immunity and leads to a sustained microbial-induced inflammatory response in the colon , where the bacterial load is high . Another theory is that the inflammation of Crohn 's was caused by an overactive T <sub> h </sub> 1 cytokine response . More recent studies argue that T <sub> h </sub> 17 is more important . The most recent ( 2007 ) gene to be implicated in Crohn 's disease is ATG16L1 , which may induce autophagy and hinder the body 's ability to attack invasive bacteria . Another recent study has theorized that the human immune system traditionally evolved with the presence of parasites inside the body , and that the lack thereof due to modern hygiene standards has weakened the immune system . Test subjects were reintroduced to harmless parasites , with positive response . # Microbes # Current thinking is that microorganisms are taking advantage of their host 's weakened mucosal layer and inability to clear bacteria from the intestinal walls , which are both symptoms of Crohn 's . Different strains found in tissue and different outcomes to antibiotics therapy and resistance suggest Crohn 's Disease is not one disease , but an umbrella of diseases related to different pathogens . Some studies have suggested a role for ' ' Mycobacterium avium subspecies paratuberculosis ' ' ( MAP ) , which causes a similar disease , Johne 's disease , in cattle . NOD2 , a gene involved in Crohns genetic susceptibility , is associated with diminished killing of MAP by macrophages , reduced innate and adaptive immunity in the host and impaired immune responses required for control of intracellular mycobacterial infection . Macrophages infected with viable MAP are associated with high production of TNF- . Other studies have linked specific strains of enteroadherent ' ' E. coli ' ' to the disease . Adherent-invasive Escherichia coli ( AIEC ) , are more common in people with CD , have the ability to make strong biofilms compared to non-AIEC strains correlating with high adhesion and invasion indices of neutrophils and the ability to block autophagy at the autolysosomal step , which allows for intracellular survival of the bacteria and induction of inflammation . Inflammation drives the proliferation of AIEC and dysbiosis in the ileum , irrespective of genotype . AIEC strains replicate extensively into macrophages inducing the secretion of very large amounts of TNF- . Mouse studies have suggested some symptoms of Crohn 's disease , ulcerative colitis and irritable bowel syndrome have the same underlying cause . Biopsy samples taken from the colons of all three patient groups were found to produce elevated levels of a serine protease . Experimental introduction of the serine protease into mice has been found to produce widespread pain associated with irritable bowel syndrome , as well as colitis , which is associated with all three diseases . Regional and temporal variations in those illnesses follow those associated with infection with the protozoan Blastocystis . The cold-chain hypothesis is that psychrotrophic bacteria such as ' ' Yersinia ' ' and ' ' Listeria ' ' species contribute to the disease . A statistical correlation was found between the advent of the use of refrigeration in the United States and various parts of Europe and the rise of the disease . In many individuals , genetic factors predispose individuals to ' ' Mycobacterium avium ' ' subsp. ' ' paratuberculosis infection ' ' . This bacterium then produces mannins , which protect both itself and various bacteria from phagocytosis , which causes a variety of secondary infections . Still , this relationship between specific types of bacteria and Crohn 's disease remains unclear . # Environmental factors # The increased incidence of Crohn 's in the industrialized world indicates an environmental component . Crohn 's is associated with an increased intake of animal protein , milk protein and an increased ratio of omega-6 to omega-3 polyunsaturated fatty acids . Those who consume vegetable proteins appear to have a lower incidence of Crohn 's disease . Consumption of fish protein has no association . Smoking increases the risk of the return of active disease ( flares ) . The introduction of hormonal contraception in the United States in the 1960s is associated with a dramatic increase in incidence , and one hypothesis is that these drugs work on the digestive system in ways similar to smoking . Isotretinoin is associated with Crohn 's . Although stress is sometimes claimed to exacerbate Crohn 's disease , there is no concrete evidence to support such claim . Dietary microparticles , such as those found in toothpaste , have been studied as they produce effects on immunity , but they were not consumed in greater amounts in patients with Crohn's. # Pathophysiology # During a colonoscopy , biopsies of the colon are often taken to confirm the diagnosis . Certain characteristic features of the pathology seen point toward Crohn 's disease ; it shows a transmural pattern of inflammation , meaning the inflammation may span the entire depth of the intestinal wall . Ulceration is an outcome seen in highly active disease . There is usually an abrupt transition between unaffected tissue and the ulcer - a characteristic sign known as skip lesions . Under a microscope , biopsies of the affected colon may show mucosal inflammation , characterized by focal infiltration of neutrophils , a type of inflammatory cell , into the epithelium . This typically occurs in the area overlying lymphoid aggregates . These neutrophils , along with mononuclear cells , may infiltrate the crypts , leading to inflammation ( crypititis ) or abscess ( crypt abscess ) . Granulomas , aggregates of macrophage derivatives known as giant cells , are found in 50% of cases and are most specific for Crohn 's disease . The granulomas of Crohn 's disease do not show caseation , a cheese-like appearance on microscopic examination characteristic of granulomas associated with infections , such as tuberculosis . Biopsies may also show chronic mucosal damage , as evidenced by blunting of the intestinal villi , atypical branching of the crypts , and a change in the tissue type ( metaplasia ) . One example of such metaplasia , ' ' Paneth cell metaplasia ' ' , involves development of Paneth cells ( typically found in the small intestine and a key regulator of intestinal microbiota ) in other parts of the gastrointestinal system . # Diagnosis # The diagnosis of Crohn 's disease can sometimes be challenging , and a number of tests are often required to assist the physician in making the diagnosis . Even with a full battery of tests , it may not be possible to diagnose Crohn 's with complete certainty ; a colonoscopy is approximately 70% effective in diagnosing the disease , with further tests being less effective . Disease in the small bowel is particularly difficult to diagnose , as a traditional colonoscopy allows access to only the colon and lower portions of the small intestines ; introduction of the capsule endoscopy aids in endoscopic diagnosis . Multinucleated giant cells , a common finding in the lesions of Crohn 's disease , are less common in the lesions of lichen nitidus . <gallery> CD colitis.jpgEndoscopic image of Crohn 's colitis showing deep ulceration CT scan gastric CD.jpgCT scan showing Crohn 's disease in the fundus of the stomach CD colitis 2. jpgThis endoscopic image of Crohn 's colitis showing diffuse loss of mucosal architecture , friability and exudate Crohn 's disease - colon - high mag.jpgEndoscopic biopsy showing granulomatous inflammation of the colon in a case of Crohn 's disease . Crohn 's transmural path.jpgSection of colectomy showing transmural inflammation </gallery> # Classification # Crohn 's disease is one type of inflammatory bowel disease ( IBD ) . It typically manifests in the gastrointestinal tract and can be categorized by the specific tract region affected . A disease of both the ileum ( the last part of the small intestine that connects to the large intestine ) , and the large intestine , Ileocolic Crohn 's accounts for fifty percent of cases . Crohn 's ileitis , manifest in the ileum only , accounts for thirty percent of cases , while Crohn 's colitis , of the large intestine , accounts for the remaining twenty percent of cases and may be particularly difficult to distinguish from ulcerative colitis . Gastroduodenal Crohn 's disease causes inflammation in the stomach and first part of the small intestine , called the duodenum . Jejunoileitis causes spotty patches of inflammation in the top half of the small intestine , called the jejunum . The disease can attack any part of the digestive tract , from mouth to anus . However , individuals affected by the disease rarely fall outside these three classifications , with presentations in other areas . Crohn 's disease may also be categorized by the behavior of disease as it progresses . These categorizations formalized in the Vienna classification of the disease . There are three categories of disease presentation in Crohn 's disease : stricturing , penetrating , and inflammatory . Stricturing disease causes narrowing of the bowel that may lead to bowel obstruction or changes in the caliber of the feces . Penetrating disease creates abnormal passageways ( fistulae ) between the bowel and other structures , such as the skin . Inflammatory disease ( or nonstricturing , nonpenetrating disease ) causes inflammation without causing strictures or fistulae. # Endoscopy # A colonoscopy is the best test for making the diagnosis of Crohn 's disease , as it allows direct visualization of the colon and the terminal ileum , identifying the pattern of disease involvement . On occasion , the colonoscope can travel past the terminal ileum , but it varies from person to person . During the procedure , the gastroenterologist can also perform a biopsy , taking small samples of tissue for laboratory analysis , which may help confirm a diagnosis . As 30% of Crohn 's disease involves only the ileum , cannulation of the terminal ileum is required in making the diagnosis . Finding a patchy distribution of disease , with involvement of the colon or ileum , but not the rectum , is suggestive of Crohn 's disease , as are other endoscopic stigmata . The utility of capsule endoscopy for this , however , is still uncertain . A cobblestone -like appearance is seen in approximately 40% of cases of Crohn 's disease upon colonoscopy , representing areas of ulceration separated by narrow areas of healthy tissue . # Radiologic tests # A small bowel follow-through may suggest the diagnosis of Crohn 's disease and is useful when the disease involves only the small intestine . Because colonoscopy and gastroscopy allow direct visualization of only the terminal ileum and beginning of the duodenum , they can not be used to evaluate the remainder of the small intestine . As a result , a barium follow-through X-ray , wherein barium sulfate suspension is ingested and fluoroscopic images of the bowel are taken over time , is useful for looking for inflammation and narrowing of the small bowel . *8;4909;!-- *8;4919;!-- Barium enemas , in which barium is inserted into the rectum and fluoroscopy is used to image the bowel , are rarely used in the work-up of Crohn 's disease due to the advent of colonoscopy . They remain useful for identifying anatomical abnormalities when strictures of the colon are too small for a colonoscope to pass through , or in the detection of colonic fistulae ( in this case contrast should be performed with iodate substances ) . CT and MRI scans are useful for evaluating the small bowel with enteroclysis protocols . They are also useful for looking for intra-abdominal complications of Crohn 's disease , such as abscesses , small bowel obstructions , or fistulae . Magnetic resonance imaging ( MRI ) is another option for imaging the small bowel as well as looking for complications , though it is more expensive and less readily available # Blood tests # A complete blood count may reveal anemia , which commonly is caused by blood loss leading to iron deficiency ( a microcytic anemia ) or by vitamin B deficiency ( a macrocytic anemia ) , usually caused by ileal disease impairing vitamin B absorption . Rarely autoimmune hemolysis may occur . Ferritin levels help assess if iron deficiency is contributing to the anemia . Erythrocyte sedimentation rate ( ESR ) and C-reactive protein help assess the degree of inflammation , which is important as ferritin can also be raised in inflammation . Serum iron , total iron binding capacity and transferrin saturation may be more easily interpreted in inflammation . Anemia of chronic disease results in a normocytic anemia . Other causes of anemia include medication used in treatment of inflammatory bowel disease , like azathioprine , which can lead to cytopenia , and sulfasalazine , which can also result in folate deficiency . Testing for ' ' Saccharomyces cerevisiae ' ' antibodies ( ASCA ) and antineutrophil cytoplasmic antibodies ( ANCA ) has been evaluated to identify inflammatory diseases of the intestine and to differentiate Crohn 's disease from ulcerative colitis . Furthermore , increasing amounts and levels of serological antibodies such as ASCA , antilaminaribioside Glc(1,3)Glb() ; ALCA , antichitobioside ( GlcNAc(1,4)GlcNAc() ; ACCA , antimannobioside Man(1,3)Man()AMCA , antiLaminarin Glc(1,3)3n ( Glc ( 1,6 ) n ; anti-L and antichitin ( GlcNAc(1,4)n ; anti-C associate with disease behavior and surgery , and may aid in the prognosis of Crohn 's disease . # Comparison with ulcerative colitis # The most common disease that mimics the symptoms of Crohn 's disease is ulcerative colitis , as both are inflammatory bowel diseases that can affect the colon with similar symptoms . It is important to differentiate these diseases , since the course of the diseases and treatments may be different . In some cases , however , it may not be possible to tell the difference , in which case the disease is classified as indeterminate colitis. # Management # There is no cure for Crohn 's disease and remission may not be possible or prolonged if achieved . In cases where remission is possible , relapse can be prevented and symptoms controlled with medication , lifestyle and dietary changes , changes to eating habits ( eating smaller amounts more often ) , reduction of stress , moderate activity and exercise . Surgery is generally contraindicated and has not been shown to prevent remission . Adequately controlled , Crohn 's disease may not significantly restrict daily living . Treatment for Crohn 's disease is only when symptoms are active and involve first treating the acute problem , then maintaining remission . # Lifestyle changes # Certain lifestyle changes can reduce symptoms , including dietary adjustments , elemental diet , proper hydration , and smoking cessation . Smoking may increase Crohn 's disease ; stopping is recommended . Eating small meals frequently instead of big meals may also help with a low appetite . To manage symptoms have a balanced diet with proper portion control . Fatigue can be helped with regular exercise , a healthy diet , and enough sleep . A food diary may help with identifying foods that trigger symptoms . Some people should follow a low dietary fiber diet to control symptoms especially if fibrous foods cause symptoms . Some find relief in eliminating casein ( protein found in cow 's milk ) and gluten ( protein found in wheat , rye and barley ) from their diets . They may have specific dietary intolerances ( not allergies ) . # Medication # Acute treatment uses medications to treat any infection ( normally antibiotics ) and to reduce inflammation ( normally aminosalicylate anti-inflammatory drugs and corticosteroids ) . When symptoms are in remission , treatment enters maintenance , with a goal of avoiding the recurrence of symptoms . Prolonged use of corticosteroids has significant side-effects ; as a result , they are , in general , not used for long-term treatment . Alternatives include aminosalicylates alone , though only a minority are able to maintain the treatment , and many require immunosuppressive drugs . It has been also suggested that antibiotics change the enteric flora , and their continuous use may pose the risk of overgrowth with pathogens such as ' ' Clostridium difficile ' ' . Medications used to treat the symptoms of Crohn 's disease include 5-aminosalicylic acid ( 5-ASA ) formulations , prednisone , immunomodulators such as azathioprine ( given as the prodrug for 6-mercaptopurine ) , methotrexate , infliximab , adalimumab , certolizumab and natalizumab . Hydrocortisone should be used in severe attacks of Crohn 's disease . The gradual loss of blood from the gastrointestinal tract , as well as chronic inflammation , often leads to anemia , and professional guidelines suggest routinely monitoring for this . Adequate disease control usually improves anemia of chronic disease , but iron deficiency may require treatment with iron supplements . Guidelines vary as to how iron should be administered . Some advise parenteral iron as first line as it works faster , has fewer gastrointestinal side effects , and is unaffected by inflammation reducing enteral absorption . Other guidelines advise oral iron as first line with parenteral iron reserved for those that fail to adequately respond as oral iron is considerably cheaper . All agree that severe anemia ( hemoglobin under 10g/dL ) should be treated with parenteral iron . Blood transfusion should be reserved for those who are cardiovascularly unstable , due the relatively poor safety profile , lack of long term efficacy , and cost . # Surgery # Crohn 's can not be cured by surgery , though it is used in the case of partial or full blockage of the intestine . Surgery may also be required for complications such as obstructions , fistulas , or abscesses , or if the disease does not respond to drugs . After the first surgery , Crohn 's usually shows up at the site of the resection , however it can appear in other locations . After a resection , scar tissue builds up , which can cause strictures , which form when the intestines become too small to allow excrement to pass through easily , which can lead to a blockage . After the first resection , another resection may be necessary within five years . For patients with an obstruction due to a stricture , two options for treatment are strictureplasty and resection of that portion of bowel . There is no statistical significance between strictureplasty alone versus strictureplasty and resection in cases of duodenal involvement . In these cases , re-operation rates were 31% and 27% , respectively , indicating that strictureplasty is a safe and effective treatment for selected people with duodenal involvement . Postsurgical recurrence of Crohn 's disease is relatively common . Crohn 's lesions are often found at the site of the resected bowel . The join ( or anastomosis ) after surgery may be inspected , usually during a colonoscopy , and disease activity graded . The Rutgeert 's score is an endoscopic scoring system for post-operative disease recurrence in Crohn 's disease . Fewer lesions result in a lower grade . Based on the score , treatment plans can be designed to give the patient the best chance of managing recurrence of the disease . Short bowel syndrome ( SBS , also short gut syndrome or simply short gut ) is caused by the surgical removal of part of the small intestine . It usually develops in those patients who have had half or more of their small intestines removed . Diarrhea is the main symptom , but others may include weight loss , cramping , bloating , and heartburn . Short bowel syndrome is treated with changes in diet , intravenous feeding , vitamin and mineral supplements , and treatment with medications . Bile acid diarrhea is another complication following surgery for Crohn 's disease in which the terminal ileum has been removed . This leads to the development of excessive watery diarrhea . It is usually thought to be due to an inability of the ileum to reabsorb bile acids after resection of the terminal ileum and was the first type of bile acid malabsorption recognized . In some cases of SBS , intestinal transplant surgery may be considered ; though the number of transplant centres offering this procedure is quite small and it comes with a high risk due to the chance of infection and rejection of the transplanted intestine . # Alternative medicine # More than half of people with Crohn 's disease have tried complementary or alternative therapy . These include diets , probiotics , fish oil and other herbal and nutritional supplements . Some scientists have suggested more research into these is needed to discriminate between effective therapies and pseudo therapies that can be ineffective .  Acupuncture is used to treat inflammatory bowel disease in China , and is being used more frequently in Western society . There is insufficient evidence to recommend the use of acupuncture , though further studies are warranted .  Homeopathy is frequently used in Germany as a treatment for Crohn 's disease , though no clinical trials exist that demonstrate homeopathy is effective . # Prognosis # Crohn 's disease is a chronic condition for which there is no cure . It is characterised by periods of improvement followed by episodes when symptoms flare up . With treatment , most people achieve a healthy weight , and the mortality rate for the disease is relatively low . It can vary from being benign to very severe and people with CD could experience just one episode or have continuous symptoms . It usually reoccurs , although some people can remain disease free for years or decades . Most people with Crohn 's live a normal lifespan . However , Crohn 's disease is associated with a small increase in risk of small bowel and colorectal carcinoma ( bowel cancer ) . # Complications # Crohn 's disease can lead to several mechanical complications within the intestines , including obstruction , fistulae , and abscesses . Obstruction typically occurs from strictures or adhesions that narrow the lumen , blocking the passage of the intestinal contents . Fistulae can develop between two loops of bowel , between the bowel and bladder , between the bowel and vagina , and between the bowel and skin . Abscesses are walled off collections of infection , which can occur in the abdomen or in the perianal area . Crohn 's is responsible for 10% of vesicoenteric fistulae , and is the most common cause of ileovesical fistulae . Crohn 's disease also increases the risk of cancer in the area of inflammation . For example , individuals with Crohn 's disease involving the small bowel are at higher risk for small intestinal cancer . Similarly , people with Crohn 's colitis have a relative risk of 5.6 for developing colon cancer . Screening for colon cancer with colonoscopy is recommended for anyone who has had Crohn 's colitis for at least eight years . Some studies suggest there is a role for chemoprotection in the prevention of colorectal cancer in Crohn 's involving the colon ; two agents have been suggested , folate and mesalamine preparations . Individuals with Crohn 's disease are at risk of malnutrition for many reasons , including decreased food intake and malabsorption . The risk increases following resection of the small bowel . Such individuals may require oral supplements to increase their caloric intake , or in severe cases , total parenteral nutrition ( TPN ) . Most people with moderate or severe Crohn 's disease are referred to a dietitian for assistance in nutrition . The major significant complications of Crohn 's disease , including bowel obstruction , abscesses , free perforation and hemorrhage , in rare cases , may be fatal . Crohn 's disease can be problematic during pregnancy , and some medications can cause adverse outcomes for the fetus or mother . Consultation with an obstetrician and gastroenterologist about Crohn 's disease and all medications facilitates preventative measures . In some cases , remission occurs during pregnancy . Certain medications can also lower sperm count or otherwise adversely affect a man 's fertility . # Epidemiology # The percentage of people with Crohn 's disease has been determined in Norway and the United States and is similar at 6 to 7.1:100,000 . The Crohn 's and Colitis Foundation of America cites this number as approx 149:100,000 ; NIH cites 28 to 199 per 100,000 . Crohn 's disease is more common in northern countries , and with higher rates still in the northern areas of these country . The incidence of Crohn 's disease is thought to be similar in Europe but lower in Asia and Africa . It also has a higher incidence in Ashkenazi Jews and smokers . Crohn 's disease begins most commonly in people in their teens and 20s , and people in their 50s through to their 70s . It is rarely diagnosed in early childhood . It usually affects females children more severely than males . However , only slightly more women than men have Crohn 's disease . Parents , siblings or children of people with Crohn 's disease are 3 to 20 times more likely to develop the disease . Twin studies find that if one has the disease there is a 55% chance the other will too . # History # Inflammatory bowel diseases were described by Giovanni Battista Morgagni ( 16821771 ) and by Scottish physician T. Kennedy Dalziel in 1913 . ' ' Ileitis terminalis ' ' was first described by Polish surgeon Antoni Leniowski in 1904 , however , due to the precedence of Crohn 's name in the alphabet , it later became known in the worldwide literature as Crohn 's disease . Only in Poland is it still called Leniowski-Crohn 's disease . Burrill Bernard Crohn , an American gastroenterologist at New York City 's Mount Sinai Hospital , described fourteen cases in 1932 , and submitted them to the American Medical Association under the rubric of Terminal ileitis : A new clinical entity . Later that year , he , along with colleagues Leon Ginzburg and Gordon Oppenheimer published the case series as Regional ileitis : a pathologic and clinical entity . # Research # The Crohn 's Allogeneic Transplant Study 's investigation team of Seattle is currently undergoing a Phase 2 clinical trial to cure Crohn 's disease , involving bone marrow transplant , noting that cases in which bone marrow transplant had been done for a secondary purpose effectively cured the person of Crohn 's . Researchers at University College London have questioned the wisdom of suppressing the immune system in Crohn 's , as the problem may be an underactive rather than an overactive immune system : Their study found that people with Crohn 's showed an abnormally low response to an introduced infection , marked by a poor flow of blood to the wound , and the response improved when the they were given sildenafil citrate . Recent studies using helminthic therapy or hookworms to treat Crohn 's Disease and other ( non-viral ) auto-immune diseases seem to yield promising results . Numerous preclinical studies demonstrate that activation of the CB1 and CB2 cannabinoid receptors exert biological functions on the gastrointestinal tract . Activation of CB1 and CB2 receptors in animals has shown a strong anti-inflammatory effect . Cannabinoids and/or modulation of the endocannabinoid system is a novel therapeutic means for the treatment of numerous GI disorders , including inflammatory bowel diseases like Crohn 's disease .  Methotrexate is a folate anti-metabolite drug that is also used for chemotherapy . It is useful in maintenance of remission for those no longer taking corticosteroids.  Metronidazole and ciprofloxacin are antibiotics used to treat Crohn 's that have colonic or perianal involvement , although , in the United States , this use has not been approved by the Food and Drug Administration ( FDA ) . They are also used for treatment of complications , including abscesses and other infections accompanying Crohn 's disease .  There is no good evidence that thalidomide or lenalidomide is useful to bring about or maintain remission . # References # 
@@63526 This article employs British spelling ; please do not try to correct coeliac to celiac , diarrhoea to diarrhea etc . See WP:ENGVAR for explanation . -- Coeliac disease ( ; celiac disease in the United States and often celiac sprue ) is an autoimmune disorder of the small intestine that occurs in genetically predisposed people of all ages from middle infancy onward . Symptoms include pain and discomfort in the digestive tract , chronic constipation and diarrhoea , failure to thrive ( in children ) , anaemia and fatigue , but these may be absent , and symptoms in other organ systems have been described . Vitamin deficiencies are often noted in people with coeliac disease owing to the reduced ability of the small intestine to properly absorb nutrients from food . Increasingly , diagnoses are being made in asymptomatic persons as a result of increased screening ; the condition is thought to affect between 1 in 1,750 worldwide and 1 in 105 people in the United States , and 1 in 100 in the UK . Coeliac disease is caused by a reaction to gliadin , a prolamin ( gluten protein ) found in wheat , and similar proteins found in the crops of the tribe Triticeae ( which includes other common grains such as barley and rye ) . Upon exposure to gliadin , and specifically to three peptides found in prolamins , the enzyme tissue transglutaminase modifies the protein , and the immune system cross-reacts with the small-bowel tissue , causing an inflammatory reaction . That leads to a truncating of the villi lining the small intestine ( called villous atrophy ) . This interferes with the absorption of nutrients because the intestinal villi are responsible for absorption . The only known effective treatment is a lifelong gluten-free diet . While the disease is caused by a reaction to wheat proteins , it is not the same as wheat allergy . This condition has several other names , including cliac disease ( with ' ' ' ' ligature ) , c(o)eliac sprue , nontropical sprue , endemic sprue , and gluten enteropathy . The term ' ' coeliac ' ' derived from the Greek ( ' ' koiliaks ' ' , abdominal ) and was introduced in the 19th century in a translation of what is generally regarded as an ancient Greek description of the disease by Aretaeus of Cappadocia. # Signs and symptoms # Severe coeliac disease leads to the characteristic symptoms of pale , loose and greasy stool ( steatorrhoea ) and weight loss or failure to gain weight ( in young children ) . People with milder coeliac disease may have symptoms that are much more subtle and occur in other organs than the bowel itself . It is also possible to have coeliac disease without any symptoms whatsoever . Many adults with subtle disease only have fatigue or anaemia. # Gastrointestinal # The diarrhoea that is characteristic of coeliac disease is ( chronic ) pale , voluminous and abnormally malodorous . Abdominal pain and cramping , bloatedness with abdominal distension ( thought to be due to fermentative production of bowel gas ) and mouth ulcers may be present . As the bowel becomes more damaged , a degree of lactose intolerance may develop . Frequently , the symptoms are ascribed to irritable bowel syndrome ( IBS ) , only later to be recognised as coeliac disease ; a small proportion of people with symptoms of IBS have underlying coeliac disease , and screening for coeliac disease is recommended for those with IBS symptoms . Coeliac disease leads to an increased risk of both adenocarcinoma and lymphoma of the small bowel ( enteropathy-associated T-cell lymphoma ( EATL ) or other non-Hodgkin 's lymphomas ) . This risk is also higher in first-degree relatives like siblings , parents and children , whether or not a gluten-free diet brings this risk back to baseline is not clear . Long-standing and untreated disease may lead to other complications , such as ulcerative jejunitis ( ulcer formation of the small bowel ) and stricturing ( narrowing as a result of scarring with obstruction of the bowel ) . # Malabsorption-related # The changes in the bowel make it less able to absorb nutrients , minerals and the fat-soluble vitamins A , D , E , and K.  The inability to absorb carbohydrates and fats may cause weight loss ( or failure to thrive/stunted growth in children ) and fatigue or lack of energy .  Anaemia may develop in several ways : iron malabsorption may cause iron deficiency anaemia , and folic acid and vitamin B <sub> 12 </sub> malabsorption may give rise to megaloblastic anaemia.  Calcium and vitamin D malabsorption ( and compensatory secondary hyperparathyroidism ) may cause osteopenia ( decreased mineral content of the bone ) or osteoporosis ( bone weakening and risk of fragility fractures ) .  A small proportion have abnormal coagulation due to vitamin K deficiency and are slightly at risk for abnormal bleeding .  Coeliac disease is also associated with bacterial overgrowth of the small intestine , which can worsen malabsorption or cause malabsorption despite adherence to treatment . # Miscellaneous # Coeliac disease has been linked with a number of conditions . In many cases , it is unclear whether the gluten-induced bowel disease is a causative factor or whether these conditions share a common predisposition.  IgA deficiency is present in 2.3% of people with coeliac disease , and in turn this condition features a tenfold increased risk of coeliac disease . Other features of this condition are an increased risk of infections and autoimmune disease .  Dermatitis herpetiformis ; this itchy cutaneous condition has been linked to a transglutaminase enzyme in the skin , features small-bowel changes identical to those in coeliac disease , and may respond to gluten withdrawal even if there are no gastrointestinal symptoms .  Growth failure and/or pubertal delay in later childhood can occur even without obvious bowel symptoms or severe malnutrition . Evaluation of growth failure often includes coeliac screening .  Pregnancy complications in case of coeliac disease as an intercurrent disease in pregnancy , with significant complications including miscarriage , intrauterine growth restriction , low birthweight and preterm birth .  Hyposplenism ( a small and underactive spleen ) ; this occurs in about a third of cases and may predispose to infection given the role of the spleen in protecting against bacteria .  Abnormal liver function tests ( randomly detected on blood tests ) . Coeliac disease is associated with a number of other medical conditions , many of which are autoimmune disorders : diabetes mellitus type 1 , hypothyroidism , primary biliary cirrhosis , and microscopic colitis . A more controversial area is a group of diseases in which antigliadin antibodies ( an older and nonspecific test for coeliac disease ) are sometimes detected but no small bowel disease can be demonstrated . Sometimes these conditions improve by removing gluten from the diet . This includes cerebellar ataxia , peripheral neuropathy , schizophrenia , and autism. # Cause # Coeliac disease is caused by a reaction to gliadin , a prolamin ( gluten protein ) found in wheat , and similar proteins found in the crops of the tribe Triticeae ( which includes other common grains such as barley and rye ) . # Other grains # Wheat subspecies ( such as spelt and durum ) and related species ( such as barley , rye , triticale and Kamut ) also induce symptoms of coeliac disease . A small minority of people with coeliac also react to oats . It is most probable that oats produce symptoms due to cross-contamination with other grains in the fields or in the distribution channels . Therefore , oats are generally not recommended . However , many companies assure the ' purity ' of oats and are therefore still able to be consumed through these sources . Other cereals such as maize , millet , sorghum , teff , rice , and wild rice are safe for people with coeliac to consume , as well as noncereals such as amaranth , quinoa , and buckwheat . Noncereal carbohydrate-rich foods such as potatoes and bananas do not contain gluten and do not trigger symptoms . # Risk modifiers # There are various theories as to what determines whether a genetically susceptible individual will go on to develop coeliac disease . Major theories include infection by rotavirus or human intestinal adenovirus . Some research has suggested that smoking is protective against adult-onset coeliac disease . People exposed to wheat , barley , or rye before the gut barrier has fully developed ( within the first three months after birth ) had five times the risk of developing coeliac disease relative to those exposed four to six months after birth . Those exposed even later than six months after birth were found to have only a slightly increased risk relative to those exposed at four to six months after birth . Early introduction of grains is protective against grain allergies . Breastfeeding may also reduce risk with prolonging breastfeeding until the introduction of gluten-containing grains into the diet associated with a 50% reduced risk of developing coeliac disease in infancy ; whether this persists into adulthood is not clear . Factors that can trigger symptoms include : surgery , pregnancy , infection and emotional stress . # Pathophysiology # Coeliac disease appears to be multifactorial , both in that more than one genetic factor can cause the disease and in that more than one factor is necessary for the disease to manifest in a person . Almost all people with coeliac disease have either the variant HLA-DQ2 allele or ( less commonly ) the HLA-DQ8 allele . However , about 2030% of people without coeliac disease have also inherited either of these alleles . This suggests additional factors are needed for coeliac disease to develop ; that is , the predisposing HLA risk allele is necessary but not sufficient to develop coeliac disease . Furthermore , around 5% of those people who do develop coeliac disease do not have typical HLA-DQ2 or HLA-DQ8 alleles ( see below ) . # Genetics # The vast majority of people with coeliac have one of two types of the HLA-DQ protein . HLA-DQ is part of the MHC class II antigen-presenting receptor ( also called the human leukocyte antigen ) system and distinguishes cells between self and non-self for the purposes of the immune system . The two subunits of the HLA-DQ protein are encoded by the HLA-DQA1 and HLA-DQB1 genes , located on the short arm of the sixth chromosome . There are seven HLA-DQ variants ( DQ2 and DQ4DQ9 ) . Over 95% of people with coeliac have the isoform of DQ2 or DQ8 , which is inherited in families . The reason these genes produce an increase in risk of coeliac disease is that the receptors formed by these genes bind to gliadin peptides more tightly than other forms of the antigen-presenting receptor . Therefore , these forms of the receptor are more likely to activate T lymphocytes and initiate the autoimmune process . Most people with coeliac bear a two-gene HLA-DQ2 haplotype referred to as DQ2.5 haplotype . This haplotype is composed of two adjacent gene alleles , DQA1*0501 and DQB1*0201 , which encode the two subunits , DQ <sup> 5 </sup> and DQ <sup> 2 </sup> . In most individuals , this DQ2.5 isoform is encoded by one of two chromosomes 6 inherited from parents ( DQ2.5cis ) . Most coeliacs inherit only one copy of this DQ2.5 haplotype , while some inherit it from ' ' both ' ' parents ; the latter are especially at risk for coeliac disease as well as being more susceptible to severe complications . Some individuals inherit DQ2.5 from one parent and an additional portion of the haplotype ( either DQB1*02 or DQA1*05 ) from the other parent , increasing risk . Less commonly , some individuals inherit the DQA1*05 allele from one parent and the DQB1*02 from the other parent ( DQ2.5trans ) ( called a trans-haplotype association ) , and these individuals are at similar risk for coeliac disease as those with a single DQ2.5-bearing chromosome 6 , but in this instance disease tends not to be familial . Among the 6% of European coeliacs that do not have DQ2.5 ( cis or trans ) or DQ8 ( encoded by the haplotype DQA1*03:DQB1*0302 ) , 4% have the DQ2.2 isoform , and the remaining 2% lack DQ2 or DQ8 . The frequency of these genes varies geographically . DQ2.5 has high frequency in peoples of North and Western Europe ( Basque Country and Ireland with highest frequencies ) and portions of Africa and is associated with disease in India , but is not found along portions of the West Pacific rim . DQ8 has a wider global distribution than DQ2.5 and is particularly common in South and Central America ; up to 90% of individuals in certain Amerindian populations carry DQ8 and thus may display the coeliac phenotype . Other genetic factors have been repeatedly reported in CD ; however , involvement in disease has variable geographic recognition . Only the HLA-DQ loci show a consistent involvement over the global population . Many of the loci detected have been found in association with other autoimmune diseases . One locus , the LPP or lipoma-preferred partner gene , is involved in the adhesion of extracellular matrix to the cell surface , and a minor variant ( SNP = rs1464510 ) increases the risk of disease by approximately 30% . This gene strongly associates with coeliac disease ( p *9;4929; 39 </sup> ) in samples taken from a broad area of Europe and the US . The prevalence of CD genotypes in the modern population is not completely understood . Given the characteristics of the disease and its apparent strong heritability , it would normally be expected that the genotypes would undergo negative selection and to be absent in societies where agriculture has been practised the longest ( compare with a similar condition , Lactose intolerance , which has been negatively selected so strongly that its prevalence went from 100% in ancestral populations to less than 5% in some European countries ) . This expectation was first proposed by Simoons ( 1981 ) . By now , however , it is apparent that this is not the case ; on the contrary , there is evidence of ' ' positive ' ' selection in CD genotypes . It is suspected that some of them may have been beneficial by providing protection against bacterial infections . # Prolamins # The majority of the proteins in food responsible for the immune reaction in coeliac disease are the prolamins . These are storage proteins rich in proline ( ' ' prol- ' ' ) and glutamine ( ' ' -amin ' ' ) that dissolve in alcohols and are resistant to proteases and peptidases of the gut . Prolamins are found in cereal grains with different grains having different but related prolamins : wheat ( gliadin ) , barley ( hordein ) , rye ( secalin ) , corn ( zein ) and as a minor protein , avenin in oats . One region of -gliadin stimulates membrane cells , enterocytes , of the intestine to allow larger molecules around the sealant between cells . Disruption of tight junctions allow peptides larger than three amino acids to enter circulation . Membrane leaking permits peptides of gliadin that stimulate two levels of immune response , the innate response and the adaptive ( T-helper cell mediated ) response . One protease-resistant peptide from -gliadin contains a region that stimulates lymphocytes and results in the release of interleukin-15 . This innate response to gliadin results in immune-system signalling that attracts inflammatory cells and increases the release of inflammatory chemicals . The strongest and most common adaptive response to gliadin is directed toward an 2-gliadin fragment of 33 amino acids in length . The response to the 33mer occurs in most coeliacs who have a DQ2 isoform . This peptide , when altered by intestinal transglutaminase , has a high density of overlapping T-cell epitopes . This increases the likelihood that the DQ2 isoform will bind and stay bound to peptide when recognised by T-cells . Gliadin in wheat is the best-understood member of this family , but other prolamins exist , and hordein ( from barley ) and secalin ( from rye ) may contribute to coeliac disease . However , not all prolamins will cause this immune reaction , and there is ongoing controversy on the ability of avenin ( the prolamin found in oats ) to induce this response in coeliac disease . # Tissue transglutaminase # Anti-transglutaminase antibodies to the enzyme tissue transglutaminase ( tTG ) are found in an overwhelming majority of cases . Tissue transglutaminase modifies gluten peptides into a form that may stimulate the immune system more effectively . These peptides are modified by tTG in two ways , deamidation or transamidation . Deamidation is the reaction by which a glutamate residue is formed by cleavage of the epsilon-amino group of a glutamine side chain . Transamidation , which occurs three times more often than deamidation , is the cross-linking of a glutamine residue from the gliadin peptide to a lysine residue of tTg in a reaction which is catalysed by the transglutaminase . Crosslinking may occur either within or outside the active site of the enzyme . The latter case yields a permanently covalently linked complex between the gliadin and the tTg . This results in the formation of new epitopes which are believed to trigger the primary immune response by which the autoantibodies against tTg develop . Stored biopsies from suspected people with coeliac have revealed that autoantibody deposits in the subclinical coeliacs are detected prior to clinical disease . These deposits are also found in people who present with other autoimmune diseases , anaemia , or malabsorption phenomena at a much increased rate over the normal population . Endomysial components of antibodies ( EMA ) to tTG are believed to be directed toward cell-surface transglutaminase , and these antibodies are still used in confirming a coeliac disease diagnosis . However , a 2006 study showed that EMA-negative people with coeliac tend to be older males with more severe abdominal symptoms and a lower frequency of atypical symptoms , including autoimmune disease . In this study , the anti-tTG antibody deposits did not correlate with the severity of villous destruction . These findings , coupled with recent work showing that gliadin has an innate response component , suggest that gliadin may be more responsible for the primary manifestations of coeliac disease , whereas tTG is a bigger factor in secondary effects such as allergic responses and secondary autoimmune diseases . In a large percentage of people with coeliac , the anti-tTG antibodies also recognise a rotavirus protein called VP7 . These antibodies stimulate monocyte proliferation , and rotavirus infection might explain some early steps in the cascade of immune cell proliferation . Indeed , earlier studies of rotavirus damage in the gut showed this causes a villous atrophy . This suggests that viral proteins may take part in the initial flattening and stimulate self-crossreactive anti-VP7 production . Antibodies to VP7 may also slow healing until the gliadin-mediated tTG presentation provides a second source of crossreactive antibodies . Other intestinal disorders may have biopsy that look like coeliac disease including lesions caused by Candida. # Villous atrophy and malabsorption # The inflammatory process , mediated by T cells , leads to disruption of the structure and function of the small bowel 's mucosal lining and causes malabsorption as it impairs the body 's ability to absorb nutrients , minerals and fat-soluble vitamins A , D , E and K from food . Lactose intolerance may be present due to the decreased bowel surface and reduced production of lactase but typically resolves once the condition is treated . Alternative causes of this tissue damage have been proposed and involve release of interleukin 15 and activation of the innate immune system by a shorter gluten peptide ( p3143/49 ) . This would trigger killing of enterocytes by lymphocytes in the epithelium . The villous atrophy seen on biopsy may also be due to unrelated causes , such as tropical sprue , giardiasis and radiation enteritis . While positive serology and typical biopsy are highly suggestive of coeliac disease , lack of response to diet may require these alternative diagnoses to be considered . # Diagnosis # There are several tests that can be used to assist in diagnosis . The level of symptoms may determine the order of the tests , but ' ' all ' ' tests lose their usefulness if the person is already eating a gluten-free diet . Intestinal damage begins to heal within weeks of gluten being removed from the diet , and antibody levels decline over months . For those who have already started on a gluten-free diet , it may be necessary to perform a rechallenge with some gluten-containing food in one meal a day over 6 weeks before repeating the investigations . Combining findings into a prediction rule to guide use of endoscopic biopsy reported a sensitivity of 100% ( it would identify all the cases ) in a population of subjects with a high index of suspicion for coeliac disease , with a concomitant specificity of 61% ( a false positive rate of 39% ) . The prediction rule recommends that people with high-risk symptoms ' ' or ' ' positive serology should undergo endoscopic biopsy of the second part of the duodenum . The study defined high-risk symptoms as weight loss , anaemia ( haemoglobin less than 120 g/l in females or less than 130 g/l in males ) , or diarrhoea ( more than three loose stools per day ) . # Blood tests # Serological blood tests are the first-line investigation required to make a diagnosis of coeliac disease . Antiendomysial antibodies of the immunoglobulin A ( IgA ) type can detect coeliac disease with a sensitivity and specificity of 90% and 99% , respectively . Serology for anti-tTG antibodies was initially reported to have a higher sensitivity ( 99% ) and specificity ( 90% ) for identifying coeliac disease . However , it is now thought to have similar characteristics to anti-endomysial antibody . Modern anti-tTG assays rely on a human recombinant protein as an antigen. tTG testing should be done first as it is an easier test to perform . An equivocal result on tTG testing should be followed by antibodies to endomysium . Because of the major implications of a diagnosis of coeliac disease , professional guidelines recommend that a positive blood test is still followed by an endoscopy/gastroscopy and biopsy . A negative serology test may still be followed by a recommendation for endoscopy and duodenal biopsy if clinical suspicion remains high due to the 1 in 100 false-negative result . As such , tissue biopsy is still considered the gold standard in the diagnosis of coeliac disease . Historically three other antibodies were measured : anti-reticulin ( ARA ) , anti-gliadin ( AGA ) and anti-endomysium ( EMA ) antibodies . ARA testing ; however , is not accurate enough for routine diagnostic use . Serology may be unreliable in young children , with anti-gliadin performing somewhat better than other tests in children under five . Serology tests are based on indirect immunofluorescence ( reticulin , gliadin and endomysium ) or ELISA ( gliadin or tissue transglutaminase , tTG ) . Guidelines recommend that a total serum IgA level is checked in parallel , as people with coeliac with IgA deficiency may be unable to produce the antibodies on which these tests depend ( false negative ) . In those people , IgG antibodies against transglutaminase ( IgG-tTG ) may be diagnostic . Antibody testing and HLA testing have similar accuracies . However , widespread use of HLA typing to rule out coeliac disease is not currently recommended . # Endoscopy # An upper endoscopy with biopsy of the duodenum ( beyond the duodenal bulb ) or jejunum is performed . It is important for the physician to obtain multiple samples ( four to eight ) from the duodenum . Not all areas may be equally affected ; if biopsies are taken from healthy bowel tissue , the result would be a false negative . Most people with coeliac disease have a small bowel that appears normal on endoscopy ; however , five concurrent endoscopic findings have been associated with a high specificity for coeliac disease : scalloping of the small bowel folds ( ' ' pictured ' ' ) , paucity in the folds , a mosaic pattern to the mucosa ( described as a cracked-mud appearance ) , prominence of the submucosa blood vessels , and a nodular pattern to the mucosa . Until the 1970s , biopsies were obtained using metal capsules attached to a suction device . The capsule was swallowed and allowed to pass into the small intestine . After x-ray verification of its position , suction was applied to collect part of the intestinal wall inside the capsule . Often-utilised capsule systems were the Watson capsule and the Crosby-Kugler capsule . This method has now been largely replaced by fibre-optic endoscopy , which carries a higher sensitivity and a lower frequency of errors . # Pathology # The classic pathology changes of coeliac disease in the small bowel are categorised by the Marsh classification :  Marsh stage 0 : normal mucosa  Marsh stage 1 : increased number of intra-epithelial lymphocytes ( IELs ) , usually exceeding 20 per 100 enterocytes  Marsh stage 2 : proliferation of the crypts of Lieberkuhn  Marsh stage 3 : partial or complete villous atrophy and crypt hypertrophy  Marsh stage 4 : hypoplasia of the small bowel architecture Marsh 's classification , introduced in 1992 , was subsequently modified in 1999 to six stages , where the previous stage 3 was split in three substages . Further studies demonstrated that this system was not always reliable and that the changes observed in coeliac disease could be described in one of three stagesA , B1 and B2with A representing lymphocytic infiltration with normal villous appearance and B1 and B2 describing partial and complete villous atrophy . The changes classically improve or reverse after gluten is removed from the diet . However , most guidelines do not recommend a repeat biopsy unless there is no improvement in the symptoms on diet . In some cases , a deliberate gluten challenge , followed by biopsy , may be conducted to confirm or refute the diagnosis . A normal biopsy and normal serology after challenge indicates the diagnosis may have been incorrect . # Other diagnostic tests # At the time of diagnosis , further investigations may be performed to identify complications , such as iron deficiency ( by full blood count and iron studies ) , folic acid and vitamin B <sub> 12 </sub> deficiency and hypocalcaemia ( low calcium levels , often due to decreased vitamin D levels ) . Thyroid function tests may be requested during blood tests to identify hypothyroidism , which is more common in people with coeliac disease . Osteopenia and osteoporosis , mildly and severely reduced bone mineral density , are often present in people with coeliac disease , and investigations to measure bone density may be performed at diagnosis , such as dual energy X-ray absorptiometry ( DXA ) scanning , to identify risk of fracture and need for bone protection medication . # Screening # Due to its high sensitivity , serology has been proposed as a screening measure , because the presence of antibodies would detect previously undiagnosed cases of coeliac disease and prevent its complications in those people . There is significant debate as to the benefits of screening . Some studies suggest that early detection would decrease the risk of osteoporosis and anaemia . In contrast , a cohort study in Cambridge suggested that people with undetected coeliac disease had a beneficial risk profile for cardiovascular disease ( less overweight , lower cholesterol levels ) . There is limited evidence that screen-detected cases benefit from a diagnosis in terms of morbidity and mortality ; hence , population-level screening is not presently thought to be beneficial . In the United Kingdom , the National Institute for Health and Clinical Excellence ( NICE ) recommends screening for coeliac disease in people with newly diagnosed chronic fatigue syndrome and irritable bowel syndrome , as well as in type 1 diabetics , especially those with insufficient weight gain or unexplained weight loss . It is also recommended in autoimmune thyroid disease , dermatitis herpetiformis , and in the first-degree relatives of those with confirmed coeliac disease . There is a large number of scenarios where testing for coeliac disease may be offered given previously described associations , such as the conditions mentioned above in miscellaneous . # Treatment # # Diet # At present , the only effective treatment is a lifelong gluten-free diet . No medication exists that will prevent damage or prevent the body from attacking the gut when gluten is present . Strict adherence to the diet allows the intestines to heal , leading to resolution of all symptoms in most cases and , depending on how soon the diet is begun , can also eliminate the heightened risk of osteoporosis and intestinal cancer and in some cases sterility . The diet can be cumbersome ; failure to comply with the diet may cause relapse . Dietitian input is generally requested to ensure the person is aware which foods contain gluten , which foods are safe , and how to have a balanced diet despite the limitations . In many countries , gluten-free products are available on prescription and may be reimbursed by health insurance plans . Gluten-free products are usually more expensive and harder to find than common gluten-containing foods . Since ready-made products often contain traces of gluten , some coeliacs may find it necessary to cook from scratch . The term ' ' gluten-free ' ' is generally used to indicate a supposed harmless level of gluten rather than a complete absence . The exact level at which gluten is harmless is uncertain and controversial . A recent systematic review tentatively concluded that consumption of less than 10 mg of gluten per day is unlikely to cause histological abnormalities , although it noted that few reliable studies had been done . Regulation of the label ' ' gluten-free ' ' varies . In the European Union , the European Commission issued regulations in 2009 limiting the use of gluten-free labels for food products to those with less than 20 mg/kg of gluten , and very low gluten labels for those with less than 100 mg/kg . In the United States , the FDA issued regulations in 2013 limiting the use of gluten-free labels for food products to those with less than 20 ppm of gluten . The current international Codex Alimentarius standard allows for 20 ppm of gluten in so-called gluten-free foods . Several organisations , such as the Gluten-Free Certification Organization ( GFCO ) , the Celiac Sprue Association ( CSA ) , and the National Foundation for Celiac Awareness ( NFCA ) , also certify products and companies as gluten-free . Even while on a diet , health-related quality of life ( HRQOL ) may be lower in people with coeliac disease . Studies in the United States have found that quality of life becomes comparable to the general population after staying on the diet , while studies in Europe have found that quality of life remains lower , although the surveys are not quite the same . Men tend to report more improvement than women . Some have persisting digestive symptoms or dermatitis herpetiformis , mouth ulcers , osteoporosis and resultant fractures . Symptoms suggestive of irritable bowel syndrome may be present , and there is an increased rate of anxiety , fatigue , dyspepsia and musculoskeletal pain . # Refractory disease # A small minority of people suffer from refractory disease , which means they do not improve on a gluten-free diet . This may be because the disease has been present for so long that the intestines are no longer able to heal on diet alone , or because the person is not adhering to the diet , or because the person is consuming foods that are inadvertently contaminated with gluten . If alternative causes have been eliminated , steroids or immunosuppressants ( such as azathioprine ) may be considered in this scenario . # Epidemiology # The disease is thought to affect between 1 in 1750 ( defined as clinical disease including dermatitis herpetiformis with limited digestive tract symptoms ) to 1 in 105 ( defined by presence of IgA TG in blood donors ) people in the United States . The prevalence of clinically diagnosed disease ( symptoms prompting diagnostic testing ) is 0.050.27% in various studies . However , population studies from parts of Europe , India , South America , Australasia and the USA ( using serology and biopsy ) indicate that the prevalence may be between 0.33 and 1.06% in children ( but 5.66% in one study of children of the predisposed Sahrawi people ) and 0.181.2% in adults . Among those in primary care populations who report gastrointestinal symptoms , the prevalence of coeliac disease is about 3% . The prevalence amongst adult blood donors in Iran , Israel , Saudi Arabia and Turkey is 0.60% , 0.64% , 1.61% , 1.15% and 1.0% , respectively . People of African , Japanese and Chinese descent are rarely diagnosed ; this reflects a much lower prevalence of the genetic risk factors , such as HLA-B8 . People of Indian ancestry seem to have a similar risk to those of Western Caucasian ancestry . Population studies also indicate that a large proportion of coeliacs remain undiagnosed ; this is due , in part , to many clinicians being unfamiliar with the condition and also do to the fact it can be asymptomatic . Coeliac disease is slightly more prevalent in women than in men . A large multicentre study in the U.S. found a prevalence of 0.75% in not-at-risk groups , rising to 1.8% in symptomatic people , 2.6% in second-degree relatives ( like grandparents , aunt or uncle , grandchildren , etc. ) of a person with coeliac disease and 4.5% in first-degree relatives ( siblings , parents or children ) . This profile is similar to the prevalence in Europe . Other populations at increased risk for coeliac disease , with prevalence rates ranging from 5% to 10% , include individuals with Down and Turner syndromes , type 1 diabetes , and autoimmune thyroid disease , including both hyperthyroidism ( overactive thyroid ) and hypothyroidism ( underactive thyroid ) . Historically , coeliac disease was thought to be rare , with a prevalence of about 0.02% . Recent increases in the number of reported cases may be due to changes in diagnostic practice . # Social and culture # # Christian churches and the Eucharist # Speaking generally , the various denominations of Christians celebrate a Eucharist in which a wafer or small piece of wheat bread is blessed and then eaten ( see Sacramental bread ) . A typical wafer weighs about half a gram . Wheat flour contains around 10 to 13% gluten , so a single communion wafer may have more than 50 mg of gluten , an amount which will harm the health of many people with coeliac especially if consumed every day ( see Diet above ) . Many Christian churches offer their communicants gluten-free alternatives , usually in the form of a rice-based cracker or gluten-free bread . These include the United Methodist Church # #Roman Catholic position# # Roman Catholic doctrine states that for a valid Eucharist , the bread to be used at Mass must be made from wheat . In 2002 , the Congregation for the Doctrine of the Faith approved German-made low-gluten hosts , which meets all of the Catholic Church 's requirements , for use in Italy ; although not entirely gluten-free , they were also approved by the Italian Celiac Association . Some Catholic coeliac sufferers have requested permission to use rice wafers ; such petitions have always been denied . As according to Catholic doctrine , Christ is present whole and entire body , blood , soul and divinity under either species , there is always the option to receive under the species of wine only . ( As the general practice for the congregation is to communicate under the species of bread alone , only excepting the occasions where there is Communion under both species , wine alone is an option for people suffering from celiac disease only . If there is no general distribution of the Chalice , the priest must be approached to make it possible in a special manner . ) The issue is more complex for priests . As a celebrant , a priest is , for the fullness of the sacrifice of the Mass , absolutely required to receive under both species . On 24 July 2003 , the Congregation for the Doctrine of the Faith stated , Given the centrality of the celebration of the Eucharist in the life of a priest , one must proceed with great caution before admitting to Holy Orders those candidates unable to ingest gluten or alcohol without serious harm . By January 2004 , extremely low-gluten Church-approved hosts had become available in the United States , Italy and Australia . # Passover # The Jewish festival of Pesach ( Passover ) may present problems with its obligation to eat matzo , which is unleavened bread made in a strictly controlled manner from wheat , barley , spelt , oats , or rye . This rules out many other grains that are normally used as substitutes for people with gluten sensitivity , especially for Ashkenazi Jews , who also avoid rice . Many kosher-for-Passover products avoid grains altogether and are therefore gluten-free . Potato starch is the primary starch used to replace the grains . Consuming matzo is mandatory on the first night of Pesach only . Jewish law holds that one should not seriously endanger one 's health in order to fulfil a commandment . Thus , a person with severe coeliac disease is not allowed , let alone required , to eat any matzo other than gluten-free matzo . The most commonly used gluten-free matzo is made from oats . # Research directions # Various other approaches are being studied that would reduce the need of dieting . All are still under development , and are not expected to be available to the general public for a while . Using genetically engineered wheat species , or wheat species that have been selectively bred to be minimally immunogenic , may allow the consumption of wheat . This , however , could interfere with the effects that gliadin has on the quality of dough . Alternatively , gluten exposure can be minimised by the ingestion of a combination of enzymes ( prolyl endopeptidase and a barley glutamine-specific cysteine endopeptidase ( EP-B2 ) that degrade the putative 33-mer peptide in the duodenum . Alternative treatments under investigation include the inhibition of zonulin , an endogenous signalling protein linked to increased permeability of the bowel wall and hence increased presentation of gliadin to the immune system , and other modifiers of other well-understood steps in the pathogenesis of coeliac disease , such as the action of HLA-DQ2 or tissue transglutaminase and the MICA/NKG2D interaction that may be involved in the killing of enterocytes. # History # Humans first started to cultivate grains in the Neolithic period ( beginning about 9500 BCE ) in the Fertile Crescent in Western Asia , and it is likely that coeliac disease did not occur before this time . Aretaeus of Cappadocia , living in the second century in the same area , recorded a malabsorptive syndrome with chronic diarrhoea , causing a debilitation of the whole body . His Cliac Affection ( ' ' coeliac ' ' from Greek ' ' koiliakos ' ' , abdominal ) gained the attention of Western medicine when Francis Adams presented a translation of Aretaeus 's work at the Sydenham Society in 1856 . The patient described in Aretaeus ' work had stomach pain and was atrophied , pale , feeble and incapable of work . The diarrhoea manifested as loose stools that were white , malodorous and flatulent , and the disease was intractable and liable to periodic return . The problem , Aretaeus believed , was a lack of heat in the stomach necessary to digest the food and a reduced ability to distribute the digestive products throughout the body , this incomplete digestion resulting in the diarrhoea . He regarded this as an affliction of the old and more commonly affecting women , explicitly excluding children . The cause , according to Aretaeus , was sometimes either another chronic disease or even consuming a copious draught of cold water . The paediatrician Samuel Gee gave the first modern-day description of the condition in children in a lecture at Hospital for Sick Children , Great Ormond Street , London , in 1887 . Gee acknowledged earlier descriptions and terms for the disease and adopted the same term as Aretaeus ( coeliac disease ) . He perceptively stated : If the patient can be cured at all , it must be by means of diet . Gee recognised that milk intolerance is a problem with coeliac children and that highly starched foods should be avoided . However , he forbade rice , sago , fruit and vegetables , which all would have been safe to eat , and he recommended raw meat as well as thin slices of toasted bread . Gee highlighted particular success with a child who was fed upon a quart of the best Dutch mussels daily . However , the child could not bear this diet for more than one season . Christian Archibald Herter , an American physician , wrote a book in 1908 on children with coeliac disease , which he called intestinal infantilism . He noted their growth was retarded and that fat was better tolerated than carbohydrate . The eponym ' ' Gee-Herter disease ' ' was sometimes used to acknowledge both contributions . Sidney V. Haas , an American paediatrician , reported positive effects of a diet of bananas in 1924 . This diet remained in vogue until the actual cause of coeliac disease was determined . While a role for carbohydrates had been suspected , the link with wheat was not made until the 1940s by the Dutch paediatrician Dr. Willem Karel Dicke . It is likely that clinical improvement of his patients during the Dutch famine of 1944 ( during which flour was scarce ) may have contributed to his discovery . Dicke noticed that the shortage of bread led to a significant drop in the death rate among children affected by CD from greater than 35% to essentially zero . He also reported that once wheat was again available after the conflict , the mortality rate soared to previous levels . The link with the gluten component of wheat was made in 1952 by a team from Birmingham , England . Villous atrophy was described by British physician John W. Paulley in 1954 on samples taken at surgery . This paved the way for biopsy samples taken by endoscopy . Throughout the 1960s , other features of coeliac disease were elucidated . Its hereditary character was recognised in 1965 . In 1966 , dermatitis herpetiformis was linked to gluten sensitivity . May has been designated as Coeliac Awareness Month . 
@@80381 Health is the level of functional or metabolic efficiency of a living organism . In humans , it is the general condition of a person 's mind and body , usually meaning to be free from illness , injury or pain ( as in ' ' good health ' ' or ' ' healthy ' ' ) . The World Health Organization ( WHO ) defined health in its broader sense in 1946 as a state of complete physical , mental , and social well-being and not merely the absence of disease or infirmity . Although this definition has been subject to controversy , in particular as lacking operational value and because of the problem created by use of the word complete , it remains the most enduring . Other definitions have been proposed , among which a recent definition that correlates health and personal satisfaction . Classification systems such as the WHO Family of International Classifications , including the International Classification of Functioning , Disability and Health ( ICF ) and the International Classification of Diseases ( ICD ) , are commonly used to define and measure the components of health . Systematic activities to prevent or cure health problems and promote good health in humans are undertaken by health care providers . Applications with regard to animal health are covered by the veterinary sciences . The term healthy is also widely used in the context of many types of non-living organizations and their impacts for the benefit of humans , such as in the sense of healthy communities , healthy cities or healthy environments . In addition to health care interventions and a person 's surroundings , a number of other factors are known to influence the health status of individuals , including their background , lifestyle , and economic , social conditions , and spirituality ; these are referred to as determinants of health . Studies have shown that high levels of stress can affect your health . # Determinants # Generally , the context in which an individual lives is of great importance for both his health status and quality of life . It is increasingly recognized that health is maintained and improved not only through the advancement and application of health science , but also through the efforts and intelligent lifestyle choices of the individual and society . According to the World Health Organization , the main determinants of health include the social and economic environment , the physical environment , and the person 's individual characteristics and behaviors . More specifically , key factors that have been found to influence whether people are healthy or unhealthy include the following :  Income and social status  Social support networks  Education and literacy  Employment/working conditions  Social environments  Physical environments  Personal health practices and coping skills  Healthy child development  Biology and genetics  Health care services  Gender  Culture An increasing number of studies and reports from different organizations and contexts examine the linkages between health and different factors , including lifestyles , environments , health care organization , and health policy such as the 1974 Lalonde report from Canada ; the Alameda County Study in California ; and the series of World Health Reports of the World Health Organization , which focuses on global health issues including access to health care and improving public health outcomes , especially in developing countries . The concept of the ' ' health field , ' ' as distinct from medical care , emerged from the Lalonde report from Canada . The report identified three interdependent fields as key determinants of an individual 's health . These are :  Lifestyle : the aggregation of personal decisions ( i.e. , over which the individual has control ) that can be said to contribute to , or cause , illness or death ;  Environmental : all matters related to health external to the human body and over which the individual has little or no control ;  Biomedical : all aspects of health , physical and mental , developed within the human body as influenced by genetic make-up . The maintenance and promotion of health is achieved through different combination of physical , mental , and social well-being , together sometimes referred to as the ' ' health triangle . ' ' The WHO 's 1986 ' ' Ottawa Charter for Health Promotion ' ' further stated that health is not just a state , but also a resource for everyday life , not the objective of living . Health is a positive concept emphasizing social and personal resources , as well as physical capacities . Focusing more on lifestyle issues and their relationships with functional health , data from the Alameda County Study suggested that people can improve their health via exercise , enough sleep , maintaining a healthy body weight , limiting alcohol use , and avoiding smoking . The ability to ' ' adapt ' ' and to ' ' self manage ' ' have been suggested as core components of human health . The environment is often cited as an important factor influencing the health status of individuals . This includes characteristics of the natural environment , the built environment , and the social environment . Factors such as clean water and air , adequate housing , and safe communities and roads all have been found to contribute to good health , especially to the health of infants and children . Some studies have shown that a lack of neighborhood recreational spaces including natural environment leads to lower levels of personal satisfaction and higher levels of obesity , linked to lower overall health and well being . This suggests that the positive health benefits of natural space in urban neighborhoods should be taken into account in public policy and land use . Genetics , or inherited traits from parents , also play a role in determining the health status of individuals and populations . This can encompass both the predisposition to certain diseases and health conditions , as well as the habits and behaviors individuals develop through the lifestyle of their families . For example , genetics may play a role in the manner in which people cope with stress , either mental , emotional or physical . For example , obesity is a very large problem in the United States that contributes to bad mental health and causes stress in a lot of people 's lives . ( One difficulty is the issue raised by the debate over the relative strengths of genetics and other factors ; interactions between genetics and environment may be of particular importance. ) # Potential issues # There are a lot of types of health issues common with many people across the globe . Disease is one of the most common . According to GlobalIssues.org , approximately 36 million people die each year from non-communicable ( not contagious ) disease including cardiovascular disease cancer , diabetes , and chronic lung disease ( Shah , 2014 ) . As for communicable diseases , both viral and bacterial , AIDS/HIV , tuberculosis , and malaria are the most common also causing millions of deaths every year ( 2014 ) . Another health issue that causes death or contributes to other health problems is malnutrition . One of the groups malnutrition affects most is young children . Approximately 7.5 million children under the age of 5 die from malnutrition , and it is usually brought on by not having the money to find or make food ( 2014 ) . Bodily injuries are also a common health issue worldwide . These injuries , including broken bones , fractures , and burns can reduce a persons quality of life or can cause fatalities including infections that resulted from the injury or the severity injury in general ( Moffett , 2013 ) . Some contributing factors to poor health are lifestyle choices . These include smoking cigarettes , which according to LIVESTRONG.com kills 443,000 people each year ( 2013 ) . It also can include a poor diet , whether it is overeating or an overly constrictive diet . Inactivity can also contribute to health issues and also a lack of sleep , excessive alcohol consumption , and neglect of oral hygiene ( 2013 ) . There are also genetic disorders that are inherited by the person and can vary in how much the affect the person and when they surface ( 2013 ) . The one health issue that is the most unfortunate because the majority of these health issues are preventable is that approximately 1 billion people lack access to health care systems ( Shah , 2014 ) . It is easy to say that the most common and harmful health issue is that a lot of people do not have access to quality remedies . # Mental health # The World Health Organization describes mental health as a state of well-being in which the individual realizes his or her own abilities , can cope with the normal stresses of life , can work productively and fruitfully , and is able to make a contribution to his or her community . Mental Health is not just the absence of mental illness . Mental illness is described as ' the spectrum of cognitive , emotional , and behavioural conditions that interfere with social and emotional well-being and the lives and productivity of people . Having a mental illness can seriously impair , temporarily or permanently , the mental functioning of a person . Other terms include : ' mental health problem ' , ' illness ' , ' disorder ' , ' dysfunction ' . ( Hungerford et al . 2012 ) . Roughly a quarter of all adults 18 and over in the US suffer from a diagnosable mental illness . Mental illnesses are the leading cause of disability in the US and Canada . Examples include , schizophrenia , ADHD , major depressive disorder , bipolar disorder , anxiety disorder , post-traumatic stress disorder and autism . Many teens suffer from mental health issues in response to the pressures of society and social problems they encounter . Some of the key mental health issues seen in teens are : depression , eating disorders , and drug abuse . There are many ways to prevent these health issues from occurring such as communicating well with your child or a teen suffering from mental health issues . Also , remember that mental health can be treated and be attentive to your child 's behavior. # Maintaining health # Achieving and maintaining health is an ongoing process , shaped by both the evolution of health care knowledge and practices as well as personal strategies and organized interventions for staying healthy known as Lifestyle Management . # Diet # An important way to maintain your personal health is to have a healthy diet . A healthy diet includes a variety of plant-based and animal-based foods that provide nutrients to your body . Such nutrients give you energy and keep your body running . Nutrients help build and strengthen bones , muscles , and tendons and also regulate body processes ( i.e. blood pressure ) . The food guide pyramid is a pyramid-shaped guide of healthy foods divided into sections . Each section shows the recommended intake for each food group ( i.e. Protein , Fat , Carbohydrates , and Sugars ) . Making healthy food choices is important because it can lower your risk of heart disease , developing some types of cancer , and it will contribute to maintaining a healthy weight . # Role of science # Health science is the branch of science focused on health . There are two main approaches to health science : the study and research of the body and health-related issues to understand how humans ( and animals ) function , and the application of that knowledge to improve health and to prevent and cure diseases and other physical and mental impairments . The science builds on many sub-fields , including biology , biochemistry , physics , epidemiology , pharmacology , medical sociology . Applied health sciences endeavor to better understand and improve human health through applications in areas such as health education , biomedical engineering , biotechnology and public health . Organized interventions to improve health based on the principles and procedures developed through the health sciences are provided by practitioners trained in medicine , nursing , nutrition , pharmacy , social work , psychology , occupational therapy , physical therapy and other health care professions . Clinical practitioners focus mainly on the health of individuals , while public health practitioners consider the overall health of communities and populations . Workplace wellness programs are increasingly adopted by companies for their value in improving the health and well-being of their employees , as are school health services in order to improve the health and well-being of children . # Role of public health # Public health has been described as the science and art of preventing disease , prolonging life and promoting health through the organized efforts and informed choices of society , organizations , public and private , communities and individuals . It is concerned with threats to the overall health of a community based on population health analysis . The population in question can be as small as a handful of people or as large as all the inhabitants of several continents ( for instance , in the case of a pandemic ) . Public health has many sub-fields , but typically includes the interdisciplinary categories of epidemiology , biostatistics and health services . Environmental health , community health , behavioral health , and occupational health are also important areas of public health . The focus of public health interventions is to prevent and manage diseases , injuries and other health conditions through surveillance of cases and the promotion of healthy behavior , communities , and ( in aspects relevant to human health ) environments . Its aim is to prevent health problems from happening or re-occurring by implementing educational programs , developing policies , administering services and conducting research . In many cases , treating a disease or controlling a pathogen can be vital to preventing it in others , such as during an outbreak . Vaccination programs and distribution of condoms to prevent the spread of communicable diseases are examples of common preventive public health measures , as are educational campaigns to promote vaccination and the use of condoms ( including overcoming resistance to such ) . Public health also takes various actions to limit the health disparities between different areas of the country and , in some cases , the continent or world . One issue is the access of individuals and communities to health care in terms of financial , geographical or socio-cultural constraints to accessing and using services . Applications of the public health system include the areas of maternal and child health , health services administration , emergency response , and prevention and control of infectious and chronic diseases . The great positive impact of public health programs is widely acknowledged . Due in part to the policies and actions developed through public health , the 20th century registered a decrease in the mortality rates for infants and children and a continual increase in life expectancy in most parts of the world . For example , it is estimated that life expectancy has increased for Americans by thirty years since 1900 , and worldwide by six years since 1990. # Self-care strategies # Personal health depends partially on the active , passive , and assisted cues people observe and adopt about their own health . These include personal actions for preventing or minimizing the effects of a disease , usually a chronic condition , through integrative care . They also include personal hygiene practices to prevent infection and illness , such as bathing and washing hands with soap ; brushing and flossing teeth ; storing , preparing and handling food safely ; and many others . The information gleaned from personal observations of daily living such as about sleep patterns , exercise behavior , nutritional intake and environmental features may be used to inform personal decisions and actions ( ' ' e.g. ' ' , I feel tired in the morning so I am going to try sleeping on a different pillow ) , as well as clinical decisions and treatment plans ( ' ' e.g. ' ' , a patient who notices his or her shoes are tighter than usual may be having exacerbation of left-sided heart failure , and may require diuretic medication to reduce fluid overload ) . Personal health also depends partially on the social structure of a person 's life . The maintenance of strong social relationships , volunteering , and other social activities have been linked to positive mental health and also increased longevity . One American study among seniors over age 70 , found that frequent volunteering was associated with reduced risk of dying compared with older persons who did not volunteer , regardless of physical health status . Another study from Singapore reported that volunteering retirees had significantly better cognitive performance scores , fewer depressive symptoms , and better mental well-being and life satisfaction than non-volunteering retirees . Prolonged psychological stress may negatively impact health , and has been cited as a factor in cognitive impairment with aging , depressive illness , and expression of disease . Stress management is the application of methods to either reduce stress or increase tolerance to stress . Relaxation techniques are physical methods used to relieve stress . Psychological methods include cognitive therapy , meditation , and positive thinking , which work by reducing response to stress . Improving relevant skills , such as problem solving and time management skills , reduces uncertainty and builds confidence , which also reduces the reaction to stress-causing situations where those skills are applicable . # Occupational health # In addition to safety risks , many jobs also present risks of disease , illness and other long-term health problems . Among the most common occupational diseases are various forms of pneumoconiosis , including silicosis and coal worker 's pneumoconiosis ( black lung disease ) . Asthma is another respiratory illness that many workers are vulnerable to . Workers may also be vulnerable to skin diseases , including eczema , dermatitis , urticaria , sunburn , and skin cancer . Other occupational diseases of concern include carpal tunnel syndrome and lead poisoning . As the number of service sector jobs has risen in developed countries , more and more jobs have become sedentary , presenting a different array of health problems than those associated with manufacturing and the primary sector . Contemporary problems such as the growing rate of obesity and issues relating to stress and overwork in many countries have further complicated the interaction between work and health . Many governments view occupational health as a social challenge and have formed public organizations to ensure the health and safety of workers . Examples of these include the British Health and Safety Executive and in the United States , the National Institute for Occupational Safety and Health , which conducts research on occupational health and safety , and the Occupational Safety and Health Administration , which handles regulation and policy relating to worker safety and health . 
@@173098 Dutch elm disease ( DED ) is caused by a member of the sac fungi ( Ascomycota ) affecting elm trees , and is spread by the elm bark beetle . Although believed to be originally native to Asia , the disease has been accidentally introduced into America and Europe , where it has devastated native populations of elms which had not had the opportunity to evolve resistance to the disease . The name Dutch elm disease refers to its identification in 1921 and later in the Netherlands by Dutch phytopathologists Bea Schwarz and Christine Buisman who both worked with Professor Johanna Westerdijk . The disease is not specific to the Dutch elm hybrid . # Overview # The causative agents of DED are ascomycete microfungi . Three species are now recognized :  ' ' Ophiostoma ulmi ' ' , which afflicted Europe from 1910 , reaching North America on imported timber in 1928.  ' ' Ophiostoma himal-ulmi ' ' , a species endemic to the western Himalaya .  ' ' Ophiostoma novo-ulmi ' ' , an extremely virulent species which was first described in Europe and North America in the 1940s and has devastated elms in both areas since the late 1960s . The origin of ' ' O. novo-ulmi ' ' remains unknown ; it was widely believed to have originated in China , but a comprehensive survey there in 1986 found no trace of it , although elm bark beetles were very common . DED is spread in North America by three species of bark beetles ( Family : Curculionidae , Subfamily : Scolytinae ) : The native elm bark beetle , ' ' Hylurgopinus rufipes ' ' . The European elm bark beetle , ' ' Scolytus multistriatus ' ' . The banded elm bark beetle , ' ' Scolytus schevyrewi ' ' . In Europe , while ' ' S. multistriatus ' ' again acts as vector for infection , it is much less effective than the large elm bark beetle , ' ' S. scolytus ' ' . ' ' H. rufipes ' ' can be a vector for the disease , but is inefficient compared to the other vectors . ' ' S. schevyrewi ' ' was found in 2003 in Colorado and Utah . # Mechanism # In an attempt to block the fungus from spreading farther , the tree reacts by plugging its own xylem tissue with gum and tyloses , bladder-like extensions of the xylem cell wall . As the xylem ( one of the two types of vascular tissue produced by the vascular cambium , the other being the phloem ) delivers water and nutrients to the rest of the plant , these plugs prevent them from travelling up the trunk of the tree , eventually killing it . ( Xylem comprises the bulk of the hard tissue of the interior of trunks and branches of woody plants and is nearly synonymous with wood . Phloem can be thought of as a thin sheet of tissue wrapped around the central cylinder of xylem , although just beneath the phloem is another thin sheet , the vascular cambium , which produces both phloem and xylem. ) # Symptoms # The first symptom of infection is usually an upper branch of the tree with leaves starting to wither and yellow in summer , months before the normal autumnal leaf shedding . This progressively spreads to the rest of the tree , with further dieback of branches . Eventually , the roots die , starved of nutrients from the leaves . Often , not all the roots die : the roots of some species , notably the English elm ' ' Ulmus procera ' ' , put up suckers which flourish for approximately 15 years , after which they too succumb . # Disease range # # Europe # Dutch elm disease was first noticed in Europe in 1910 , and spread slowly , reaching Britain in 1927 and eventually extending to all other countries in Europe except Greece and Finland . This first strain was a relatively mild one , which killed only a small proportion of elms , more often just killing a few branches , and had largely died out by 1940 owing to its susceptibility to viruses . The disease was isolated in The Netherlands in 1921 by Bea Schwarz , a pioneering Dutch phytopathologist , and this discovery would lend the disease its name . Circa 1967 , a new , far more virulent strain arrived in Britain on a shipment of Rock Elm ' ' U. thomasii ' ' logs from North America , and this strain proved both highly contagious and lethal to European elms ; more than 25 million trees have died in the UK alone , while France has lost over 90% of her elms . The disease is still migrating northwards through Scotland , reaching Edinburgh in the late 1970s , and Inverness in 2006 . By 1990 , very few mature elms were left in Britain or much of continental Europe . One of the most distinctive English countryside trees ( See John Constable 's painting ' ' Salisbury Cathedral from the South-West ' ' ) , the English elm ' ' U. procera ' ' <small> Salisb. </small> , is particularly susceptible . Thirty years after the outbreak of the epidemic , nearly all these trees , which often grew to more than 45 m high , are gone . The species still survives in hedgerows , as the roots are not killed and send up root sprouts ( suckers ) . These suckers rarely reach more than 5 m tall before succumbing to a new attack of the fungus . However , established hedges kept low by clipping have remained apparently healthy throughout the nearly 40 years since the onset of the disease in the UK . The largest concentrations of mature elms in Europe are now in Amsterdam and The Hague . In 2005 , Amsterdam was declared the ' Elm City of Europe ' : the citys streets and canals are lined with at least 75,000 elms , including several generations of research-elms ( see below : Resistant trees ) . Some 30,000 of the 100,000 mature trees in The Hague are elms , planted because of their tolerance of salty sea-winds . Since the 1990s , a programme of antifungal injections of the most prominent 10,000 elms , and of sanitation felling , has reduced annual elm losses in The Hague from 7% to less than 1% ( see below : Preventive treatment ) . The losses are made up by the planting of disease-resistant cultivars . The largest concentration of mature elm trees remaining in England is in Brighton and Hove , East Sussex , where of the 30,000 elms in 1983 15,000 still stand ( 2005 figures ) , several of which are estimated to be over 400 years old . Their survival is owing to the isolation of the area , between the English Channel and the South Downs , and the assiduous efforts of local authorities to identify and remove infected sections of trees immediately when they show symptoms of the disease . Empowered by the Dutch Elm Disease ( Local Authorities ) ( Amendment ) Order 1988 , local authorities may order the destruction of any infected trees or timber , although in practice they usually do it themselves , successfully reducing the numbers of elm bark beetle ' ' Scolytus ' ' spp. , the vector of elm disease . Sanitary felling has also , to date , preserved most of the 250,000 elms on the Isle of Man . The largest concentration of mature elms in Scotland is in Edinburgh , where over 5000 mature elms still stand ( 2009 figures ) out of some 35,000 in 1976 . Edinburgh 's Leith Links has the highest concentration of mature elms of any U.K. park ( 2012 ) . A policy of sanitary felling has kept losses in the city to an average of 1000 a year . Elm was the commonest tree in Paris from the 17th century ; before the 1970s there were some 30,000 ' ' ormes parisiens ' ' . Today , only 1000 mature elms survive in the city , including examples in the large avenues ( Avenue d'Italie , Avenue de Choisy , Boulevard Lefebvre , Boulevard de Grenelle , Boulevard Garibaldi ) and two very old specimens , one in the garden of the Tuileries in front of the l'Orangerie and another in the Place Saint-Gervais in front of l'htel de ville de Paris . Losses are now being made up with disease-resistant cultivars , especially the Dutch-French research elm ' Nanguen ' ( <tt> Lutce ) , named after the city . # North America # The disease was first reported in the United States in 1928 , with the beetles believed to have arrived in a shipment of logs from The Netherlands destined for use as veneer in the Ohio furniture industry . The disease spread slowly from New England westward and southward , almost completely destroying the famous elms in the ' Elm City ' of New Haven , reaching the Detroit area in 1950 , the Chicago area by 1960 , and Minneapolis by 1970 . Of the estimated 77 million elms in North America in 1930 , over 75% had been lost by 1989 . Dutch elm disease reached eastern Canada during the Second World War , and spread to Ontario in 1967 , Manitoba in 1975 and Saskatchewan in 1981 . In Toronto , 80% of the elm trees have been lost to Dutch elm disease ; many more fell victim in Ottawa , Montreal and other cities during the 1970s and 1980s . Quebec City still has about 21,000 elms , thanks to a prevention program initiated in 1981 . Alberta and British Columbia are the only provinces that are currently free of Dutch elm disease , although , in an isolated case , an elm tree in southeastern Alberta found diseased in 1998 was immediately destroyed . Today , Alberta has the largest number of elms unaffected by Dutch elm disease in the world The largest surviving urban forest of elm trees in North America is believed to be in the city of Winnipeg , Manitoba , where close to 200,000 elms remain at least double that of Amsterdam , the Elm City of Europe . The city of Winnipeg spends $3 million annually to aggressively combat the disease using Dursban Turf and the Dutch Trig vaccine , losing 15004000 trees per year . # New Zealand # Dutch elm disease has reached New Zealand . It was found in Napier where it was eradicated and was also found in the Auckland Region in 1989 . The Ministry of Agriculture funded a national management programme but it was cancelled to allow more funds to be available for pests of a higher priority . A major outbreak occurred in New Zealand in July 2013 , particularly at the site of Kingseat Hospital . # Preventive treatment # # Mechanical # The first attempts to control Dutch elm disease consisted of pruning trees to remove and burn diseased timber . While this method was effective in New York State and adjacent areas , its cost made it uneconomical except in large cities where elms were considered valuable attractions . # Chemical # When Dutch elm disease spread away from the Atlantic coast , control focused on controlling the bark beetle by means of such insecticides as DDT and dieldrin , which were sprayed heavily across all parts of elm trees , usually twice a year in the spring and again at a lower concentration in the summer . In its early years it was generally thought by observers that pesticides did slow the spread of the disease across the United States but as early as 1947 concern was raised that many bird species were killed in large numbers via ingesting poisoned invertebrates . In areas sprayed during the 1950s local people observed birds such as the American Woodcock , American Robin , White-breasted Nuthatch , Brown Creeper and various ' ' Poecile ' ' species dying . Biologist Rachel Carson consequently argued against spraying elms and for improved sanitation , which she saw as having been more effective in areas with earlier and greater experience countering Dutch elm disease . Although modern critics of Carson have argued that the bird deaths were caused by other factors such as mercury poisoning in the soil , spraying against elm bark beetles declined very rapidly after 1962 , a trend aided by fungicides without dangerous side-effects being discovered for the first time after many years of research . Lignasan BLP ( carbendazim phosphate ) , introduced in the 1970s , was the first fungicide used to control Dutch elm disease . This had to be injected into the base of the tree using specialized equipment , and was never especially effective . It is still sold under the name Elm Fungicide . Arbotect ( thiabendazole hypophosphite ) became available some years later , and it has been proven effective . Arbotect must be injected every two to three years to provide ongoing control ; the disease generally can not be eradicated once a tree is infected . There is a process called tracing that was invented by Rainbow Treecare in Minneapolis . It has proven to be effective at saving infected elms as long as the Dutch elm disease fungus has not grown into the roots . Arbotect is not effective on root graft infections from adjacent elm trees . It is more than 99.5% effective for three years from beetle infections , which is the primary mode of tree infection . Alamo ( propiconazole ) has become available more recently , though several university studies show it to be effective for only the current season it is injected . Alamo is primarily recommended for treatment of oak wilt . Multistriatin is a pheromone produced by females elm bark beetles , which can be produced synthetically . It has potential in being to used to trap male beetles , which carry the fungus . # Biological # Because of the ban on the use of chemicals on street and park trees in the Netherlands , the University of Amsterdam developed a biological vaccine by the late 1980s . Dutch Trig is nonchemical and nontoxic , consisting of a suspension in distilled water of spores of a strain of the fungus ' ' Verticillium albo-atrum ' ' that has lost much of its pathogenic capabilities , injected in the elm in spring . The strain is believed to have enough pathogenicity left to induce an immune response in the elm , protecting it against DED during one growing season . This is called induced resistance . Trials with the American elm have been very successful ; in a six-year experiment with the American elm in Denver , CO , annual Dutch elm disease losses declined significantly after the first year from seven to between 0.4 and 0.6 per cent ; a greater and more rapid reduction in disease incidence than the accompanying tree sanitation and plant health care programs . Preventive treatment is usually only justified when a tree has unusual symbolic value or occupies a particularly important place in the landscape . # Resistant trees # Research to select resistant cultivars and varieties began in the Netherlands in 1928 , followed by the USA in 1937 . Initial efforts in the Netherlands involved crossing varieties of ' ' U. minor ' ' and ' ' U. glabra ' ' , but later included the Himalayan or Kashmir elm ' ' U. wallichiana ' ' as a source of antifungal genes . Early efforts in the USA involved the hybridization of the Siberian elm ' ' U. pumila ' ' with American red elm ' ' U. rubra ' ' to produce resistant trees . Resulting cultivars lacked the traditional shape and landscape value of the American elm ; few were planted . In 2005 , the National Elm Trial ( USA ) began a 10-year evaluation of 19 cultivars in plantings across the United States . The trees in the trial are exclusively American developments ; no European cultivars have been included . Recent research in Sweden has established that early-flushing clones are less susceptible to DED owing to an asynchrony between DED susceptibility and infection . # Testing for disease resistance # Elms are tested for resistance by inoculation with the fungal pathogen in late May when the tree 's growth is at its annual peak . Clones raised for testing are grown to an age of 3 or 4 years . In Europe , the inoculum is introduced into the cambium by a knife wound . However this method , developed in the Netherlands , was considered too severe in America , where the principal disease vector is the bark beetle ' ' Scolytus multistriatus ' ' , a far less effective vector than the larger beetle endemic to Europe , ' ' Scolytus scolytus ' ' , which is unknown in America . In the method devised by the USDA , the inoculum is introduced to the cambium via a 2 mm-diameter hole drilled through the bark in the lower third of the tree . This method was further refined by the University of Wisconsin team , which drilled holes in the branches to simulate natural infection by the bark beetles feeding in the twig crotches , but results from this method were found to exaggerate the genetic resistance of the host . Consequently , tests were conducted on specimens in a controlled environment , either in greenhouses or customized plant chambers , facilitating more accurate evaluation of both internal and external symptoms of disease . Another variable is the composition of the inoculum ; while an inoculum strength of 10 <sup> 6 </sup> spores / ml is standard in both continents , its composition reflects the different ' ' Ophiostoma ' ' species , subspecies and hybrids endemic to the two continents . In Italy for example , two subspecies , ' ' americana ' ' and ' ' novo-ulmi ' ' , are present together with their hybrid , whereas in North America , ssp. ' ' novo-ulmi ' ' is unknown . The differences in method and inocula possibly explain why the American cultivar ' Princeton ' , displaying high resistance in the USA , has often succumbed to Dutch elm disease in Europe . # Hybrid cultivars # Many attempts to breed disease resistant cultivar hybrids have usually involved a genetic contribution from Asian elm species which have demonstrable resistance to this fungal disease . Much of the early work was undertaken in the Netherlands . The Dutch research programme began in 1928 , and ended after 64 years in 1992 , during which time well over 1000 cultivars were raised and evaluated . The programme had three major successes : ' Columella ' , ' Nanguen ' <tt> LUTCE </tt> , and ' Wanoux ' <tt> VADA </tt> , all found to have an extremely high resistance to the disease when inoculated with unnaturally large doses of the fungus . Only ' Columella ' was released during the lifetime of the Dutch programme , in 1987 ; patents for the <tt> LUTCE </tt> and <tt> VADA </tt> clones were purchased by the French Institut National de la Recherche Agronomique ( INRA ) , which subjected the trees to 20 years of field trials in the Bois de Vincennes , Paris , before releasing them to commerce in 2002 and 2006 , respectively . Asian species to feature in the American DED research programs were the Siberian elm ' ' U. pumila ' ' , Japanese elm ' ' U. davidiana ' ' var. ' ' japonica ' ' , and the Chinese elm ' ' U. parvifolia ' ' , giving rise to several dozen hybrid cultivars resistant not just to DED , but also to the extreme cold of Asian winters . Among the most widely planted of these , both in North America and in Europe , are ' Sapporo Autumn Gold ' and ' New Horizon ' . Some hybrid cultivars , such as ' Regal ' , are the product of both Dutch and American research . Hybridization experiments using the slippery or red elm ' ' U. rubra ' ' resulted in the release of ' Coolshade ' and ' Rosehill ' in the 1940s and 50s . The species last featured in hybridization as the female parent of ' Repura ' and ' Revera ' , both patented in 1993 , although neither has yet appeared in commerce . In Italy , research is continuing at the Istituto per la Protezione delle Piante , Florence , to produce a range of disease-resistant trees adapted to the warmer Mediterranean climate , using a variety of Asiatic species crossed with the early Dutch hybrid ' Plantyn ' as a safeguard against any future mutation of the disease . Two trees with very high levels of resistance , ' San Zanobi ' and ' Plinio ' , were released in 2003 . ' Arno ' and ' Fiorente ' were patented in 2006 and entered commerce in 2012 . All four have the Siberian elm ' ' U. pumila ' ' as a parent , the source of disease-resistance and drought-tolerance genes . Further releases are planned , notably of the clone ' Morpheo ' , derived from a crossing of Dutch elm ' ' Ulmus hollandica ' ' with the Chinese species ' ' U. chenmoui ' ' , currently available commercially only in England ( Ashridge Trees Limited ) . # Species and species cultivars # # #North America# # Ten resistant American elm ' ' U. americana ' ' cultivars are now in commerce in North America , but only two ( ' Princeton ' and ' Valley Forge ' ) are currently available in Europe . No cultivar is immune to DED ; even highly resistant cultivars can become infected , particularly if already stressed by drought or other environmental conditions where the disease prevalence is high . With the exception of ' Princeton ' , no trees have yet been grown to maturity . Trees can not be said to be mature until they have reached an age of 60 years . Notable cultivars include :  ' Princeton ' , is a cultivar selected in 1922 by Princeton Nurseries for its landscape merit . By coincidence , this cultivar was found to be highly resistant in inoculation studies carried out by the USDA in the early 1990s . As trees planted in the 1920s still survive , the properties of the mature plant are well known . However , ' Princeton ' has not proven resistant in Europe , and many of the 50 trees planted by HRH Charles , Prince of Wales , in 2006 at Highgrove had died from Dutch Elm disease by 2011.  ' American Liberty ' , is , in fact , a set of six cultivars of moderate to high resistance produced through selection over several generations starting in the 1970s . Although ' American Liberty ' is marketed as a single variety , nurseries selling the Liberty Elm actually distribute the six cultivars at random and thus , unfortunately , the resistance of any particular tree can not be known . One of the cultivars , ' Independence ' , is covered by patent ( U. S. Plant patent 6227 ) . The oldest ' American Liberty ' elm was planted in about 1980.  ' Valley Forge ' , released in 1995 , has demonstrated the highest resistance of all the clones to Dutch elm disease in controlled USDA tests .  ' Lewis and Clark ' ( <tt> Prairie Expedition TM </tt> ) , released in 2004 , was cloned from a tree found growing in North Dakota which had survived unscathed when all around had succumbed to disease . In 2007 , the from the University of Guelph in Ontario , Canada reported that cuttings from healthy surviving old elms surveyed across Ontario had been grown to produce a bank of resistant trees , isolated for selective breeding of highly resistant cultivars . The University of Minnesota USA is testing various elms , including a huge now-patented century-old survivor known as The St. Croix Elm , which is located in a Minneapolis-St . Paul , MN suburb ( Afton ) in the St. Croix River valley a designated National Scenic Riverway . The slippery or red elm ' ' U. rubra ' ' is marginally less susceptible to Dutch elm disease than the other American species , but this quality seems to have been largely ignored in American research . No cultivars were ever selected , although the tree was used in hybridization experiments ( see above ) . # #Europe# # Among European species , there is the unique example of the European white elm ' ' U. laevis ' ' , which has little innate resistance to DED , but is eschewed by the vector bark beetles and only rarely becomes infected . Recent research has indicated it is the presence of certain organic compounds , such as triterpenes and sterols , which serves to make the tree bark unattractive to the beetle species that spread the disease . In Europe the testing of clones of surviving Field Elms for innate resistance has been carried out since the 1990s by national research institutes , with findings centrally assessed and published . The first results of this ongoing project suggest that in some countries a very small number of native Field Elm genotypes have comparatively high levels of tolerance to DED . In Spain , for example , of around 5,000 native elms evaluated to 2013 , some 25 genotypes ( 0.5% of those tested ) fall into this category ; and it is now hoped that the controlled crossing of the best seven of these ( genetically and aesthetically ) will produce ' ' Ulmus minor ' ' hybrids with effective ' field resistance ' and market appeal . Similar results are beginning to emerge in trials on surviving Field Elms in Greece . Much of the work in the United Kingdom is by the Forestry Commission 's research arm , which has had Dutch elm disease on its agenda since the 1920s . In 1994 a Research Information Note ( no 252 ) was published , written by John Gibbs , Clive Brasier and Joan Webber who are still active in the field ; and in 2010 a Pathology Advisory Note , as well as throughout the period a stream of more academic papers : notable results have been the observation that the progress of the disease through Scotland has been quite slow , and that genetic engineering has been tried to improve the resistance of the English elm . In England The Conservation Foundation has begun propagating , distributing and planting clones of surviving indigenous elms , including Field Elms ( but not the highly susceptible English elm ) , as part of a scheme to return elms to city and countryside . The Foundation is currently running two elm programmes : the ' Great British Elm Experiment ' and ' Ulmus londinium ' , an elm programme for London these use saplings cultivated through micropropagation from mature parent elms found growing in the British countryside : parent trees are monitored for disease , while saplings are offered free to schools and community groups , who are asked to monitor their trees ' progress on the Foundation 's online elm map ; elms are available at a small price to others who do not qualify for a free tree ; in London , places with ' elm ' in their name are offered a sapling in an attempt to find out why some elms have survived while others succumbed to Dutch elm disease . The spread of DED to Scotland has focused attention on a small number of Wych elms ' ' U. glabra ' ' surviving in areas of high infectivity , prompting the Royal Botanic Garden Edinburgh to begin a programme of cloning of the trees and inoculation of their saplings with the fungus , with a view to determining innate resistance ( 2010 ) . Independent of these programmes , clones from two UK elms , thought to be nearly 200 years old , that have so far survived in an area of high infectivity ( Essex ) are now available commercially . Mr Paul King of King &amp; Co The Tree Nursery took and potted cuttings from these trees in 1990 , cultivated the cuttings by micropropagation . However it should be noted that these trees have not been scientifically tested for resistance to DED . King points to the research findings of R. H. Richens in his paper Essex Elms , which describes natural hybridisation of ' ' Ulmus ' ' species in the area and the resulting resistance to DED of some trees . Mr King does not claim that his trees are immune from DED , but the continuing survival of the original mature trees , of the first cuttings and of the micropropogated stock bodes well . In 2001-4 , English elm ' ' U. procera ' ' was genetically engineered to resist disease , in experiments at Abertay University , Dundee , Scotland , by transferring antifungal genes into the elm genome using minute DNA-coated ball bearings . However , owing to the hostility to GM developments , there are no plans to release the trees into the countryside . # Possible earlier occurrences # # The ' Elm Decline ' # From analysis of fossil pollen in peat samples , it is apparent that elms , an abundant tree in prehistoric times , all but disappeared from northwestern Europe during the mid-Holocene period about 6000 years ago , and to a lesser extent 3000 years ago . This roughly synchronous and widespread event has come to be known as the ' Elm Decline ' . When first detected in the mid-20th century , the decline was attributed to the impact of forest-clearance by Neolithic farmers , and of elm-coppicing for animal fodder , though the numbers of settlers could not have been large . The devastation caused recently by DED has provided an alternative explanation . Examination of subfossil elm wood showing signs of the changes associated with the disease has suggested that a form of DED ' ' may ' ' have been responsible . Fossil finds from this period of elm bark beetles support this theory . A consensus of opinion today is that the Elm Decline was probably driven by both factors . # Historic period # A less devastating form of the disease , caused by a different fungus , had possibly been present in Britain for some time . Dr Oliver Rackham of Cambridge University presented evidence of an outbreak of elm disease in north-west Europe , c.1819-1867 . Indications from annual rings a reference to the dark staining in an annual ring in infected elms confirm that Dutch elm disease was certainly present in 1867 , he wrote , quoting contemporary accounts of diseased and dying elms , including this passage in Richard Jefferies ' 1883 book , ' ' Nature near London ' ' : : There is something wrong with elm trees . In the early part of this summer , not long after the leaves were fairly out upon them , here and there a branch appeared as if it had been touched with red-hot iron and burnt up , all the leaves withered and browned on the boughs . First one tree was thus affected , then another , then a third , till , looking round the fields , it seemed as if every fourth or fifth tree had thus been burnt . ... Upon mentioning this I found that it had been noticed in elm avenues and groups a hundred miles distant , so that it is not a local circumstance . Earlier still , Rackham noted , The name ' ' Scolytus destructor ' ' was given to the great bark beetle on evidence , dating from c.1780 , that it was destroying elms around Oxford . It has been suggested , indeed , that for thousands of years elms have flourished in natural balance with the ' ' scolytidae ' ' , combating occasional infections of Dutch elm disease . Sir Thomas Browne , writing in 1658 , noted in ' ' The Garden of Cyrus ' ' an elm disease that was spreading through English hedgerows , and described symptoms reminiscent of DED . 
@@196991 ICDO = MeshID = D005764 Gastroesophageal reflux disease ( GERD ) , gastro-oesophageal reflux disease ( GORD ) , gastric reflux disease , or acid reflux disease is a chronic symptom of mucosal damage caused by stomach acid coming up from the stomach into the esophagus . GERD is usually caused by changes in the barrier between the stomach and the esophagus , including abnormal relaxation of the lower esophageal sphincter , which normally holds the top of the stomach closed , impaired expulsion of gastric reflux from the esophagus , or a hiatal hernia . These changes may be permanent or temporary . Treatment is typically via lifestyle changes and medications such as proton pump inhibitors , H <sub> 2 </sub> receptor blockers or antacids with or without alginic acid . Surgery may be an option in those who do not improve . In the Western world between 10 and 20% of the population is affected . # Signs and symptoms # # Adults # The most-common symptoms of GERD are :  Heartburn  Regurgitation Less-common symptoms include :  Pain with swallowing/sore throat ( odynophagia )  Increased salivation ( also known as water brash )  Nausea  Chest pain  Coughing GERD sometimes causes injury of the esophagus . These injuries may include :  Reflux esophagitis necrosis of esophageal epithelium causing ulcers near the junction of the stomach and esophagus  Esophageal strictures the persistent narrowing of the esophagus caused by reflux-induced inflammation  Barrett 's esophagus intestinal metaplasia ( changes of the epithelial cells from squamous to intestinal columnar epithelium ) of the distal esophagus  Esophageal adenocarcinoma a rare form of cancer Some people have proposed that symptoms such as sinusitis , recurrent ear infections , and idiopathic pulmonary fibrosis are due to GERD ; however , a causative role has not been established . # Children # GERD may be difficult to detect in infants and children , since they can not describe what they are feeling and indicators must be observed . Symptoms may vary from typical adult symptoms . GERD in children may cause repeated vomiting , effortless spitting up , coughing , and other respiratory problems , such as wheezing . Inconsolable crying , refusing food , crying for food and then pulling off the bottle or breast only to cry for it again , failure to gain adequate weight , bad breath , and belching or burping are also common . Children may have one symptom or many ; no single symptom is universal in all children with GERD . Of the estimated 4 million babies born in the US each year , up to 35% of them may have difficulties with reflux in the first few months of their lives , known as ' spitting up ' . One theory for this is the fourth trimester theory which notes most animals are born with significant mobility , but humans are relatively helpless at birth , and suggests there may have once been a fourth trimester , but children began to be born earlier , evolutionarily , to accommodate the development of larger heads and brains and allow them to pass through the birth canal and this leaves them with partially undeveloped digestive systems . Most children will outgrow their reflux by their first birthday . However , a small but significant number of them will not outgrow the condition . This is particularly true when a family history of GERD is present . # Barrett 's esophagus # GERD may lead to Barrett 's esophagus , a type of intestinal metaplasia , which is in turn a precursor condition for carcinoma . The risk of progression from Barrett 's to dysplasia is uncertain , but is estimated at about 20% of cases . Due to the risk of chronic heartburn progressing to Barrett 's , EGD every five years is recommended for people with chronic heartburn , or who take drugs for chronic GERD. # Causes # GERD is caused by a failure of the lower esophageal sphincter . In healthy patients , the Angle of His -- the angle at which the esophagus enters the stomach -- creates a valve that prevents duodenal bile , enzymes , and stomach acid from traveling back into the esophagus where they can cause burning and inflammation of sensitive esophageal tissue . Factors that can contribute to GERD :  Hiatal hernia , which increases the likelihood of GERD due to mechanical and motility factors .  Obesity : increasing body mass index is associated with more severe GERD . In a large series of 2000 patients with symptomatic reflux disease , it has been shown that 13% of changes in esophageal acid exposure is attributable to changes in body mass index .  Zollinger-Ellison syndrome , which can be present with increased gastric acidity due to gastrin production .  Hypercalcemia , which can increase gastrin production , leading to increased acidity .  Scleroderma and systemic sclerosis , which can feature esophageal dysmotility.  The use of medicines such as prednisolone .  Visceroptosis or Glnard syndrome , in which the stomach has sunk in the abdomen upsetting the motility and acid secretion of the stomach . GERD has been linked to a variety of respiratory and laryngeal complaints such as laryngitis , chronic cough , pulmonary fibrosis , earache , and asthma , even when not clinically apparent . These atypical manifestations of GERD is commonly referred to as laryngopharyngeal reflux ( LPR ) or as extraesophageal reflux disease ( EERD ) . Factors that have been linked with GERD , but not conclusively :  Obstructive sleep apnea  Gallstones , which can impede the flow of bile into the Duodenum , which can affect the ability to neutralize gastric acid In 1999 , a review of existing studies found that , on average , 40% of GERD patients also had ' ' H. pylori ' ' infection . The eradication of ' ' H. pylori ' ' can lead to an increase in acid secretion , leading to the question of whether ' ' H. pylori ' ' -infected GERD patients are any different than non-infected GERD patients . A double-blind study , reported in 2004 , found no clinically significant difference between these two types of patients with regard to the subjective or objective measures of disease severity . # Diagnosis # The diagnosis of GERD is usually made when typical symptoms are present . Reflux can be present in people without symptoms and the diagnosis requires both symptoms or complications and reflux of stomach content . Other investigations may include *26;1665;TOOLONG ( EGD ) . Barium swallow X-rays should not be used for diagnosis . Esophageal manometry is not recommended for use in diagnosis being recommended only prior to surgery . Ambulatory esophageal pH monitoring may be useful in those who do not improve after PPIs and is not needed in those in whom Barrett 's esophagus is seen . Investigations for H. pylori is not usually needed . The current gold standard for diagnosis of GERD is esophageal pH monitoring . It is the most objective test to diagnose the reflux disease and allows monitoring GERD patients in their response to medical or surgical treatment . One practice for diagnosis of GERD is a short-term treatment with proton-pump inhibitors , with improvement in symptoms suggesting a positive diagnosis . Short-term treatment with proton-pump inhibitors may help predict abnormal 24-hr pH monitoring results among patients with symptoms suggestive of GERD. # Endoscopy # Endoscopy , the looking down into the stomach with a fiber-optic scope , is not routinely needed if the case is typical and responds to treatment . It is recommended when people either do not respond well to treatment or have alarm symptoms , including dysphagia , anemia , blood in the stool ( detected chemically ) , wheezing , weight loss , or voice changes . Some physicians advocate either once-in-a-lifetime or 5- to 10-yearly endoscopy for people with longstanding GERD , to evaluate the possible presence of dysplasia or Barrett 's esophagus . Biopsies performed during gastroscopy may show :  Edema and basal hyperplasia ( nonspecific inflammatory changes )  Lymphocytic inflammation ( nonspecific )  Neutrophilic inflammation ( usually due to reflux or ' ' Helicobacter ' ' gastritis )  Eosinophilic inflammation ( usually due to reflux ) : The presence of intraepithelial eosinophils may suggest a diagnosis of eosinophilic esophagitis ( EE ) if eosinophils are present in high enough numbers . Less than 20 eosinophils per high-power microscopic field in the distal esophagus , in the presence of other histologic features of GERD , is more consistent with GERD than EE .  Goblet cell intestinal metaplasia or Barrett 's esophagus  Elongation of the papillae  Thinning of the squamous cell layer  Dysplasia  Carcinoma Reflux changes may not be erosive in nature , leading to nonerosive reflux disease . # Differential diagnosis # Other causes of chest pain such as heart disease should be ruled out before making the diagnosis . Another kind of acid reflux , which causes respiratory and laryngeal signs and symptoms , is called laryngopharyngeal reflux ( LPR ) or extraesophageal reflux disease ( EERD ) . Unlike GERD , LPR rarely produces heartburn , and is sometimes called ' ' silent reflux ' ' . # Treatment # The treatments for GERD include lifestyle modifications , medications , and possibly surgery . Initial treatment is frequently with a proton-pump inhibitor such as omeprazole. # Lifestyle # Certain foods and lifestyle are considered to promote gastroesophageal reflux , however most dietary interventions have little supporting evidence . Weight loss and elevating the head of the bed are generally useful . Moderate exercise improves symptoms , however in those with GERD vigorous exercise may worsen them . Stopping smoking and not drinking alcohol do not appear to result in significant improvement in symptoms . Avoidance of specific foods and of eating before lying down should only be recommended to those in which they are associated with the symptoms . Foods that have been implicated include coffee , alcohol , chocolate , fatty foods , acidic foods , and spicy foods . # Medications # The primary medications used for GERD are proton-pump inhibitors , H <sub> 2 </sub> receptor blockers and antacids with or without alginic acid . Proton-pump inhibitors ( PPIs ) ( such as omeprazole ) are the most effective followed by H <sub> 2 </sub> receptor blockers ( such as ranitidine ) . If a once daily PPI is only partially effective they may be used twice a day . They should be taken one half to one hour before a meal . There is no significant difference between agents in this class . When these medications are used long term , the lowest effective dose should be taken . They may also be taken only when symptoms occur in those with frequent problems . H <sub> 2 </sub> receptor blockers lead to roughly a 40% improvement . The evidence for antacids is weaker with a benefit of about 10% ( NNT=13 ) while a combination of an antacid and alginic acid ( such as Gaviscon ) may improve symptoms 60% ( NNT=4 ) . Metoclopramide ( a prokinetic ) is not recommended either alone or in combination with other treatments due to concerns around adverse effects . The benefit of the prokinetic mosapride is modest . Sucralfate has a similar effectiveness to H <sub> 2 </sub> receptor blockers ; however , sucralfate needs to be taken multiple times a day , thus limiting its use . Baclofen , an agonist of the GABA <sub> B </sub> receptor , while effective , has similar issues of needing frequent dosing in addition to greater adverse effects compared to other medications. # Surgery # The standard surgical treatment for severe GERD is the Nissen fundoplication . In this procedure , the upper part of the stomach is wrapped around the lower esophageal sphincter to strengthen the sphincter and prevent acid reflux and to repair a hiatal hernia . It is only recommended in those who improve with PPIs . Benefits are equal to medical treatment in those with chronic symptoms . In addition , in the short and medium term , laparoscopic fundoplication improves quality of life compared to medical management . When comparing different fundoplication techniques , partial posterior fundoplication surgery is more effective than partial anterior fundoplication surgery . # Pregnancy # In pregnancy , dietary modifications and lifestyle changes may be attempted , but often have little effect . Calcium-based antacids are recommended if these changes are not effective . Aluminum- and magnesium-based antacids are also safe , as is ranitidine and PPIs. # Infants # Infants may see relief with changes in feeding techniques , such as smaller , more frequent feedings , changes in position during feedings , or more frequent burping during feedings . They may also be treated with medicines such as ranitidine or proton pump inhibitors . Proton pump inhibitors however have not been found to be effective in this population and there is a lack of evidence for safety . # Overtreatment # The use of acid suppression therapy is a common response to GERD symptoms and many patients get more of this kind of treatment than their individual case merits . The overuse of this treatment is a problem because of the side effects and costs which the patient will have from undergoing unnecessary therapy , and patients should not take more treatment than they need . In some cases , a person with GERD symptoms can manage them by taking over-the-counter drugs and making lifestyle changes . This is often safer and less expensive than taking prescription drugs . Some guidelines recommend trying to treat symptoms with an H <sub> 2 </sub> antagonist before using a proton-pump inhibitor because of cost and safety concerns . # Epidemiology # In Western populations GERD affects approximately 10% to 20% of the population and 0.4% newly develop the condition . For instance , an estimated 3.4 million to 6.8 million Canadians are GERD sufferers . The prevalence rate of GERD in developed nations is also tightly linked with age , with adults aged 60 to 70 being the most commonly affected . In the United States 20% of people have symptoms in a given week and 7% every day . No data support sex predominance with regard to GERD. # History # An obsolete treatment is vagotomy ( highly selective vagotomy ) , the surgical removal of vagus nerve branches that innervate the stomach lining . This treatment has been largely replaced by medication . # Research # A number of endoscopic devices have been tested to treat chronic heartburn . One system , Endocinch , puts stitches in the lower esophogeal sphincter to create small pleats to help strengthen the muscle . However , long-term results were disappointing , and the device is no longer sold by Bard . Another , the Stretta procedure , uses electrodes to apply radio-frequency energy to the LES . The long-term outcomes of both procedures compared to a Nissen fundoplication are still being determined . The NDO Surgical Plicator creates a plication , or fold , of tissue near the gastroesophageal junction , and fixates the plication with a suture-based implant . The company ceased operations in mid-2008 , and the device is no longer on the market . Another treatment , transoral incisionless fundoplication , which uses a device called Esophyx , may be effective . On March 22 , 2012 the FDA approved a device for those with severe symptoms that do not respond to other treatments . The device consists of a series of metal beads with magnetic cores that are placed surgically around the lower esophageal sphincter to strengthen it . Small studies provided evidence of improvement of GERD symptoms in many of the patients , with benefits determined to outweigh the risks . No data regarding long-term effects is available . Adverse responses include difficulty swallowing , chest pain , vomiting , and nausea . Contraindications that would advise against use of the device are patients who are or may be allergic to titanium , stainless steel , nickel , or ferrous iron materials . A warning advises that the device should not be used by patients who could be exposed to , or undergo , magnetic resonance imaging ( MRI ) because of serious injury to the patient and damage to the device . # References # # Further reading #    
@@199884 Osteopathic medicine is a branch of the medical profession in the United States . Osteopathic physicians ( D.O.s ) are licensed to practice medicine and surgery in all 50 states and are recognized in sixty other countries , including all Canadian provinces . Frontier physician Andrew Taylor Still founded the profession as a rejection of the prevailing system of medical thought of the 19th century . Still 's techniques relied on holistic measures , such as the manipulation of joints and bones , to diagnose and treat illness , and he called his practices osteopathy . By the middle of the 20th century , the profession had moved closer to mainstream medicine , adopting modern public health and biomedical principles . American osteopaths became osteopathic medical physicians , ultimately achieving full practice rights as medical doctors in all 50 states , including serving in the U.S. armed forces as physicians . In the 21st century , the training of osteopathic medical physicians in the United States is very similar to the training of Doctors of Medicine ( M.D.s ) . Dennis L. Kasper , Eugene Braunwald , Anthony S. Fauci , Stephen L. Hauser , Dan L. Longo , J. Larry Jameson , and Kurt J. Isselbacher , Eds . ' ' ' ' Harrison 's Principles of Internal Medicine , 16th Ed. 2005 . McGraw Hill . Osteopathic medical physicians attend four years of medical school followed by an internship and a minimum two years of residency . They use all conventional methods of diagnosis and treatment . Though still trained in Osteopathic Manipulative Medicine ( OMM ) , the modern derivative of Still 's techniques , they are increasingly reluctant to use it in actual practice . In modern medicine , any distinction between the M.D. and the D.O . professions has eroded steadily ; diminishing numbers of D.O . graduates enter primary care fields , fewer use OMM , and increasing numbers of osteopathic graduates choose to train in non-osteopathic residency programs . Further , holistic patient care models are increasingly being taught at M.D. schools . Discussions about the future of modern medicine frequently debate the utility of maintaining separate , distinct pathways for educating physicians in the United States . # Nomenclature # Physicians and surgeons who graduate from osteopathic medical schools are known as physicians or osteopathic medical physicians . Upon graduation , they are conferred a professional doctorate , the Doctor of Osteopathic Medicine ( D.O. ) . Osteopathic curricula in other countries differ from those in the United States . European-trained practitioners of osteopathic manipulative techniques are referred to as osteopaths : their scope of practice excludes most medical therapies and relies more on osteopathic manipulative medicine and alternative medical modalities . While it was once common for D.O . graduates in the United States to refer to themselves as ' osteopaths , ' this term is now considered archaic and those holding the Doctor of Osteopathic Medicine degree are commonly referred to as ' osteopathic medical physicians ' . # Demographics # Currently , there are 30 accredited osteopathic medical schools offering education in 42 locations across the United States and 141 accredited U.S. M.D. medical schools .  In 1960 , there were 13,708 physicians who were graduates of the 5 osteopathic medical schools .  In 2002 , there were 49,210 physicians from 19 osteopathic medical schools .  Between 1980 and 2005 , the number of osteopathic graduates per year increased over 250 percent from about 1,000 to 2,800 . This number is expected to approach 5,000 by 2015.  In 2011 , there were 26 colleges of osteopathic medicine in 34 locations . One in five medical students in the United States is enrolled in an osteopathic medical school .  As of 2012 , there are more than 82,500 osteopathic medical physicians in the United States .  By 2020 , the number of osteopathic medical physicians will be over 100,000 , say expert predictions , according to the American Medical Association . Osteopathic physicians are not evenly distributed in the United States . States with the highest concentration of osteopathic medical physicians are Oklahoma , Iowa , and Michigan where osteopathic medical physicians comprise 17-20% of the total physician workforce . suggestive of a kind of social movement within the field of medicine , one that promotes a more patient-centered , holistic approach to medicine , and emphasizes the role of the primary care physician within the health care system . Others point out that there is nothing in the principles that would distinguish D.O . from M.D. training in any fundamental way . One study , published in ' ' The Journal of the American Osteopathic Association ' ' found a majority of M.D. medical school administrators and faculty saw nothing objectionable in the core principles , and many would endorse them generally as sound medical principles . # History # # 19th century , a new movement within medicine # Frontier physician Andrew Taylor Still , M.D. , DO , founded the American School of Osteopathy ( now the A.T . Still University-Kirksville ( Mo . ) College of Osteopathic Medicine ) in Kirksville , MO , in 1892 as a radical protest against the turn-of-the-century medical system . A.T . Still believed that the conventional medical system lacked credible efficacy , was morally corrupt , and treated effects rather than causes of disease . He founded osteopathic medicine in rural Missouri at a time when medications , surgery , and other traditional therapeutic regimens often caused more harm than good . Some of the medicines commonly given to patients during this time were arsenic , castor oil , whiskey , and opium . In addition , unsanitary surgical practices often resulted in more deaths than cures . Dr. Still intended his new system of medicine to be a reformation of the existing 19th century medical practices . He imagined that someday rational medical therapy would consist of manipulation of the musculoskeletal system , surgery , and very sparingly used drugs . He invented the name osteopathy by blending two Greek roots ' ' osteon- ' ' for bone and ' ' -pathos ' ' for suffering in order to communicate his theory that disease and physiologic dysfunction were etiologically grounded in a disordered musculoskeletal system . Thus , by diagnosing and treating the musculoskeletal system , he believed that physicians could treat a variety of diseases and spare patients the negative side-effects of drugs . One notable advocate for the fledgling movement was Mark Twain . Manipulative treatments had purportedly alleviated the symptoms of his daughter Jean 's epilepsy as well as Twain 's own chronic bronchitis . In 1909 , he spoke before the New York State Assembly at a hearing regarding the practice of osteopathy in the state . I do n't know as I cared much about these osteopaths until I heard you were going to drive them out of the state , but since I heard that I have n't been able to sleep . Philosophically opposed to the American Medical Association 's stance that its own type of medical practice was the only legitimate one , he spoke in favor of licensing for osteopaths . Physicians from the New York County Medical Society responded with a vigorous attack on Twain , who retorted with the physicians think they are moved by regard for the best interests of the public . Is n't there a little touch of self-interest back of it all ? ... The objection is , people are curing people without a license and you are afraid it will bust up business . class= infobox cellpadding= 4 style= font-size:105% ; style= ; float:left ; # 19161966 , federal recognition # Recognition by the U.S. federal government was a key goal of the osteopathic medical profession in its effort to establish equivalency with its M.D. counterparts . Between 1916 and 1966 , the profession engaged in a long and tortuous struggle for the right to serve as physicians and surgeons in the U.S. Military Medical Corps . On May 3 , 1966 Secretary of Defense Robert McNamara authorized the acceptance of osteopathic physicians into all the medical military services on the same basis as MDs . The first osteopathic physician to take the oath of office to serve as a military physician was Harry J. Walter . The acceptance of osteopathic physicians was further solidified in 1996 when Ronald Blanck , DO was appointed to serve as Surgeon General of the Army , the only osteopathic physician to hold the post . # 1962 , California # In the 1960s in California , the American Medical Association ( AMA ) , sensing increased competition from osteopathic medicine , spent nearly $8 million to end the practice of osteopathic medicine in the state . In 1962 , Proposition 22 , a statewide ballot initiative in California , eliminated the practice of osteopathic medicine in the state . The California Medical Association ( CMA ) issued M.D. degrees to all DOs in the state of California for a nominal fee . By attending a short seminar and paying $65 , a doctor of osteopathy ( D.O. ) could obtain an M.D. degree ; 86 percent of the DOs in the state ( out of a total of about 2000 ) chose to do so . Immediately following , the AMA re-accredited the formerly osteopathic University of California at Irvine College of Osteopathic Medicine as University of California , Irvine School of Medicine , an M.D. medical school . It also placed a ban on issuing physician licenses to DOs moving to California from other states . However , the decision proved to be controversial . In 1974 , after protest and lobbying by influential and prominent DOs , the California Supreme Court ruled in Osteopathic Physicians and Surgeons of California v. California Medical Association , that licensing of DOs in that state must be resumed . Four years later , in 1978 , the College of Osteopathic Medicine of the Pacific opened in Pomona , and in 1997 Touro University California opened in Vallejo . As of 2012 , there were 6,368 D.O.s practicing in California . # 1969 , AMA House of Delegates approval # In 1969 , the American Medical Association ( AMA ) approved a measure allowing qualified osteopathic physicians as full and active members of the Association . The measure also allowed osteopathic physicians to participate in AMA-approved intern and residency programs . However , the American Osteopathic Association rejected this measure , claiming it was an attempt to eliminate the distinctiveness of osteopathic medicine . In 1970 , AMA President Dwight L. Wilbur , M.D. sponsored a measure in the AMA 's House of Delegates permitting the AMA Board of Trustees ' plan for the merger of D.O . and M.D. professions . Today , a majority of osteopathic physicians are trained alongside MDs , in residency programs governed by the ACGME , an independent board of the AMA. # 1993 , first African-American woman to serve as dean of a U.S. medical school # In 1993 , Barbara Ross-Lee , DO was appointed to the position of dean of the Ohio University College of Osteopathic Medicine ; she was the first African-American woman to serve as the dean of a U.S. medical school . # Non-discrimination policies # Recent years have seen a professional rapprochement between the two groups . DOs have been admitted to full active membership in the American Medical Association since 1969 . The AMA has invited a representative of the American Osteopathic Association to sit as a voting member in the AMA legislative body , the house of delegates . # #2006 , American Medical Student Association # # In 2006 , during the presidency of an osteopathic medical student , the American Medical Student Association ( AMSA ) adopted a policy regarding the membership rights of osteopathic medical students in their main policy document , the Preamble , Purposes and Principles . # #2007 , AMA # # In recent years , the largest M.D. organization in the U.S. , the American Medical Association , adopted a fee non-discrimination policy discouraging differential pricing based on attendance of an M.D. or D.O . medical school . In 2006 , calls for an investigation into the existence of differential fees charged for visiting D.O . and M.D. medical students at American medical schools were brought to the American Medical Association . After an internal investigation into the fee structure for visiting D.O . and M.D. medical students at M.D. medical schools , it was found that one institution of the 102 surveyed charged different fees for D.O . and M.D. students . The house of delegates of the American Medical Association adopted resolution 809 , I-05 in 2007. # State licensing of practice rights # In the United States , laws regulating physician licenses are governed by the states . Between 1901 and 1989 , osteopathic physicians lobbied state legislatures to pass laws giving those with a D.O . degree the same legal privilege to practice medicine as those with an M.D. degree . In many states , the debate was long and protracted . Both the AOA and the AMA were heavily involved in influencing the legislative process . The first state to pass such a law was California in 1901 , the last was Nebraska in 1989. # Current status # class= infobox cellpadding= 0 style= font-size:90% ; style= ; float:left ; width:20% # Education and training # According to Harrison 's Principles of Internal Medicine , the training , practice , credentialing , licensure , and reimbursement of osteopathic physicians is virtually indistinguishable from those of allopathic ( MD ) physicians , with 4 years of osteopathic medical school followed by specialty and subspecialty training and Board certificationboard certification . D.O.-granting U.S. medical schools have curricula identical for the most part to those of M.D.-granting schools . Generally , the first two years are classroom-based , while the third and fourth years consist of clinical rotations through the major specialties of medicine . Some schools of Osteopathic Medicine have been criticized by the osteopathic community for relying too heavily on clinical rotations with private practitioners , who may not be able to provide sufficient instruction to the rotating student . Other D.O.-granting and M.D.-granting schools place their students in hospital-based clinical rotations where the attending physicians are faculty of the school , and who have a clear duty to teach medical students while treating patients . # #Graduate medical education# # Osteopathic physicians may apply to residency programs accredited by either the AOA or the Accreditation Council for Graduate Medical Education ( ACGME ) . Currently , osteopathic physicians participate in more ACGME programs than in programs approved by the American Osteopathic Association ( AOA ) . By 2015 , all AOA residencies will also have ACGME accreditation . # Osteopathic manipulative treatment ( OMT ) # Within the osteopathic medical curriculum , manipulative treatment is taught as an adjunctive measure to other biomedical interventions for a number of disorders and diseases . However , a 2001 survey of osteopathic physicians found that more than 50% of the respondents used OMT on less than 5% of their patients . The survey follows many indicators that osteopathic physicians have become more like M.D. physicians in every respect few perform OMT , and most prescribe drugs or suggest surgery as a first line of treatment . The American Osteopathic Association has made an effort in recent years to support scientific inquiry into the effectiveness of osteopathic manipulation as well as to encourage osteopathic physicians to consistently offer manipulative treatments to their patients . However , the number of osteopathic physicians who report consistently prescribing and performing manipulative treatment has been falling steadily . Medical historian and sociologist Norman Gevitz cites poor educational quarters and few full-time OMM instructors as major factors for the decreasing interest of medical students in OMM . He describes problems with the quality , breadth , nature , and orientation of OMM instruction , and he claims that the teaching of osteopathic medicine has not changed sufficiently over the years to meet the intellectual and practical needs of students . At the same time , recent studies show an increasingly positive attitude of patients and physicians ( M.D. and D.O. ) towards the use of manual therapy as a valid , safe and effective treatment modality . One survey , published in the ' ' Journal of Continuing Medical Education ' ' , found that a majority of physicians ( 81% ) and patients ( 76% ) felt that manual manipulation ( MM ) was safe , and over half ( 56% of physicians and 59% of patients ) felt that manipulation should be available in the primary care setting . Although less than half ( 40% ) of the physicians reported any educational exposure to MM and less than one-quarter ( 20% ) have administered MM in their practice , most ( 71% ) respondents endorsed desiring more instruction in MM . Another small study examined the interest and ability of M.D. residents in learning osteopathic principles and skills , including OMM . It showed that after a 1-month elective rotation , the M.D. residents responded favorably to the experience . # Professional attitudes # In 1998 , a New York Times article described the increasing numbers , public awareness , and mainstreaming of osteopathic medical physicians , illustrating an increasingly cooperative climate between the D.O . and M.D. professions . In 2005 , during his tenure as president of the American Association of Medical Colleges , Jordan Cohen described a climate of cooperation between D.O . and M.D. practitioners : Elsewhere , he has remarked that osteopathic manipulative medicine ( OMM ) can be an aid to the physician in fostering a relationship with the patient . # International practice rights # Each country has different requirements and procedures for licensing or registering osteopathic physicians and osteopaths . The only osteopathic practitioners that the U.S. Department of Education recognizes as physicians are graduates of osteopathic medical colleges in the United States . Therefore , osteopaths who have trained outside the United States are not eligible for medical licensure in the United States . On the other hand , U.S.-trained DOs are currently able to practice in 45 countries with full medical rights and in several others with restricted rights . The ' ' Bureau on International Osteopathic Medical Education and Affairs ' ' ( BIOMEA ) is an independent board of the American Osteopathic Association . The BIOMEA monitors the licensing and registration practices of physicians in countries outside of the United States and advances the recognition of American-trained DOs . Towards this end , the BIOMEA works with international health organizations like the World Health Organization ( WHO ) , the Pan American Health Organization ( PAHO ) as well as other groups . The procedure by which international countries consider granting physician licensure to foreigners varies widely . For U.S. trained physicians , the ability to qualify for unlimited practice rights also varies according to one 's degree , M.D. or D.O . ' ' AOA International License Summary . ' ' American Osteopathic Association . Council on International Osteopathic Medical Education and Affairs . Many countries recognize U.S.-trained MDs as applicants for licensure , granting successful applicants unlimited practice rights . The American Osteopathic Association has lobbied the governments of other countries to recognize U.S.-trained DOs similarly to their M.D. counterparts , with some success . In over 60 countries , U.S.-trained DOs have unlimited practice rights . In 2005 , after one year of deliberations , the General Medical Council announced that U.S.-trained DOs will be accepted for full medical practice rights in the United Kingdom . According to Josh Kerr of the AOA , some countries do nt understand the differences in training between an osteopathic physician and an osteopath . The American Medical Student Association strongly advocates for U.S.-trained D.O . international practice rights equal to that of M.D. qualified physicians . Preamble , Purposes and Principles . American Medical Student Association . # Osteopathic medicine and primary care # Osteopathic physicians have historically entered primary care fields at a higher rate than their M.D. counterparts . Some osteopathic organizations make claims to a greater emphasis on the importance of primary care within osteopathic medicine . However , the proportion of osteopathic students choosing primary care fields , like that of their M.D. peers , is declining . Currently , only one in five osteopathic medical students enters a family medicine residency ( the largest primary care field ) . In 2004 , only 32% of osteopathic seniors planned careers in any primary care field ; this percentage was down from a peak in 1996 of more than 50%. # Criticism and internal debate # # OMM # Traditional osteopathic medicine , specifically OMM , has been criticized for many techniques such as cranial and cranio-sacral manipulation . A recent study questions the therapeutic utility of osteopathic manipulative treatment modalities . Also , New York University health information website claims that it is difficult to properly ascertain the effectiveness of a hands-on therapy like OMT. # Research emphasis # Another area of criticism has been the relative lack of research and lesser emphasis on scientific inquiry at D.O . schools in comparison with M.D. schools . Shannon , Stephen C. ' ' ' ' Inside Osteopathic Medical Education . Vol 2 . No 2 . February 1 , 2008. p1 . JD Howell , author of ' ' The Paradox of Osteopathy , ' ' notes claims of a fundamental yet ineffable difference between MD and DO qualified physicians are based on practices such as preventive medicine and seeing patients in a sociological context that are widely encountered not only in osteopathic medicine but also in allopathic medicine . Studies have confirmed the lack of any philosophic concept or resultant practice behavior that would distinguish a D.O . from an M.D. Howell summarizes the questions framing the debate over the future of osteopathic distinctiveness thus : # #Rapid expansion# # As the number of osteopathic schools has increased , the debate over distinctiveness has often seen the leadership of the American Osteopathic Association at odds with the community of osteopathic physicians . The rapid expansion has raised concerns about the number of available faculty at osteopathic schools and the role those faculty play in maintaining the integrity of the academic program of the schools . Norman Gevitz , author of the leading text on the history of osteopathic medicine , recently published , The president of the American Association of Colleges of Osteopathic Medicine commented on the current climate of crisis within the profession . # For-profit medical education # The accreditation of Rocky Vista University College of Osteopathic Medicine ( RVUCOM ) generated some controversy before the school held its first class . Like all osteopathic medical schools , RVUCOM is accredited by a board of the American Osteopathic Association ( AOA ) Commission on Osteopathic College Accreditation ( COCA ) . Unlike the other 29 osteopathic and 141 M.D. medical colleges in the U.S. , RVUCOM is organized as a for-profit corporation.Croasdale , Myrle . . American Medical News . Oct 1 , 2007 . Critics claimed the AOA 's approval of a for-profit school will negatively affect osteopathic medical schools ' credibility , especially in comparison to their M.D. counterparts . The Liaison Committee on Medical Education , which accredits the M.D.-granting U.S. medical schools , has banned for-profit schools . School officials insist the for-profit status of the school will not compromise the integrity of its educational mission . AOA president ( 20072008 ) and orthopedic surgeon Peter Ajluni , D.O . responded , there are many socially minded for-profit companies that contribute time , resources , and profits to their communities and for-profit institutions like RVUCOM can further the cause of osteopathic medicine in the United States . 
@@205264 Internal medicine or general medicine ( in Commonwealth nations ) is the medical specialty dealing with the prevention , diagnosis , and treatment of adult diseases . Physicians specializing in internal medicine are called internists , or physicians ( without a modifier ) in Commonwealth nations . Internists are especially skilled in the management of patients who have undifferentiated or multi-system disease processes . Internists care for hospitalized and ambulatory patients and may play a major role in teaching and research . Since internal medicine patients are often seriously ill or require complex investigations , internists do much of their work in hospitals . Internists often have subspecialty interests in diseases affecting particular organs or organ systems . Internal medicine is also a specialty within clinical pharmacy and veterinary medicine . # History # Historically , internal medicine physicians have practiced both in clinics and in hospitals , often in the same day . Pressures on time have led to many internal medicine physicians to choose one practice setting , who may choose to practice only in the hospital , as a hospitalist , or only in an outpatient clinic , as a primary care physician . # Terminology # The term ' ' internal medicine ' ' originates from the German term ' ' Innere Medizin ' ' , popularized in Germany in the late 19th century to describe physicians who combined the science of the laboratory with the care of patients . Many early-20th century American physicians studied medicine in Germany and brought this medical field to the United States . Thus , the name internal medicine was adopted in imitation of the existing German term . Much confusion surrounds the meaning of internal medicine and the role of an internist . Internists are qualified physicians with postgraduate training in internal medicine and should not be confused with interns , who are doctors in their first year of residency training ( officially the term intern is no longer in use ) . Although internists may act as primary care physicians , they are not family physicians , family practitioners , or general practitioners , whose training is not solely concentrated on adults and may include surgery , obstetrics , and pediatrics . The American College of Physicians defines internists as physicians who specialize in the prevention , detection and treatment of illnesses in adults . # Education and training of internists # The training and career pathways for internists vary considerably across the world . Many programs require previous undergraduate education prior to medical school admission . This pre-medical education is typically four or five years in length . Graduate medical education programs , which vary in length by country . Medical education programs are tertiary-level courses , undertaken at a medical school attached to a university . In the United States , medical school consists of four years . Hence , gaining a basic medical education may typically take eight years , depending on jurisdiction and university . Following completion of entry-level training , newly graduated medical practitioners are often required to undertake a period of supervised practice before the licensure , or ' ' registration ' ' , is granted , typically one or two years . This period may be referred to as internship , conditional registration , or foundation programme . Then , doctors may finally follow specialty training in internal medicine if they wish , typically being selected to training programs through competition . In North America , this period of postgraduate training is referred to as residency training , followed by an optional fellowship if the internist decides to train in a subspecialty . In Commonwealth countries , during that training period in internal medicine , trainees are often called senior house officers , and advance to registrar grade when they undergo a compulsory subspecialty training whilst commonly continuing service provision in the main speciality . In the United States , residency training for internal medicine lasts three years . # Certification of specialists # In the United States , three organizations are responsible for certification of trained internists ( i.e. , doctors who have completed an accredited residency training program ) in terms of their knowledge , skills , and attitudes that are essential for excellent patient care : the American Board of Internal Medicine , the American Osteopathic Board of Internal Medicine and the Board of Certification in Internal Medicine . # Subspecialties # # United States # In the United States , two organizations are responsible for certification of subspecialists within the field : the American Board of Internal Medicine and the American Osteopathic Board of Internal Medicine . Physicians ( not only internists ) that successfully pass board exams get board certified status , and , as of 2011 , earn on average an 88.8% higher salary in the USA. # #American Board of Internal Medicine# # The following are the subspecialties recognized by the American Board of Internal Medicine . Adolescent medicine Cardiology , dealing with disorders of the heart and blood vessels Clinical cardiac electrophysiology Critical care medicine Endocrinology , dealing with disorders of the endocrine system and its specific secretions called hormones Gastroenterology , concerned with the field of digestive diseases Geriatric medicine Hematology , concerned with blood , the blood-forming organs and its disorders . Hospital medicine Infectious disease , concerned with disease caused by a biological agent such as by a virus , bacterium or parasite Interventional cardiology Medical oncology , dealing with the chemotherapeutic ( chemical ) treatment of cancer Nephrology , dealing with the study of the function and diseases of the kidney Pulmonology , dealing with diseases of the lungs and the respiratory tract Rheumatology , devoted to the diagnosis and therapy of rheumatic diseases . Sleep medicine Sports medicine Transplant hepatology Internists may also specialize in allergy and immunology . The American Board of Allergy , Asthma , and Immunology is a conjoint board between internal medicine and pediatrics . # #American College of Osteopathic Internists# # The American College of Osteopathic Internists recognizes the following subspecialties : Allergy/Immunology Cardiology Critical care medicine Endocrinology Gastroenterology Geriatric medicine Hematology/Oncology Infectious diseases Nuclear medicine Nephrology Pulmonology Rheumatology # United Kingdom # In the United Kingdom , the three medical Royal Colleges ( the Royal College of Physicians of London , the Royal College of Physicians of Edinburgh and the Royal College of Physicians and Surgeons of Glasgow ) are responsible for setting curricula and training programmes through the Joint Royal Colleges Postgraduate Training Board ( JRCPTB ) , although the process is monitored and accredited by the General Medical Council ( which also maintains the specialist register ) . Doctors who have completed medical school spend two years in foundation training completing a basic postgraduate curriculum . After two years of Core Medical Training ( CT1/CT2 ) and attaining the Membership of the Royal College of Physicians , physicians commit to one of the medical specialties :  Acute medicine ( with possible accreditations in stroke medicine or pre-hospital emergency medicine )  Allergy  Audiovestibular medicine  Cardiology ( with possible accreditation in stroke medicine )  Clinical genetics  Clinical neurophysiology  Clinical pharmacology and therapeutics ( with possible accreditation in stroke medicine )  Dermatology  Endocrinology and diabetes mellitus  Gastroenterology ( with possible accreditation in hepatology )  General ( internal ) medicine ( with possible accreditation in metabolic medicine or stroke medicine )  Genito-urinary medicine  Geriatric medicine ( with possible accreditation in stroke medicine )  Hematology  Immunology  Infectious diseases  Medical oncology ( clinical or radiation oncology falls under the Royal College of Radiologists , although entry is through CMT and MRCP is required )  Medical ophthalmology  Neurology ( with possible accreditation in stroke medicine )  Nuclear medicine  Pediatric cardiology ( the only pediatric subspecialty not under the Royal College of Paediatrics and Child Health )  Palliative medicine  Pharmaceutical medicine  Rehabilitation medicine ( with possible accreditation in stroke medicine )  Renal medicine  Respiratory medicine  Rheumatology  Sport and exercise medicine  Tropical medicine Many training programmes provide dual accreditation with general ( internal ) medicine and are involved in the general care to hospitalized patients . These are acute medicine , cardiology , clinical pharmacology and therapeutics , endocrinology and diabetes mellitus , gastroenterology , infectious diseases , renal medicine , respiratory medicine and ( often ) rheumatology . The role of general medicine , after a period of decline , was reemphasized by the Royal College of Physicians of London report from the Future Hospital Commission ( 2013 ) . # Medical diagnosis and treatment # Medicine is mainly focused on the art of diagnosis and treatment with medication , but many subspecialties administer surgical treatment :  Cardiology : angioplasty , cardioversion , cardiac ablation , intra-aortic balloon pump  Critical care medicine : mechanical ventilation  Gastroenterology : endoscopy and ERCP  Nephrology : dialysis  Pulmonology : Bronchoscopy # See also # Royal College of Physicians and Surgeons of Canada Royal Australasian College of Physicians 
@@216516 Health Canada ( ' ' French : Sant Canada ' ' ) is the department of the government of Canada with responsibility for national public health . The current Minister of Health is Rona Ambrose , a Conservative Member of Parliament appointed to the position by Prime Minister Stephen Harper . # Branches , regions and agencies # Health Canada has the following branches , regions and agencies : # Ministers and officers # Minister of Health Deputy Minister - George Da Pont Associate Deputy Minister - Paul Glover Chief Public Health Officer # Branches # Audit &amp; Accountability Bureau Chief Financial Officer Branch Corporate Services Branch First Nations &amp; Inuit Health Branch Healthy Environments &amp; Consumer Safety Branch Health Products &amp; Food Branch Public Affairs , Consultation and Communications Branch Regions and Programs Branch Strategic Policy Branch Departmental Secretariat Legal Services Pest Management Regulatory Agency ( operates as a branch ) # Agencies # Public Health Agency of Canada Assisted Human Reproduction Canada Canadian Institutes of Health Research Hazardous Materials Information Review Commission Patented Medicines Prices Review Board # Offices # Office of the Cameron Visiting Chair Office of the Chief Dental Officer The National Office of the Workplace Hazardous Materials Information System Nurse Recruitment Public Services Health Medical Centre # Laboratories # Laboratory Centre for Disease Control Sir Frederick G Banting Research Centre # Compliance and Enforcement # The Compliance and Enforcement Directorate supports Health Canada 's mission to help Canadians maintain and improve their health by enforcing the laws and regulations related to the production , distribution , importation , sale and/or use of consumer products , tobacco , pest control products , drugs , biologics , medical devices and natural health products . The Directorate conducts inspections and investigations to ensure products are safe , of good quality , and properly labelled and distributed , in order to better protect Canadians from potentially harmful products and consumables . Compliance and Enforcement Directorate is divided into six distinct programs : Canada Vigilance Program Controlled Substances Program Inspectorate Program Pesticide Control Program Product Safety Program Tobacco Control Program # Related legislation # Acts for which Health Canada has Total or Partial Responsibility  Assisted Human Reproduction Act  Canada Health Act  Canadian Centre on Substance Abuse Act  Canadian Environmental Protection Act , 1999  Canadian Institutes of Health Research Act  Controlled Drugs and Substances Act  Comprehensive Nuclear Test-Ban Treaty Implementation Act ( Not in force )  Department of Health Act  Financial Administration Act  Fitness and Amateur Sport Act  Food and Drugs Act  Hazardous Materials Information Review Act  Hazardous Products Act  Patent Act  Pest Control Products Act  Pesticide Residue Compensation Act  Quarantine Act , 2005  Radiation Emitting Devices Act  Tobacco Act &amp; Act to Amend the Tobacco Act ( Sponsorship ) Acts for which Health Canada is Involved or has a Special Interest  Broadcasting Act  Canada Labour Code  Canada Medical Act  Canada Shipping Act  Canadian Food Inspection Agency Act  Emergency Preparedness Act  Energy Supplies Emergency Act  Excise Tax Act  Federal-Provincial Fiscal Arrangements Act  Feeds Act  Immigration and Refugee Protection Act  National Parks Act  Nuclear Safety and Control Act  Non-Smokers Health Act  Queen Elizabeth II Canadian Research Fund Act  Trade Marks Act # Criticisms # An editorial published by the Canadian Medical Association Journal has called for Health Canada to more strictly regulate natural health products . The editorial cited weaknesses in current legislation that allow natural health products to make baseless health claims , to neglect side-effects research prior to products reaching market , and to be sold without being evaluated by Health Canada . On Sept 12 a report on CBC television questioned the safety of drugs sold in North America . The Brandon Sun reported that Health Canada is secretive about inspections about drugs manufactured overseas , leaving the public unsure about the safety of these drugs . 
@@224130 footnotes = The Public Health Service Act of 1944 structured the United States Public Health Service ( PHS ) , founded 1798 , as the primary division of the U.S. Department of Health , Education and Welfare ( HEW ) , ( which was established in 1953 ) , which later became the United States Department of Health and Human Services in 1979-1980 , ( when the Education agencies were separated into their own U.S. Department of Education ) . The Office of the Surgeon General was created in 1871 . The PHS comprises all Agency Divisions of Health and Human Services and the Commissioned Corps . The Assistant Secretary for Health ( ASH ) oversees the PHS and the United States Public Health Service , Commissioned Corps. # Agencies # Agencies within the Public Health Service  Agency for Healthcare Research and Quality ( AHRQ )  Agency for Toxic Substances and Disease Registry ( ATSDR )  Centers for Disease Control and Prevention ( CDC )  Food and Drug Administration ( FDA )  Health Resources and Services Administration ( HRSA )  Indian Health Service ( IHS )  National Institutes of Health ( NIH )  Substance Abuse and Mental Health Services Administration ( SAMHSA ) # United States Public Health Service Commissioned Corps # The United States Public Health Service Commissioned Corps ( PHSCC ) employs more than 6,000 public health professionals for the purpose of delivering public health promotion and disease prevention programs and advancing public health science . Members of the Commissioned Corps often serve on the frontlines in the fight against disease and poor health conditions . As one of the United States seven uniformed services , the PHS Commissioned Corps fills public health leadership and service roles within federal government agencies and programs . The PHS Commissioned Corps includes officers drawn from many professions , including environmental and occupational health , medicine , nursing , dentistry , pharmacy , psychology , social work , hospital administration , health record administration , nutrition , engineering , science , veterinary , health information technology , and other health-related occupations . Officers of the Corps wear uniforms similar to those of the United States Navy with special PHSCC insignia , and the Corps uses the same commissioned officer ranks as the U.S. Navy , the U.S. Coast Guard , and the Commissioned Officer Corps of the National Oceanic and Atmospheric Administration from ensign to admiral , uniformed services pay grades O-1 through O-10 respectively . # Mission # The mission of the U.S. Public Health Service Commissioned Corps is to protect , promote , and advance the health and safety of the United States . According to the PHSCC , this mission is achieved through rapid and effective response to public health needs , leadership and excellence in public health practices , and advancement of public health science . # History # The origins of the Public Health Service can be traced to the passage , by the 5th Congress of the United States , of An Act for the Relief of Sick and Disabled Seamen in 1798 . The earliest Marine Hospitals created to care for the seamen were located along the East Coast , at the harbors of the major port cities , with Boston being the site of the first such facility , followed later by others including in the Baltimore vicinity at Curtis Bay . Later they were also established during the 1830s and 1840s along inland waterways , the Great Lakes , and the Gulf of Mexico . By the 1850s to the Pacific Coasts as the country expanded westward . Funding for the hospitals was provided by a mandatory tax of about 1% of the wages of all maritime sailors . A reorganization in 1870 converted the loose network of locally controlled hospitals into a centrally controlled Marine Hospital Service , with its headquarters in Washington , D.C. The position of Supervising Surgeon ( later titled the Surgeon General ) was created to administer the Service , and John Maynard Woodworth , ( 1837-1879 ) , was appointed as the first incumbent in 1871 . He moved quickly to reform the system and adopted a military model for his medical staff , instituting examinations for applicants and putting his physicians in uniforms . Woodworth created a cadre of mobile , career service physicians who could be assigned as needed to the various Marine Hospitals . The commissioned officer corps ( now known as the Commissioned Corps of the U.S. Public Health Service or the Public Health Service , Commissioned Corps ) was established by legislation in 1889 , and signed by 22nd/24th President Grover Cleveland . At first open only to physicians , over the course of the 20th Century , the Corps expanded to include veterinarians , dentists , physician assistants , sanitary engineers , pharmacists , nurses , environmental health officers , scientists , and other types of health professionals . The scope of activities of the Marine Hospital Service also began to expand well beyond the care of merchant seamen in the closing decades of the nineteenth century , beginning with the control of infectious disease . Quarantine was originally a State function rather than Federal , but the National Quarantine Act of 1878 vested quarantine authority to the Marine Hospital Service and the National Board of Health . The National Board was not reauthorized by Congress in 1883 and its powers reverted to the Marine Hospital Service . Over the next half a century , the Marine Hospital Service increasingly took over quarantine functions from State authorities . As immigration increased dramatically in the late 19th Century , the Federal Government also took over the processing of immigrants from the States , beginning in 1891 . The Marine Hospital Service was assigned the responsibility for the medical inspection of arriving immigrants at sites such as Ellis Island in New York Harbor . Commissioned officers played a major role in fulfilling the Service 's commitment to prevent disease from entering the country . Because of the broadening responsibilities of the Service , its name was changed in 1902 to the Public Health and Marine Hospital Service , and again in 1912 to just the Public Health Service , as the emphasis and decommissioning of the various old Marine Hospitals began . The Service continued to expand its public health activities as the Nation entered the 20th Century , with the PHS 's Commissioned Corps leading the way . As the century progressed , PHS commissioned officers served their country by controlling the spread of contagious diseases such as smallpox and yellow fever , conducting important biomedical research , regulating the food and drug supply , providing health care to underserved groups , supplying medical assistance in the aftermath of disasters , and in numerous other ways . Today the mission of the Commissioned Corps of the PHS is Protecting , promoting , and advancing the health and safety of the Nation . # ' ' Tuskegee Study of Untreated Syphilis in the Black Male ' ' # In 1932 , the Public Health Service , working with the Tuskegee Institute in Tuskegee , Alabama , began a study to record the natural history of syphilis in hopes of justifying treatment programs for blacks . It was called the ' ' Tuskegee Study of Untreated Syphilis in the Negro Male ' ' . The study initially involved 600 black men 399 with syphilis , 201 who did not have the disease . The study was conducted without the benefit of patients ' informed consent . Researchers told the men they were being treated for bad blood , a local term referring to several ailments , including syphilis , anemia , and fatigue . In truth , they did not receive the proper treatment needed to cure their illness . In exchange for taking part in the study , the men received free medical exams , free meals , and burial insurance . Although originally projected to last 6 months , the study actually went on for 40 years . It has been called arguably the most ' infamous ' biomedical research study in U.S. history . # Syphilis Studies in Guatemala # A USPHS physician who took part in the 1932-1972 Tuskegee program , John Charles Cutler , was in charge of the U.S. government 's syphilis experiments in Guatemala , in which in the Central American Republic of Guatemala , Guatemalan prisoners , soldiers , orphaned children , and others were deliberately infected with syphilis and other sexually-transmitted diseases from 1946-1948 , ( coincidentally at a time of civil unrest and turmoil in the country including later alleged CIA involvement by 1954 in a coup de etat ) in order to scientifically study the disease , in a project funded by a grant from the National Institutes of Health of the United States in Bethesda , Maryland . Secretary of State Hillary Clinton apologized to the Republic of Guatemala for this program in 2010 , in light of the now serious ethical lapses in moral judgement which occurred , even just 60 years ago . # Emergency response since 1999 # Commissioned Corps emergency response teams are managed by the Office of the Surgeon General . They are trained and equipped to respond to public health crises and national emergencies , such as natural disasters , disease outbreaks , or terrorist attacks . The teams are multidisciplinary and are capable of responding to domestic and international humanitarian missions . Officers have responded to many such emergencies in the past , including :  1999 - Hospital center at Fort Dix , New Jersey , for Kosovo Refugees  2001 - September 11 attacks  2001 - 2001 anthrax attacks  2004 - 2004 Indian Ocean earthquake and tsunami  2005 - Hurricane Katrina  2005 - Hurricane Rita  2006 - 2006 Hawaii earthquake  2007 - Medicine Contamination in Panama  2008 - Hurricane Gustav  2008 - Hurricane Ike  2009 - 2009 Samoa earthquake  2010 - 2010 Haiti earthquake  2010 - Deepwater Horizon oil spill  2011 - 2011 Japan Tsunami and Earthquake  2012 - Hurricane Sandy - New York/New Jersey coastal areas 
@@227123 The United States Occupational Safety and Health Administration ( OSHA ) is an agency of the United States Department of Labor . Congress established the agency under the Occupational Safety and Health Act , which President Richard M. Nixon signed into law on December 29 , 1970 . OSHA 's mission is to assure safe and healthful working conditions for working men and women by setting and enforcing standards and by providing training , outreach , education and assistance . The agency is also charged with enforcing a variety of whistleblower statutes and regulations . OSHA is currently headed by Assistant Secretary of Labor David Michaels. # History # OSHA officially formed on April 28 , 1971 , the date that the OSH Act became effective . George Guenther was appointed as the agency 's first director . OSHA has developed a number of training , compliance assistance , and health and safety recognition programs throughout its history . The OSHA Training Institute , which trains government and private sector health and safety personnel , began in 1972 . In 1978 , the agency began a grantmaking program , now called the Susan Harwood Training Grant Program , to train workers and employers in reducing workplace hazards . OSHA started the Voluntary Protection Programs in 1982 , which allows employers to apply as model workplaces to achieve special designation if they meet certain requirements . # Health and safety standards # The Occupational Safety and Health Act allows OSHA to issue workplace health and safety regulations . These regulations include limits on chemical exposure , employee access to information , requirements for the use of personal protective equipment , and requirements for safety procedures . In its first year of operation , OSHA was permitted to adopt regulations based on guidelines set by certain standards organizations , such as the American Conference of Governmental Industrial Hygienists , without going through all of the requirements of a typical rulemaking . In 2000 , OSHA issued an ergonomics standard . In March 2001 , Congress voted to repeal the standard through the Congressional Review Act . The repeal , one of the first major pieces of legislation signed by President George W. Bush , is the only instance that Congress has successfully used the Congressional Review Act to block a regulation . Between 2001 and 2011 , OSHA has issued just four new health and safety standards ; during this period , the agency has promulgated regulations at a far slower rate than during any other decade in the agency 's history . # Enforcement # OSHA is responsible for enforcing its standards on regulated entities . The agency sends Compliance Safety and Health Officers to work sites , where they carry out inspections and assess fines for regulatory violations . Inspections are planned for work sites in particularly hazardous industries . Inspections can also result in response to workplace incidents , worker complaints or referrals by other individuals . OSHA covers approximately 7 million workplaces . According to a report by AFLCIO , it would take OSHA 129 years to inspect all workplaces under its jurisdiction . # Complaint reporting system # Those authorized to report workplace safety issues include :  An authorized representative of an employee bargaining unit , such as a certified or recognized labor organization .  An attorney acting for an employee .  Any other person acting in a ' ' bona fide ' ' representative capacity , including , but not limited to , members of the clergy , social workers , spouses and other family members , and government officials or nonprofit groups and organizations acting upon specific complaints and injuries from individuals who are employees . # Exemptions # Certain workplaces are exempted from OSHA inspections because they fall outside of the scope of the Occupational Safety and Health Act , are regulated by other agencies , or are exempted through Department of Labor appropriations bills . Exempted workers include :  Mine and quarry workers ( regulated by the Mine Safety and Health Administration )  Independent contractors and other self-employed individuals  Public sector employees ( covered only in jurisdictions with state plans ; the United States Postal Service is covered under the Postal Employees Safety Enhancement Act )  Domestic workers ( workers whose workplace is a household )  Flight crews ( covered by the Federal Aviation Administration )  Farms employing only family members and farms employing fewer than 10 employees with no migrant labor housing Additionally , workplaces participating in OSHA 's Voluntary Protection Programs are exempted from programmatic inspections , though they can still be subject to accident- , complaint- , or referral-initiated inspections. # Whistleblower laws # In addition to enforcing regulations issued under the Occupational Safety and Health Act , OSHA is also responsible for enforcing whistleblower provisions of 21 statutes . Over the years , Congress has designated OSHA as responsible for enforcing these laws , regardless of their relationship to occupational safety and health matters . Most recently , Congress designated OSHA as the agency responsible for enforcing the whistleblower provisions of the Dodd-Frank Wall Street Reform and Consumer Protection Act . # State plans # Under the Occupational Safety and Health Act , U.S. states and territories are permitted to adopt federally approved occupational safety and health plans . These plans , which replace federal OSHA enforcement and receive partial funding from the federal government , are required to be at least as effective in protecting workers as OSHA . They are also required to cover public sector employees ( federal OSHA does not cover such workers ) . Twenty-two states administer occupational safety and health plans . An additional five jurisdictions , Connecticut , New York , New Jersey , Illinois , and the Virgin Islands , have occupational safety and health plans that exclusively cover public sector workers and do not supplant federal OSHA in private sector enforcement . # Controversy # Much of the debate about OSHA regulations and enforcement policies revolves around the cost of regulations and enforcement , versus the actual benefit in reduced worker injury , illness and death . A 1995 study of several OSHA standards by the Office of Technology Assessment ( OTA ) found that regulated industries as well as OSHA typically overestimate the expected cost of proposed OSHA standards . OSHA has come under considerable criticism for the ineffectiveness of its penalties , particularly its criminal penalties . The maximum penalty is a misdemeanor with a maximum of 6-months in jail . In response to the criticism , OSHA , in conjunction with the Department of Justice , has pursued several high-profile criminal prosecutions for violations under the Act , and has announced a joint enforcement initiative between OSHA and the United States Environmental Protection Agency ( EPA ) which has the ability to issue much higher fines than OSHA . Meanwhile , Congressional Democrats , labor unions and community safety and health advocates are attempting to revise the OSH Act to make it a felony with much higher penalties to commit a willful violation that results in the death of a worker . Some local prosecutors are charging company executives with manslaughter and other felonies when criminal negligence leads to the death of a worker . During its more than 40 years of existence , OSHA has secured only 12 criminal convictions . OSHA has been accused of being more devoted to the numbers of inspections than to actual safety . Industry associations and unions have resorted to court action to force OSHA to promulgate new standards such as the Hexavalent Chromium standard . OSHA has also been criticized for taking decades to develop new regulations . Speaking about OSHA on the specific issue of combustible dust explosions : # Carolyn Merritt was appointed to the Chemical Safety Board by President Bush . Asked what her experience has been with regard to safety regulations in the Bush administration , Merritt says , ' The basic disappointment has been this attitude of no new regulation . They do n't want industry to be pestered . In some instances , industry has to be pestered in order to comply . ' # # See also #  American Society of Safety Engineers  Construction site safety  Ergonomics  Voluntary Protection Programs Participants ' Association  Mine Safety and Health Administration ( MSHA )  MIOSHA  National Institute for Occupational Safety and Health ( NIOSH )  Occupational safety and health  Occupational fatality  Oregon OSHA  Regulatory Flexibility Act  OSHA History  U.S. Chemical Safety and Hazard Investigation Board  OSHA Official 1910.1030 Bloodborne Pathogen Regulation 
@@242729 leadertitle2 =CAO ( Municipal Services ) footnotes = Medicine Hat is a city of 61,180 people in southeast Alberta , Canada . It is approximately 169km mi east of Lethbridge and 295km mi southeast of Calgary . This city and the adjacent Town of Redcliff to the northwest are surrounded by Cypress County . It is situated on the Trans-Canada Highway ( Highway 1 ) , the eastern terminus of the Crowsnest Highway , and the South Saskatchewan River . Nearby communities considered part of the Medicine Hat area include the Town of Redcliff ( located immediately adjacent to the city 's northwest boundary ) and the hamlets of Desert Blume , Dunmore , Irvine , Seven Persons , and Veinerville . The Cypress Hills ( including Cypress Hills Interprovincial Park ) is a relatively short distance ( by car ) to the southeast of the city . Historically , Medicine Hat has been known for its large natural gas fields , being immortalised by Rudyard Kipling as having all hell for a basement . Because of these reserves , the city is known as The Gas City . It is Alberta 's sixth largest city . In October 2008 , Medicine Hat was named one of Alberta 's Top Employers by Mediacorp Canada Inc. , which was announced by the ' ' Calgary Herald ' ' and the ' ' Edmonton Journal ' ' . # History # # Name origins # The name Medicine Hat is the English translation of <nowiki> ' </nowiki> ' ' Saamis ' ' <nowiki> ' </nowiki> ( SA-MUS ) the Blackfoot word for the eagle tail feather headdress worn by medicine men or ' Medicine Hat ' . Several legends are associated with the name from a mythical mer-man river serpent named ' Soy-yee-daa-bee ' the Creator who appeared to a hunter and instructed him to sacrifice his wife to get mystical powers which were manifest in a special hat . Another legend tells of a battle long ago between the Blackfoot and the Cree in which a retreating Cree Medicine Man lost his headdress in the South Saskatchewan River . A number of factors have always made Medicine Hat a natural gathering place . Prior to the arrival of Europeans the Blackfoot , Cree and Assiniboine nations used the area for hundreds of years . The gently sloping valley with its converging water ways and hardy native cottonwood trees attracted both man and the migratory bison herds which passed through the area . # Founding # In 1883 , when the Canadian Pacific Railway ( CPR ) reached Medicine Hat and crossed the river a town site was established using the name from the Indian legends . As the west developed , Medicine Hat became instrumental with the development of the first hospital past Winnipeg in 1889 and as a CPR divisional point . It was incorporated as a town on October 31 , 1898 , and as a city on May 9 , 1906 . Medicine Hat is halfway between Winnipeg and Vancouver . # Progress and growth # Rich in natural resources including natural gas , coal , clay , and farmland , the town was known in the early days as the Pittsburgh of the West . A number of large industries located here , under the inducement of cheap and plentiful energy resources . Coal mines , brick works , pottery and glass bottle manufacturing plants , flour mills , etc. became established . The agricultural potential of the surrounding area , both in crop and livestock , also made the town a viable service centre with a well established transportation route . An economic boom was experienced between 19091914 bringing the population to over 10,000 . Little growth occurred between the World Wars , although the population swelled in the mid-1940s due to the town hosting one of the largest Second World War P.O.W. camps in Canada . It was not until the 1950s that the town again experienced significant commercial development . Today , Medicine Hat prides itself as one of the most economical places to live in Canada , with its unique city-owned gas utility and power generation plant being predominant factors . Major industries have included chemical plants , a Goodyear tire and rubber plant , greenhouses , numerous oil and gas related companies , a foundry , I-XL Industries ( a brickworks dating from the 1880s ) , to name a few . # Geography # The Medicine Hat landscape is dominated by the South Saskatchewan River valley . In addition to this major river , both the Seven Persons Creek and Ross Creek empty into the South Saskatchewan River within the City of Medicine Hat boundary . The presence of these water bodies provide for a dramatic valley landscape with numerous cliffs , and finger coulees throughout the city . Beyond the city and river valley the land is flat to slightly rolling and is characterized by short-grass vegetation . Medicine Hat is also known as Canada 's sunniest city . Forty kilometres ( about twenty-five miles ) to the east at lies the Badlands Guardian Geological Feature . It is a landscape formation taking the form of a head wearing a feathered headdress . The head is 1000 ft wide . It is in inverse relief , formed by valleys rather than raised ground . # Climate # Located in the steppe region known as Palliser 's Triangle , Medicine Hat has a semi-arid , continental climate ( Kppen climate classification ' ' BSk ' ' ) , with cold , dry winters and warm to hot summers . However , the winter cold is occasionally ameliorated by mild and dry chinook winds blowing from the west , and hot summer daytime temperatures are made more tolerable by low humidity and rapid cooling in the evening hours . Medicine Hat receives less precipitation annually than most other cities on the Canadian Prairies and plentiful sunshine ( widely known as The sunniest city in Canada ) , making it a popular retirement city . Maximum precipitation typically occurs in the late spring and early summer . # Neighbourhoods # Cottonwood A community located above the Cottonwood golf course , between the light industrial area and the airport . Overlooks the World 's Largest Teepee. Crescent Heights Mainly built in the 1950s through to the 1960s . Located on the north side of city on the entire hill above the river valley . Crestwood and Norwood This is an older area of town mainly built in the 1950s . It is located on a plateau southeast of the South Flats and the Seven Person 's Creek . The Medicine Hat Stampede and Exhibition centre is within this area . Hamptons - A four-phase neighbourhood approved for development in 2005 . It is located in south Medicine Hat , and is bounded by South Boundary Road to the south , 13 Avenue SE to the east , South Vista Heights to the west and Southridge to the north . It features architectural controls implemented by the developer . North Flats The oldest area in Medicine Hat . Located northeast of the CPR marshaling yards near the South Saskatchewan River and downtown . An inner-city neighbourhood that is home to residential and industrial uses . This area is in the east valley . Park Meadows An area that was developed in the 1990s , adjacent to Crestwood . Primarily residential with several apartments . Parkview A subdivision developed in the 1990s , and located north of the South Saskatchewan River . It is adjacent to Police Point Park and Medicine Hat Golf and Country Club . Ranchlands A neighbourhood developed in the mid 2000s and located in the northeast sector of the city . The neighborhood includes residential lands both above and in the South Saskatchewan River valley . River Heights Located on the Southwest Hill north of the hospital , and south of the South Saskatchewan River . Includes River Heights Elementary School and an extended care wing , which was originally a part of the hospital . Riverside A mature inner-city neighbourhood along the north bank of the South Saskatchewan River . The community has experienced gentrification . Mature trees and boulevards line the streets . Ross Glen Low density middle-class neighbourhood located in the southeast end of the city . Saamis Heights Located west of South Ridge in the south sector of the city . Saamis Heights was developed in under five years . The community borders the Seven Person 's Creek valley and thus provides some walkout view lots . South Flats Located south of the CPR marshaling yard , also in the valley , and adjacent to downtown . South Ridge The first residential development south of the Trans Canada Highway . First developed in the late 1970s . Adjacent to the World 's Largest Teepee. South Vista Heights A new residential suburban community south of the Trans Canada Highway . Southeast Hill One of the oldest areas of the city . It originally overlooked downtown on the north side of the hill and Kin Coulee on the south side . Originally this area housed CPR workers . It is home to four schools . Southlands A community that opened in 2007 . It is home to a significant regional commercial centre including Wal-Mart , Staples , Canadian Tire and Home Depot . The residential community includes parks , future school sites , many low residential lots , and several large multi-family sites . Southview Located in the southeast part of the city between Ross Glen and Crestwood. Southwest Hill Located west of Division Avenue next to the SE Hill area . It is home to five schools and the city 's hospital . # # Housing # # The average home price in Medicine Hat as of the end of September 2012 was $258,535. # Demographics # The population of the City of Medicine Hat according to its 2012 municipal census is 61,180 , a 0.1% increase over its 2009 municipal census population of 61,097 . In the 2011 Census , the City of Medicine Hat had a population of 60,005 living in 25,445 of its 27,342 total dwellings , a 5.3% change from its 2006 population of 56,997 . With a land area of 112.01km2 sqmi , it had a population density of in 2011 . Also in 2011 , the Medicine Hat population centre had a population of 65,671 , while the Medicine Hat census agglomeration had a population of 72,807 . The population centre includes the adjacent Town of Redcliff to the northwest and a small portion of Cypress County to the east that includes the Hamlet of Veinerville , while the census agglomeration includes Redcliff and Cypress County in its entirety . In 2006 , Medicine Hat had a population of 56,997 living in 24,729 dwellings , an 11.2% increase from 2001 . The city has a land area of 112.01km2 sqmi and a population density of 508.9/km2 /sqmi . More than 89 percent of residents identified English as their first language at the time of the 2006 census , while 6 percent identified German and just over 1 percent each identified Spanish and French as their first language learned . The next most common languages were Ukrainian , Chinese , Dutch , and Polish . More than 79 percent of residents identified as Christian at the time of the 2001 census while almost 20 percent indicated they had no religious affiliation . For specific denominations Statistics Canada counted 16,175 Roman Catholics ( 26.5 percent ) , 9,445 members of the United Church of Canada ( 15.5 percent ) , and 6,170 Lutherans ( slightly more than 10 percent ) . Less numerous denominations included 3,780 Anglicans ( more than 6 percent ) , 1,745 members of the Evangelical Missionary Church ( almost 3 percent ) , 1,470 Baptists ( over 2 percent ) , 1,220 identifying as Pentecostal ( 2 percent ) , 1,220 Latter-day Saints ( 2 percent ) , and 675 Presbyterians ( just over 1 percent ) . # Arts and culture # -- # Attractions # The Medicine Hat Clay Industries National Historic District is a living , working museum that offers a unique and extensive experience through collections , exhibits , interpretation , guided tours and educational and artistic programming . The Medalta Potteries and Hycroft China Factory Complexes are the focal points in this 150acrekm2 1 region . This nationally recognized industrial historic district is a cultural initiative of the Friends of Medalta Society with Federal , Provincial , Municipal and Private support . Restoration , preservation and cultural development of the Medicine Hat Clay Industries National Historic District for the purpose of education and public enjoyment is ongoing . Just south of the Trans-Canada Highway and overlooking the Blackfoot buffalo jump is the world 's tallest teepee , the Saamis Teepee . Designed for the 1988 Winter Olympics in Calgary as a symbol of Canada 's Aboriginal heritage , it was moved to Medicine Hat in 1991 . It stands over 20 stories high and was designed to withstand extreme temperatures and winds up to 240 km/h ( 150 mph ) . During a January 2007 windstorm , a portion of the teepee was damaged . Upon further inspection , it was discovered that extensive weathering was partially to blame . After repairs were complete , the Saamis Teepee now stands approximately 15 ft shorter . The Medicine Hat Family Leisure Centre is the largest indoor multi-purpose facility in the city . The building is 90000sqftm2 -3 and is sited on 57 acre in the north end of the city . The facility includes an Olympic-sized ice rink , 50m pool , waterslide , diving platforms , kiddies pool , wave pool and cafe . In the area surrounding the Leisure Centre facility there are several other sporting venues including ; 4 ball diamonds , lighted football field , 3 soccer pitches and one of the largest BMX racing facilities in Southern Alberta . Located in downtown Medicine Hat , The Esplanade is a large multi purpose cultural centre . The facility features a 700+ seat performing arts theatre , art gallery , museum , archives , gift shop , and cafe . The Esplanade officially opened in October 2005 . The Medicine Hat Drag Racing Association is located just off the Trans Canada Highway on Boundary Road or the spectators entrance on Box Springs Road . This is Alberta 's only sanctioned NHRA track and is a 1/4 mile in length . The facility proudly supports affordable family entertainment and encourages people to race the strip , not the street . The seasons typically run from May till September hosting a variety of events from jet and alcohol cars , bracket racing and the NHRA National open which attracts approx. 300+ cars from all over North America . Medicine Hat Public Library is located across the street from The Esplanade . It has over 10,000 annual members and is the resource library for the Shortgrass Library System of Southern Alberta . # Parks # There are over 100 km of walking trails in the city . All of the major parks are linked by the extensive trail system . Police Point Park was an early North-West Mounted Police outpost , and the park is now a 300acrekm2 1 nature-lovers ' dream with shale paths next to the South Saskatchewan River . It is also one of Southern Alberta 's well known birding destinations . The park encompasses The Medicine Hat Interpretive Program building , where they run programs and inform the public about the happenings of nature around the city . Strathcona Island Park is located along the south bank of the South Saskatchewan River . The park has 5 km of walking trails , playgrounds , a water park , ball diamonds , a pavilion centre , washrooms , ice skating , kitchens and fire pits . The park is heavily treed. Kin Coulee Park is located along the banks of the Seven Persons Creek . This 100acrekm2 1 park is almost entirely manicured . The park features a skateboard park , 2 ball diamonds , beach volleyball courts , fire pits , a band shell , washrooms , and 2 playgrounds . It 's also the venue for the annual Canada Day festival and fireworks. Echodale Regional Park is a 650 acre ( 2.6 km ) park that includes an artificial swimming lake . Amenities include a beach , walking trails , fire pits , canoe rentals , paddle boats , snack bar , washrooms and historic ranch . Central Park located in the Southeast Hill neighborhood is surrounded by large cottonwood trees and , on the north side , a row of cedar trees . It also has play structures and a spray-deck . A street basketball court can be found here , which is usually in full use during the summer months . Riverside Veterans ' Memorial Park located downtown across River Road from the South Saskatchewan river and across 6th Avenue from city hall is home to the city 's Cenotaph , a WWII era Sherman tank , a brick mural by James Marshall and two Canadian Pacific Railway locomotives . # Sports # The city is home to the Medicine Hat Tigers , a major junior ice hockey team in the Western Hockey League ( WHL ) . Established in 1970 , the team has won seven division titles , five WHL league championships and back-to-back Canadian Hockey League ( CHL ) Memorial Cups in 1987 and 1988 in its history . Numerous Tigers alumni moved on to play in the National Hockey League ( NHL ) . # Government # Long-serving MP Monte Solberg revealed in September 2008 that he would not be running in the next election . LaVar Payne won election as MP for Medicine Hat in the subsequent election in October , 2008 , and again in 2011 . Both Solberg and Payne are members of the Conservative Party of Canada . # Infrastructure # Alberta Transportation is currently negotiating with landowners south of the city to secure land for the future Highway 1 ( Trans-Canada Highway ) bypass . Beginning in 2009 , several ICT business leaders began working together to facilitate economic growth and diversify the local economy by building a robust community network based on fiber optic technologies . # Education # Medicine Hat School District No. 76 has been serving the needs of public school students since it came into existence in 1886 . The District has five trustees and comprises three secondary schools , Alexandra Middle School ( formerly Alexandra Junior High School ) , Crescent Heights High School and Medicine Hat High School , 12 elementary ( K6 ) schools , a special needs school for the severely disabled , as well as an Alternative School program which incorporates a joint partnership with the YMCA Teen Moms ' Program , YMCA Stay-in-School Program , a program with the former Palliser Health Region for secondary students and a program supported by Alberta Children Services for students with behavioural needs . French immersion programming is provided as an option . The Medicine Hat Catholic/Separate School District provides educational programming for students from kindergarten through Grade 12 . French immersion programming is provided as an option in select District schools . It operates one high school , Monsignor McCoy , and nine other schools . Medicine Hat also has a Francophone school , cole Les Cyprs , and a public/charter school , the Centre for Academic and Personal Excellence ( CAPE ) . The Medicine Hat College is located in south Medicine Hat . The first students were accepted to the college in 1965 . Now with over 2,500 students and three campuses , the college has grown into an integral part of the community . The Medicine Hat College Rattlers athletic program include basketball , volleyball , golf , soccer and futsol. # Media # Medicine Hat has several radio and television stations broadcasting from it , as well as a few distant AM radio stations from Calgary . ' ' Medicine Hat News ' ' publishes a daily newspaper . # Military # Medicine Hat is home to the South Alberta Light Horse ( SALH ) , an army reserve unit . The SALH dates back to 1885 when it took part in the North-West Rebellion . Since then it has gained battle honours in the First and Second World Wars and today its members continue to serve overseas on United Nations and North Atlantic Treaty Organization missions . Currently the SALH has members serving in Afghanistan . Medicine Hat was also home to a British Commonwealth Air Training Plan airfield and a POW camp during the Second World War . Canadian Forces Base Suffield is located 50 km west of the city . It is estimated that the base contributes C$120 million annually to the local economy , principally through its two lodger units : British Army Training Unit Suffield , and Defence Research and Development Canada Suffield ) . # Notable residents #  Roloff Beny , artist and exhibitor  Terri Clark , country singer  Murray Craven , former professional hockey player  Glen Edwards , test pilot and namesake of Edwards Air Force Base  Daniel Federkeil , professional football player  Bruno Gerussi , actor  Clyde Gilmour , broadcaster , radio host , and officer of the Order of Canada  Darren Helm , professional hockey player  Corey Hirsch , former professional hockey player  Richard Hortness , Olympic swimmer  Kelly Hrudey , CBC ' ' Hockey Night in Canada ' ' commentator , former professional hockey player  Mike Hudema , social and environmental activist  Gordie Johnson , lead singer of Big Sugar  Matt Keetley , professional hockey player  Blaine Lacher , former professional hockey player  Trevor Linden , former professional hockey player , member of the Order of Canada , and recipient of the Order of British Columbia  Liam McFarlane world champion short track speed skater  Greg Morrison , former professional baseball player  Susan Nattrass , Olympian , competitive shooter , and officer of the Order of Canada  Jess Nowicki , Canadian Railroad Hall of Fame Inductee  Bud Olson , former Member of Parliament and Senator for Medicine Hat , former Lieutenant Governor of Alberta  Chris Osgood , former professional hockey player  Zaac Pick , singer-songwriter  Kalan Porter , singer-songwriter and winner of ' ' Canadian Idol ' ' ( season 2 )  Kenneth Sauer , former public schools superintendent , city alderman and member of the Order of Canada and the Alberta Order of Excellence  Richard Edward Taylor , co-recipient of the 1990 Nobel Prize for Physics  Arnold Tremere , Executive Director of the Canadian International Grains Institute ( government official )  Tommy Tweed , playwright , actor , broadcaster , recipient of the John Drainie Award , and officer of the Order of Canada # See also # List of communities in Alberta List of cities in Alberta Medicine Hat Tigers # References # 
@@244113 MedlinePlus = 001319 MeshID = D008193 Lyme disease ( Lyme borreliosis ) is an infectious disease caused by at least three species of bacteria belonging to the genus ' ' Borrelia ' ' . Early symptoms may include fever , headache , and fatigue . A rash occurs in 7080% of infected persons at the site of the tick bite after a delay of 330 days ( average is about 7 days ) , and may or may not appear as the well-publicized bull's-eye ( erythema migrans ) . The rash is only rarely painful or itchy , although it may be warm to the touch . About 2030% of infected persons do not experience a rash . Left untreated , later symptoms may involve the joints , heart , and central nervous system . In most cases , the infection and its symptoms are eliminated by antibiotics , especially if the illness is treated early . Delayed or inadequate treatment can lead to more serious symptoms , which can be disabling and difficult to treat . ' ' Borrelia burgdorferi sensu stricto ' ' is the main cause of Lyme disease in North America , whereas ' ' Borrelia afzelii ' ' and ' ' Borrelia garinii ' ' cause most European cases . ' ' Borrelia ' ' is transmitted to humans by the bite of infected ticks belonging to a few species of the genus ' ' Ixodes ' ' ( hard ticks ) . Lyme disease is the most common tick-borne disease in the Northern Hemisphere . The term chronic Lyme disease is controversial and not recognized in the medical literature , and most medical authorities advise against long-term antibiotic treatment for chronic Lyme disease . The first known existence of the ' ' Borrelia ' ' bacteria dates back to up to 20 million years ago . The disease is named after the towns of Lyme and Old Lyme , Connecticut , US , where a number of cases were identified in 1975 . Although it was known in 1978 that Lyme disease was a tick-borne disease , the cause of the disease remained a mystery until 1981 , when ' ' B. burgdorferi ' ' was identified by entomologist Dr. Willy Burgdorfer. # Signs and symptoms # Lyme disease can affect multiple body systems and produce a range of symptoms . Not all patients with Lyme disease will have all symptoms , and many of the symptoms are not specific to Lyme disease , but can occur with other diseases , as well . The incubation period from infection to the onset of symptoms is usually one to two weeks , but can be much shorter ( days ) , or much longer ( months to years ) . Symptoms most often occur from May to September , because the nymphal stage of the tick is responsible for most cases . Asymptomatic infection exists , but occurs in less than 7% of infected individuals in the United States . Asymptomatic infection may be much more common among those infected in Europe . # Early localized infection # Early localized infection can occur when the infection has not yet spread throughout the body . Only the site where the infection has first come into contact with the skin is affected . The classic sign of early local infection with Lyme disease is a circular , outwardly expanding rash called erythema chronicum migrans ( also erythema migrans or EM ) , which occurs at the site of the tick bite three to 30 days after the tick bite . The rash is red , and may be warm , but is generally painless . Classically , the innermost portion remains dark red and becomes indurated ( is thicker and firmer ) ; the outer edge remains red ; and the portion in between clears , giving the appearance of a bull 's eye . However , partial clearing is uncommon , and the bull's-eye pattern more often involves central redness . The EM rash associated with early infection is found in about 80% of patients and can have a range of appearances including the classic target bull's-eye lesion and nontarget appearing lesions . The 20% without the EM and the nontarget lesions can often cause misidentification of Lyme disease . Patients can also experience flu-like symptoms , such as headache , muscle soreness , fever , and malaise . Lyme disease can progress to later stages even in patients who do not develop a rash . # Early disseminated infection # Within days to weeks after the onset of local infection , the ' ' Borrelia ' ' bacteria may begin to spread through the bloodstream . EM may develop at sites across the body that bear no relation to the original tick bite . Another skin condition , apparently absent in North American patients , but found in Europe , is borrelial lymphocytoma , a purplish lump that develops on the ear lobe , nipple , or scrotum . Other discrete symptoms include migrating pain in muscles , joints , and tendons , and dizziness . Various acute neurological problems , termed neuroborreliosis , appear in 1015% of untreated patients . These include Bell 's palsy # Late disseminated infection # After several months , untreated or inadequately treated patients may go on to develop severe and chronic symptoms that affect many parts of the body , including the brain , nerves , eyes , joints , and heart . Many disabling symptoms can occur , including permanent impairment of motor or sensory function of the lower extremities in extreme cases . The associated nerve pain radiating out from the spine is termed Bannwarth syndrome , named after Alfred Bannwarth . The late disseminated stage is where the infection has fully spread throughout the body . Chronic neurologic symptoms occur in up to 5% of untreated patients . A polyneuropathy that involves shooting pains , numbness , and tingling in the hands or feet may develop . A neurologic syndrome called Lyme encephalopathy is associated with subtle cognitive problems , such as difficulties with concentration and short-term memory . These patients may also experience fatigue . However , other problems , such as depression and fibromyalgia , are no more common in people with Lyme disease than in the general population . Chronic encephalomyelitis , which may be progressive , can involve cognitive impairment , weakness in the legs , awkward gait , facial palsy , bladder problems , vertigo , and back pain . In rare cases , untreated Lyme disease may cause frank psychosis , which has been misdiagnosed as schizophrenia or bipolar disorder . Panic attacks and anxiety can occur ; also , delusional behavior may be seen , including somatoform delusions , sometimes accompanied by a depersonalization or derealization syndrome , where the patients begin to feel detached from themselves or from reality . Lyme arthritis usually affects the knees . In a minority of patients , arthritis can occur in other joints , including the ankles , elbows , wrist , hips , and shoulders . Pain is often mild or moderate , usually with swelling at the involved joint . Baker 's cysts may form and rupture . In some cases , joint erosion occurs . Acrodermatitis chronica atrophicans ( ACA ) is a chronic skin disorder observed primarily in Europe among the elderly . ACA begins as a reddish-blue patch of discolored skin , often on the backs of the hands or feet . The lesion slowly atrophies over several weeks or months , with the skin becoming first thin and wrinkled and then , if untreated , completely dry and hairless . # Cause # Lyme disease is caused by spirochetal bacteria from the genus ' ' Borrelia ' ' . Spirochetes are surrounded by peptidoglycan and flagella , along with an outer membrane similar to other Gram-negative bacteria . Because of their double-membrane envelope , ' ' Borrelia ' ' bacteria are often mistakenly described as Gram negative despite the considerable differences in their envelope components from Gram-negative bacteria . The Lyme-related ' ' Borrelia ' ' species are collectively known as ' ' Borrelia burgdorferi sensu lato ' ' , and show a great deal of genetic diversity . ' ' B. burgdorferi sensu lato ' ' is made up of 18 closely related species , but only three clearly cause Lyme disease : ' ' B. burgdorferi sensu stricto ' ' ( predominant in North America , but also present in Europe ) , ' ' B. afzelii ' ' , and ' ' B. garinii ' ' ( both predominant in Eurasia ) . Some studies have also proposed ' ' B. bissettii ' ' and ' ' B. valaisiana ' ' may sometimes infect humans , but these species do not seem to be important causes of disease . # Transmission # Lyme disease is classified as a zoonosis , as it is transmitted to humans from a natural reservoir among rodents by ticks that feed on both sets of hosts . Hard-bodied ticks of the genus ' ' Ixodes ' ' are the main vectors of Lyme disease ( also the vector for ' ' Babesia ' ' ) . Most infections are caused by ticks in the nymphal stage , as they are very small and may feed for long periods of time undetected . Larval ticks are very rarely infected . Although deer are the preferred hosts of deer ticks , and the size of the tick population parallels that of the deer population , ticks can not acquire Lyme disease spirochetes from deer . Rather , deer ticks acquire ' ' Borrelia ' ' microbes from infected rodents , such as the white-footed mouse , ' ' Peromyscus leucopus ' ' . # Tick-borne coinfections # Ticks that transmit ' ' B. burgdorferi ' ' to humans can also carry and transmit several other parasites , such as ' ' Theileria microti ' ' and ' ' Anaplasma phagocytophilum ' ' , which cause the diseases babesiosis and human granulocytic anaplasmosis ( HGA ) , respectively . Among early Lyme disease patients , depending on their location , 212% will also have HGA and 240% will have babesiosis . Ticks in certain regions , including the lands along the eastern Baltic Sea , also transmit tick-borne encephalitis . Coinfections complicate Lyme symptoms , especially diagnosis and treatment . It is possible for a tick to carry and transmit one of the coinfections and not ' ' Borrelia ' ' , making diagnosis difficult and often elusive . The Centers for Disease Control studied 100 ticks in rural New Jersey , and found 55% of the ticks were infected with at least one of the pathogens. # Pathophysiology # ' ' B. burgdorferi ' ' can spread throughout the body during the course of the disease , and has been found in the skin , heart , joints , peripheral nervous system , and central nervous system . Many of the signs and symptoms of Lyme disease are a consequence of the immune response to the spirochete in those tissues . ' ' B. burgdorferi ' ' is injected into the skin by the bite of an infected ' ' Ixodes ' ' tick . Tick saliva , which accompanies the spirochete into the skin during the feeding process , contains substances that disrupt the immune response at the site of the bite . This provides a protective environment where the spirochete can establish infection . The spirochetes multiply and migrate outward within the dermis . The host inflammatory response to the bacteria in the skin causes the characteristic circular EM lesion . Neutrophils , however , which are necessary to eliminate the spirochetes from the skin , fail to appear in the developing EM lesion . This allows the bacteria to survive and eventually spread throughout the body . Days to weeks following the tick bite , the spirochetes spread via the bloodstream to joints , heart , nervous system , and distant skin sites , where their presence gives rise to the variety of symptoms of disseminated disease . The spread of ' ' B. burgdorferi ' ' is aided by the attachment of the host protease plasmin to the surface of the spirochete . If untreated , the bacteria may persist in the body for months or even years , despite the production of ' ' B. burgdorferi ' ' antibodies by the immune system . The spirochetes may avoid the immune response by decreasing expression of surface proteins that are targeted by antibodies , antigenic variation of the VlsE surface protein , inactivating key immune components such as complement , and hiding in the extracellular matrix , which may interfere with the function of immune factors . In the brain , ' ' B. burgdorferi ' ' may induce astrocytes to undergo astrogliosis ( proliferation followed by apoptosis ) , which may contribute to neurodysfunction . The spirochetes may also induce host cells to secrete products toxic to nerve cells , including quinolinic acid and the cytokines IL-6 and TNF-alpha , which can produce fatigue and malaise . Both microglia and astrocytes secrete IL-6 and TNF-alpha in the presence of the spirochete . This cytokine response may contribute to cognitive impairment . In Lyme encephalopathy , diffuse white matter pathology can disrupt grey matter connections , and could account for deficits in attention , memory , visuospatial ability , complex cognition , and emotional status . White matter disease may have a greater potential for recovery than gray matter disease , perhaps because neuronal loss is less common . Resolution of MRI white matter hyperintensities after antibiotic treatment has been observed . A developing hypothesis is that the chronic secretion of stress hormones as a result of ' ' Borrelia ' ' infection may reduce the effect of neurotransmitters , or other receptors in the brain by cell-mediated proinflammatory pathways , thereby leading to the dysregulation of neurohormones , specifically glucocorticoids and catecholamines , the major stress hormones . This process is mediated by the *30;633956;TOOLONG axis . Additionally , tryptophan , a precursor to serotonin , appears to be reduced within the central nervous system in a number of infectious diseases that affect the brain , including Lyme . Researchers are investigating if this neurohormone secretion is the cause of neuropsychiatric disorders developing in some patients with borreliosis. # Immunological studies # Exposure to the ' ' Borrelia ' ' bacterium during Lyme disease possibly causes a long-lived and damaging inflammatory response , a form of pathogen-induced autoimmune disease . The production of this reaction might be due to a form of molecular mimicry , where ' ' Borrelia ' ' avoids being killed by the immune system by resembling normal parts of the body 's tissues . Chronic symptoms from an autoimmune reaction could explain why some symptoms persist even after the spirochetes have been eliminated from the body . This hypothesis may explain why chronic arthritis persists after antibiotic therapy , similar to rheumatic fever , but its wider application is controversial . # Persistence # The National Institute of Health has supported research into bacterial resistance which has demonstrated persistence after antibiotic therapy in several animal models , including mice and primates . However , it was not possible to culture these bacteria and it is not known if they are infectious , or if they contribute to symptom persistence post-treatment . An ' ' in vitro ' ' study of isolated B. burgdorferi persisters published in July 2014 showed that front-line antibiotics doxycycline and amoxicillin are ineffective in eradicating persister populations , which may contribute to symptoms post-treatment . The study went on to show that 27 other drug candidates have a higher potential for eradicating these persister populations , and that those drugs may have implications in the development of treatment plans for patients suffering long-term symptoms of Lyme Disease . # Diagnosis # Lyme disease is diagnosed clinically based on symptoms , objective physical findings ( such as EM , facial palsy , or arthritis ) or a history of possible exposure to infected ticks , as well as serological blood tests . The EM rash is not always a bull 's eye , i.e. , it can be solid red . When making a diagnosis of Lyme disease , health care providers should consider other diseases that may cause similar illness . Not all patients infected with Lyme disease develop the characteristic bull's-eye rash , and many may not recall a tick bite . Because of the difficulty in culturing ' ' Borrelia ' ' bacteria in the laboratory , diagnosis of Lyme disease is typically based on the clinical exam findings and a history of exposure to endemic Lyme areas . The EM rash , which does not occur in all cases , is considered sufficient to establish a diagnosis of Lyme disease even when serologic blood tests are negative . Serological testing can be used to support a clinically suspected case , but is not diagnostic by itself . Diagnosis of late-stage Lyme disease is often complicated by a multifaceted appearance and nonspecific symptoms , prompting one reviewer to call Lyme the new great imitator . Lyme disease may be misdiagnosed as multiple sclerosis , rheumatoid arthritis , fibromyalgia , chronic fatigue syndrome , lupus , Crohn 's disease , HIV , or other autoimmune and neurodegenerative diseases . As all patients with later stage infection will have a positive antibody test , simple blood tests can exclude Lyme disease as a possible cause of the patients ' symptoms . # Laboratory testing # Several forms of laboratory testing for Lyme disease are available , some of which have not been adequately validated . The most widely used tests are serologies , which measure levels of specific antibodies in a patient 's blood . These tests may be negative in early infection , as the body may not have produced a significant quantity of antibodies , but they are considered a reliable aid in the diagnosis of later stages of Lyme disease . Serologic tests for Lyme disease are of limited use in people lacking objective signs of Lyme disease because of false positive results and cost . The serological laboratory tests most widely available and employed are the Western blot and ELISA . A two-tiered protocol is recommended by the Centers for Disease Control and Prevention : the sensitive ELISA test is performed first , and if it is positive or equivocal , then the more specific Western blot is run . The reliability of testing in diagnosis remains controversial . Studies show the Western blot IgM has a specificity of 9496% for patients with clinical symptoms of early Lyme disease . The initial ELISA test has a sensitivity of about 70% , and in two-tiered testing , the overall sensitivity is only 64% , although this rises to 100% in the subset of people with disseminated symptoms , such as arthritis . Erroneous test results have been widely reported in both early and late stages of the disease , and can be caused by several factors , including antibody cross-reactions from other infections , including Epstein-Barr virus and cytomegalovirus , The overall rate of false positives is low , only about 1 to 3% , in comparison to a false negative rate of up to 36% in the early stages of infection using two-tiered testing . Polymerase chain reaction ( PCR ) tests for Lyme disease have also been developed to detect the genetic material ( DNA ) of the Lyme disease spirochete . PCR tests are susceptible to false positive results from poor laboratory technique . Even when properly performed , PCR often shows false negative results with blood and cerebrospinal fluid specimens . Hence , PCR is not widely performed for diagnosis of Lyme disease , but it may have a role in diagnosis of Lyme arthritis , because it is a highly sensitive way of detecting ' ' ospA ' ' DNA in synovial fluid . With the exception of culture or PCR , no practical means for detecting the presence of the organism is currently available , as serologic studies only test for antibodies of ' ' Borrelia ' ' . High titers of either immunoglobulin G ( IgG ) or immunoglobulin M ( IgM ) antibodies to ' ' Borrelia ' ' antigens indicate disease , but lower titers can be misleading , because the IgM antibodies may remain after the initial infection , and IgG antibodies may remain for years . Western blot , ELISA , and PCR can be performed by either blood test via venipuncture or cerebrospinal fluid ( CSF ) via lumbar puncture . Though lumbar puncture is more definitive of diagnosis , antigen capture in the CSF is much more elusive ; reportedly , CSF yields positive results in only 1030% of patients cultured . The diagnosis of neurologic infection by ' ' Borrelia ' ' should not be excluded solely on the basis of normal routine CSF or negative CSF antibody analyses . New techniques for clinical testing of ' ' Borrelia ' ' infection have been developed , such as LTT-MELISA , although the results of studies are contradictory , The first peer reviewed study assessing the diagnostic sensitivity and specificity of the test has been presented in 2012 , showing potential for LTT to become a supportive diagnostic tool . Others , such as focus floating microscopy , are under investigation . New research indicates chemokine CXCL13 may also be a possible marker for neuroborreliosis . Some laboratories offer Lyme disease testing using assays whose accuracy and clinical usefulness have not been adequately established . These tests include urine antigen tests , PCR tests on urine , immunofluorescent staining for cell wall-deficient forms of ' ' B. burgdorferi ' ' , and lymphocyte transformation tests . The CDC does not recommend these tests , and a stated their use is of great concern and is strongly discouraged . In addition to laboratory testing on patients , ticks can be tested after removal from the host . Several laboratories perform PCR testing on live or dead ticks for a panel of tick-borne diseases , including ' ' Borrelia ' ' , ' ' Babesia ' ' , and ' ' Ehrlichia ' ' . # Imaging # Neuroimaging is controversial in whether it provides specific patterns unique to neuroborreliosis , but may aid in differential diagnosis and in understanding the pathophysiology of the disease . Though controversial , some evidence shows certain neuroimaging tests can provide data that are helpful in the diagnosis of a patient . Magnetic resonance imaging ( MRI ) , as well as single-photon emission computed tomography ( SPECT ) are two of the tests that can identify abnormalities in the brain of a patient affected with this disease . Neuroimaging findings in an MRI include lesions in the periventricular white matter , as well as enlarged ventricles and cortical atrophy . The findings are considered somewhat unexceptional because the lesions have been found to be reversible following antibiotic treatment . Images produced using SPECT show numerous areas where an insufficient amount of blood is being delivered the cortex and subcortical white matter . However , SPECT images are known to be not specific because they show a heterogeneous pattern in the imaging . The abnormalities seen in the SPECT images are very similar to those seen in patients with cerebral vacuities and Creutzfeldt-Jakob disease , which makes them questionable . # Prevention # Protective clothing includes a hat , long-sleeved shirt , and long trousers tucked into socks or boots . Light-colored clothing makes the tick more easily visible before it attaches itself . People should use special care in handling and allowing outdoor pets inside homes because they can bring ticks into the house . Permethrin sprayed on clothing kills ticks on contact , and is sold for this purpose . Insect repellents with Picaridin , IR3535 , DEET , or oil of lemon eucalyptus repel ticks , as well . A community can reduce the incidence of Lyme disease by reducing the numbers of primary hosts on which the deer tick depends , such as rodents , other small mammals , and deer . Reduction of the deer population may , over time , help break the reproductive cycle of the deer ticks and their ability to flourish in suburban and rural areas . An unusual , organic approach to control of ticks and prevention of Lyme disease involves the use of domesticated guineafowl . Guineafowl are voracious consumers of insects and arachnids , and have a particular fondness for ticks . Localized use of domesticated guineafowl may reduce dependence on chemical pest-control methods . # Management of host animals # Lyme and all other deer tick-borne diseases can be prevented on a regional level by reducing the deer population on which the ticks depend for reproductive success . ( Although deer ticks do acquire Lyme disease pathogens from rodents and not from deer , the size of the tick population tends to parallel that of the deer population . ) This has been demonstrated in the communities of Monhegan , Maine and Mumford Cove , Connecticut . For example , in the U.S. , reducing the deer population to levels of 8 to 10 per square mile ( from the current levels of 60 or more deer per square mile in the areas of the country with the highest Lyme disease rates ) , the tick numbers can be brought down to levels too low to spread Lyme and other tick-borne diseases . However , such a drastic reduction may be impractical in many areas . Routine veterinary control of ticks of domestic animals , including livestock , by use of chemical acaricides can contribute to reducing exposure of humans to ticks . However , the risk of acquiring Lyme disease does not depend on the existence of a local deer population , as is commonly assumed . Eliminating deer from smaller areas 2.5ha acre may in fact lead to an increase in tick density and the rise of tick-borne disease hotspots . Action can be taken to avoid getting bitten by ticks by using insect repellants , for example those that contain DEET . DEET-containing repellants are thought to be moderately effective in the prevention of tick bites . In Europe , The reservoir species that contain the most pathogens are the European roe deer ' ' Capreolus capreolus ' ' ( incompetent host for ' ' B. burgdorferi ' ' and TBE virus but important for feeding the ticks ) , in which two species of ' ' Rickettsia ' ' and two species of ' ' Borrelia ' ' were identified , and ' ' Sus scrofa ' ' , in which one ' ' Rickettsia ' ' and three ' ' Borrelia ' ' species were identified , with high risks of coinfection in roe deer . # Vaccination # A recombinant vaccine against Lyme disease , based on the outer surface protein A ( ospA ) of ' ' B. burgdorferi ' ' , was developed by SmithKline Beecham . In clinical trials involving more than 10,000 people , the vaccine , called LYMErix , was found to confer protective immunity to ' ' Borrelia ' ' in 76% of adults and 100% of children with only mild or moderate and transient adverse effects . LYMErix was approved on the basis of these trials by the Food and Drug Administration ( FDA ) on December 21 , 1998 . Following approval of the vaccine , its entry in clinical practice was slow for a variety of reasons , including its cost , which was often not reimbursed by insurance companies . Subsequently , hundreds of vaccine recipients reported they had developed autoimmune side effects . Supported by some patient advocacy groups , a number of class-action lawsuits were filed against GlaxoSmithKline , alleging the vaccine had caused these health problems . These claims were investigated by the FDA and the U.S. Centers for Disease Control , which found no connection between the vaccine and the autoimmune complaints . Despite the lack of evidence that the complaints were caused by the vaccine , sales plummeted and LYMErix was withdrawn from the U.S. market by GlaxoSmithKline in February 2002 , in the setting of negative media coverage and fears of vaccine side effects . The fate of LYMErix was described in the medical literature as a cautionary tale ; an editorial in ' ' Nature ' ' cited the withdrawal of LYMErix as an instance in which unfounded public fears place pressures on vaccine developers that go beyond reasonable safety considerations . The original developer of the OspA vaccine at the Max Planck Institute told ' ' Nature ' ' : This just shows how irrational the world can be .. There was no scientific justification for the first OspA vaccine LYMErix being pulled . New vaccines are being researched using outer surface protein C ( OspC ) and glycolipoprotein as methods of immunization . Vaccines have been formulated and approved for prevention of Lyme disease in dogs . Currently , three Lyme disease vaccines are available . LymeVax , formulated by Fort Dodge Laboratories , contains intact dead spirochetes which expose the host to the organism . Galaxy Lyme , *26;633988;TOOLONG vaccine , targets proteins OspC and OspA . The OspC antibodies kill any of the bacteria that have not been killed by the OspA antibodies . Canine Recombinant Lyme , formulated by Merial , generates antibodies against the OspA protein so a tick feeding on a vaccinated dog draws in blood full of anti-OspA antibodies , which kill the spirochetes in the tick 's gut before they are transmitted to the dog . # Tick removal # Attached ticks should be removed promptly , as removal within 36 hours can reduce transmission rates . Folk remedies for tick removal tend to be ineffective , offer no advantages in preventing the transfer of disease , and may increase the risks of transmission or infection . The best method is simply to pull the tick out with tweezers as close to the skin as possible , without twisting , and avoiding crushing the body of the tick or removing the head from the tick 's body . The risk of infection increases with the time the tick is attached , and if a tick is attached for less than 24 hours , infection is unlikely . However , since these ticks are very small , especially in the nymph stage , prompt detection is quite difficult . # Treatment # Antibiotics are the primary treatment . The specific approach to their use is dependent on the individual affected and the stage of the disease . For most people with early localized infection , oral administration of doxycycline is widely recommended as the first choice , as it is effective against not only ' ' Borrelia ' ' bacteria but also a variety of other illnesses carried by ticks . Doxycycline is contraindicated in children younger than eight years of age and women who are pregnant or breastfeeding ; alternatives to doxycycline are amoxicillin , cefuroxime axetil , and azithromycin . Individuals with early disseminated or late infection may have symptomatic cardiac disease , refractory Lyme arthritis , or neurologic symptoms like meningitis or encephalitis . Intravenous administration of ceftriaxone is recommended as the first choice in these cases ; cefotaxime and doxycycline are available as alternatives . These treatment regimens last from one to four weeks . If joint swelling persists or returns , a second round of antibiotics may be considered . Outside of that , a prolonged antibiotic regimen lasting more than 28 days is not recommended as no clinical evidence shows it to be effective . IgM and IgG antibody levels may be elevated for years even after successful treatment with antibiotics . As antibody levels are not indicative of treatment success , testing for them is not recommended . The risk of infectious transmission increases with the duration of tick attachment . It requires between 36 and 48 hours of attachment for the bacteria that causes Lyme to travel from within the tick into its saliva . If a deer tick sufficiently likely to be carrying ' ' Borrelia ' ' is found attached to a person and removed , and if the tick has been attached for 36 hours or is engorged , a single dose of doxycycline administered within the 72 hours after removal may reduce the risk of Lyme disease . # Prognosis # For early cases , prompt treatment is usually curative . However , the severity and treatment of Lyme disease may be complicated due to late diagnosis , failure of antibiotic treatment , and simultaneous infection with other tick-borne diseases ( coinfections ) , including ehrlichiosis , babesiosis , and immune suppression in the patient . A meta-analysis published in 2005 found some patients with Lyme disease have fatigue , joint or muscle pain , and neurocognitive symptoms persisting for years , despite antibiotic treatment . Patients with late stage Lyme disease have been shown to experience a level of physical disability equivalent to that seen in congestive heart failure . In dogs , a serious long-term prognosis may result in glomerular disease , which is a category of kidney damage that may cause chronic kidney disease . Dogs may also experience chronic joint disease if the disease is left untreated . However , the majority of cases of Lyme disease in dogs result in a complete recovery with , and sometimes without , treatment with antibiotics . In rare cases , Lyme disease can be fatal to both humans and dogs . # Epidemiology # Lyme disease is endemic in Northern Hemisphere temperate regions . # Africa # In northern Africa , ' ' B. burgdorferi sensu lato ' ' has been identified in Morocco , Algeria , Egypt and Tunisia . Lyme disease in sub-Saharan Africa is presently unknown , but evidence indicates it may occur in humans in this region . The abundance of hosts and tick vectors would favor the establishment of Lyme infection in Africa . In East Africa , two cases of Lyme disease have been reported in Kenya . # Asia # ' ' B. burgdorferi sensu lato ' ' -infested ticks are being found more frequently in Japan , as well as in northwest China , Nepal , Thailand and far eastern Russia . ' ' Borrelia ' ' has also been isolated in Mongolia . # Europe # In Europe , Lyme disease is caused by infection with one or more pathogenic European genospecies of the spirochaete ' ' B. burgdorferi sensu lato ' ' , mainly transmitted by the tick ' ' Ixodes ricinus ' ' . Cases of ' ' B. burgdorferi sensu lato ' ' -infected ticks are found predominantly in central Europe , particularly in Slovenia and Austria , but have been isolated in almost every country on the continent . Incidence in southern Europe , such as Italy and Portugal , is much lower . # #United Kingdom# # In the United Kingdom the number of laboratory confirmed cases of Lyme disease has been rising steadily since voluntary reporting was introduced in 1986 when 68 cases were recorded in the UK and Republic of Ireland combined . In the UK there were 23 confirmed cases in 1988 and 19 in 1990 , but 973 in 2009 and 953 in 2010 . Provisional figures for the first 3 quarters of 2011 show a 26% increase on the same period in 2010 . It is thought , however , that the actual number of cases is significantly higher than suggested by the above figures , with the UK 's Health Protection Agency estimating that there are between 2,000 and 3,000 cases per year , ( with an average of around 15% of the infections acquired overseas ) , while Dr Darrel Ho-Yen , Director of the Scottish Toxoplasma Reference Laboratory and National Lyme 's Disease Testing Service , believes that the number of confirmed cases should be multiplied by 10 to take account of wrongly diagnosed cases , tests giving false results , sufferers who were n't tested , people who are infected but not showing symptoms , failures to notify and infected individuals who do n't consult a doctor . Despite Lyme disease ( Borrelia burgdorferi infection ) being a notifiable disease in Scotland since January 1990 which should therefore be reported on the basis of clinical suspicion , it is believed that many GPs are unaware of the requirement . Mandatory reporting , limited to laboratory test results only , was introduced throughout the UK in October 2010 , under the Health Protection ( Notification ) Regulations 2010 . Although there is a greater incidence of Lyme disease in the New Forest , Salisbury Plain , Exmoor , the South Downs , parts of Wiltshire and Berkshire , Thetford Forest and the West coast and islands of Scotland infected ticks are widespread , and can even be found in the parks of London . A 1989 report found that 25% of forestry workers in the New Forest were seropositive , as were between 2% and 4-5% of the general local population of the area . Tests on pet dogs , carried out throughout the country in 2009 indicated that around 2.5% of ticks in the UK may be infected , considerably higher than previously thought . It is thought that global warming may lead to an increase in tick activity in the future , as well as an increase in the amount of time that people spend in public parks , thus increasing the risk of infection . # North America # Many studies in North America have examined ecological and environmental correlates of Lyme disease prevalence . A 2005 study using climate suitability modelling of ' ' I. scapularis ' ' projected that climate change would cause an overall 213% increase in suitable vector habitat by the year 2080 , with northward expansions in Canada , increased suitability in the central U.S. , and decreased suitable habitat and vector retraction in the southern U.S. A 2008 review of published studies concluded that the presence of forests or forested areas was the only variable that consistently elevated the risk of Lyme disease , and that other environmental variables showed little or no concordance between studies . The authors argued that the factors influencing tick density and human risk between sites are still poorly understood , and that future studies should be conducted over longer time periods , become more standardized across regions , and incorporate existing knowledge of regional Lyme disease ecology . # #Canada# # Owing to changing climate , the range of ticks able to carry Lyme disease has expanded from a limited area of Ontario to include areas of southern Quebec , Manitoba , northern Ontario , southern New Brunswick , south-west Nova Scotia and limited parts of Saskatchewan and Alberta , as well as British Columbia . Cases have been reported as far east as the island of Newfoundland . A model-based prediction by Leighton ' ' et al . ' ' ( 2012 ) suggests that the range of the ' ' I. scapularis ' ' tick will expand into Canada by 46 km/year over the next decade , with warming climactic temperatures as the main driver of increased speed of spread . # #Mexico# # A 2007 study suggests ' ' Borrelia burgdorferi ' ' infections are endemic to Mexico , from four cases reported between 1999 and 2000 . The recognition that the patients in the United States had EM led to the recognition that Lyme arthritis was one manifestation of the same tick-borne condition known in Europe . Before 1976 , elements of ' ' B. burgdorferi sensu lato ' ' infection were called or known as tick-borne meningopolyneuritis , Garin-Bujadoux syndrome , Bannwarth syndrome , Afzelius ' disease , antibiotic regimens in adult patients with Lyme disease . In the same year , New York State Health Dept. epidemiologist Jorge Benach provided Willy Burgdorfer , a researcher at the Rocky Mountain Biological Laboratory , with collections of ' ' I. dammini ' ' ' ' scapularis ' ' from Shelter Island , NY , a known Lyme-endemic area as part of an ongoing investigation of Rocky Mountain spotted fever . In examining the ticks for rickettsiae , Burgdorfer noticed poorly stained , rather long , irregularly coiled spirochetes . Further examination revealed spirochetes in 60% of the ticks . Burgdorfer credited his familiarity with the European literature for his realization that the spirochetes might be the long-sought cause of ECM and Lyme disease . Benach supplied him with more ticks from Shelter Island and sera from patients diagnosed with Lyme disease . University of Texas Health Science Center researcher Alan Barbour offered his expertise to culture and immunochemically characterize the organism . Burgdorfer subsequently confirmed his discovery by isolating , from patients with Lyme disease , spirochetes identical to those found in ticks . In June 1982 , he published his findings in Science , and the spirochete was named ' ' Borrelia burgdorferi ' ' in his honor . After the identification of ' ' B. burgdorferi ' ' as the causative agent of Lyme disease , antibiotics were selected for testing , guided by ' ' in vitro ' ' antibiotic sensitivities , including tetracycline antibiotics , amoxicillin , cefuroxime axetil , intravenous and intramuscular penicillin and intravenous ceftriaxone . The mechanism of tick transmission was also the subject of much discussion . ' ' B. burgdorferi ' ' spirochetes were identified in tick saliva in 1987 , confirming the hypothesis that transmission occurred via tick salivary glands . Jonathan Edlow , Professor of Medicine at Harvard Medical School , quotes the late Ed Masters ( discoverer of STARI , a Lyme-like illness ) in his book ' ' Bull's-Eye ' ' , on the history of Lyme disease . Edlow writes : # Society and culture # Urbanization and other anthropogenic factors can be implicated in the spread of Lyme disease to humans . In many areas , expansion of suburban neighborhoods has led to gradual deforestation of surrounding wooded areas and increased border contact between humans and tick-dense areas . Human expansion has also resulted in reduction of predators that hunt deer as well as mice , chipmunks and other small rodentsthe primary reservoirs for Lyme disease . As a consequence of increased human contact with host and vector , the likelihood of transmission of the disease has greatly increased . Researchers are investigating possible links between global warming and the spread of vector-borne diseases , including Lyme disease . # Controversy over term chronic Lyme disease # The term chronic Lyme disease is controversial and not recognized in the medical literature , and most medical authorities advise against long-term antibiotic treatment for Lyme disease . Studies have shown that most patients diagnosed with chronic Lyme disease either have no objective evidence of previous or current infection with ' ' B. burgdorferi ' ' or are patients who should be classified as having post-treatment Lyme disease syndrome(PTLDS) , which is defined as continuing or relapsing non-specific symptoms ( such as fatigue , musculoskeletal pain , and cognitive complaints ) in a patient previously treated for Lyme disease . # Other animals # Prevention of Lyme disease is an important step in keeping dogs safe in endemic areas . Prevention education and a number of preventative measures are available . First , for dog owners who live near or who often frequent tick-infested areas , routine vaccinations of their dogs is an important step . Another crucial preventive measure is the use of persistent acaricides , such as topical repellents or pesticides that contain triazapentadienes ( Amitraz ) , phenylpyrazoles ( Fipronil ) , or permethrin ( pyrethroids ) . These acaricides target primarily the adult stages of Lyme-carrying ticks and reduce the number of reproductively active ticks in the environment . Formulations of these ingredients are available in a variety of topical forms , including spot-ons , sprays , powders , impregnated collars , solutions , and shampoos . Examination of a dog for ticks after being in a tick-infested area is an important precautionary measure to take in the prevention of Lyme disease . Key spots to examine include the head , neck , and ears . # Notes # -- # Further reading #    
@@261925 Health care ( or healthcare ) is the diagnosis , treatment , and prevention of disease , illness , injury , and other physical and mental impairments in human beings . Health care is delivered by practitioners in allied health , dentistry , midwifery-obstetrics , medicine , nursing , optometry , pharmacy , psychology and other care providers . It refers to the work done in providing primary care , secondary care , and tertiary care , as well as in public health . Access to health care varies across countries , groups , and individuals , largely influenced by social and economic conditions as well as the health policies in place . Countries and jurisdictions have different policies and plans in relation to the personal and population-based health care goals within their societies . Health care systems are organizations established to meet the health needs of target populations . Their exact configuration varies between national and subnational entities . In some countries and jurisdictions , health care planning is distributed among market participants , whereas in others , planning occurs more centrally among governments or other coordinating bodies . In all cases , according to the World Health Organization ( WHO ) , a well-functioning health care system requires a robust financing mechanism ; a well-trained and adequately-paid workforce ; reliable information on which to base decisions and policies ; and well maintained facilities and logistics to deliver quality medicines and technologies . Health care can contribute to a significant part of a country 's economy . In 2011 , the health care industry consumed an average of 9.3 percent of the GDP or US$ 3,322 ( PPP-adjusted ) per capita across the 34 members of OECD countries . The USA ( 17.7% , or US$ PPP 8,508 ) , the Netherlands ( 11.9% , 5,099 ) , France ( 11.6% , 4,118 ) , Germany ( 11.3% , 4,495 ) , Canada ( 11.2% , 5669 ) , and Switzerland ( 11% , 5,634 ) were the top spenders , however life expectancy in total population at birth was highest in Switzerland ( 82.8 years ) , Japan and Italy ( 82.7 ) , Spain and Iceland ( 82.4 ) , France ( 82.2 ) and Australia ( 82.0 ) , while OECD 's average exceeds 80 years for the first time ever in 2011 : 80.1 years , a gain of 10 years since 1970 . The USA ( 78.7 years ) ranges only on place 26 among the 34 OECD member countries , but has the highest costs by far . All OECD countries have achieved universal ( or almost universal ) health coverage , except Mexico and the USA. ( see also international comparisons . ) Health care is conventionally regarded as an important determinant in promoting the general physical and mental health and well-being of people around the world . An example of this was the worldwide eradication of smallpox in 1980 , declared by the WHO as the first disease in human history to be completely eliminated by deliberate health care interventions . # Health care delivery # The delivery of modern health care depends on groups of trained professionals and paraprofessionals coming together as interdisciplinary teams . This includes professionals in medicine , psychology , physiotherapy , nursing , dentistry , midwifery-obstetrics and allied health , plus many others such as public health practitioners , community health workers and assistive personnel , who systematically provide personal and population-based preventive , curative and rehabilitative care services . While the definitions of the various types of health care vary depending on the different cultural , political , organizational and disciplinary perspectives , there appears to be some consensus that primary care constitutes the first element of a continuing health care process , that may also include the provision of secondary and tertiary levels of care . Healthcare can be defined as either public or private . # Primary care # Primary care refers to the work of health care professionals who act as a first point of consultation for all patients within the health care system . Such a professional would usually be a primary care physician , such as a general practitioner or family physician , a licensed independent practitioner such as a physiotherapist , or a non-physician primary care provider ( mid-level provider ) such as a physician assistant or nurse practitioner . Depending on the locality , health system organization , and sometimes at the patient 's discretion , they may see another health care professional first , such as a pharmacist , a nurse ( such as in the United Kingdom ) , a clinical officer ( such as in parts of Africa ) , or an Ayurvedic or other traditional medicine professional ( such as in parts of Asia ) . Depending on the nature of the health condition , patients may then be referred for secondary or tertiary care . Primary care is often used as the term for the health care services which play a role in the local community . It can be provided in different settings , such as Urgent care centres which provide services to patients same day with appointment or walk-in bases . Primary care involves the widest scope of health care , including all ages of patients , patients of all socioeconomic and geographic origins , patients seeking to maintain optimal health , and patients with all manner of acute and chronic physical , mental and social health issues , including multiple chronic diseases . Consequently , a primary care practitioner must possess a wide breadth of knowledge in many areas . Continuity is a key characteristic of primary care , as patients usually prefer to consult the same practitioner for routine check-ups and preventive care , health education , and every time they require an initial consultation about a new health problem . The International Classification of Primary Care ( ICPC ) is a standardized tool for understanding and analyzing information on interventions in primary care by the reason for the patient visit . Common chronic illnesses usually treated in primary care may include , for example : hypertension , diabetes , asthma , COPD , depression and anxiety , back pain , arthritis or thyroid dysfunction . Primary care also includes many basic maternal and child health care services , such as family planning services and vaccinations . In the United States , the 2013 National Health Interview Survey found that skin disorders ( 42.7% ) , osteoarthritis and joint disorders ( 33.6% ) , back problems ( 23.9% ) , disorders of lipid metabolism ( 22.4% ) , and upper respiratory tract disease ( 22.1% , excluding asthma ) were the most common reasons for accessing a physician . In context of global population aging , with increasing numbers of older adults at greater risk of chronic non-communicable diseases , rapidly increasing demand for primary care services is expected around the world , in both developed and developing countries . The World Health Organization attributes the provision of essential primary care as an integral component of an inclusive primary health care strategy . # Secondary care # Secondary care is the health care services provided by medical specialists and other health professionals who generally do not have first contact with patients , for example , cardiologists , urologists and dermatologists . It includes acute care : necessary treatment for a short period of time for a brief but serious illness , injury or other health condition , such as in a hospital emergency department . It also includes skilled attendance during childbirth , intensive care , and medical imaging services . The secondary care is sometimes used synonymously with hospital care . However many secondary care providers do not necessarily work in hospitals , such as psychiatrists , clinical psychologists , occupational therapists or physiotherapists ( physiotherapists are also primary care providers and a referral is not required to see a physiotherapist ) , and some primary care services are delivered within hospitals . Depending on the organization and policies of the national health system , patients may be required to see a primary care provider for a referral before they can access secondary care . For example in the United States , which operates under a mixed market health care system , some physicians might voluntarily limit their practice to secondary care by requiring patients to see a primary care provider first , or this restriction may be imposed under the terms of the payment agreements in private or group health insurance plans . In other cases medical specialists may see patients without a referral , and patients may decide whether self-referral is preferred . In the United Kingdom and Canada , patient self-referral to a medical specialist for secondary care is rare as prior referral from another physician ( either a primary care physician or another specialist ) is considered necessary , regardless of whether the funding is from private insurance schemes or national health insurance . Allied health professionals , such as physical therapists , respiratory therapists , occupational therapists , speech therapists , and dietitians , also generally work in secondary care , accessed through either patient self-referral or through physician referral . # Tertiary care # Tertiary care is specialized consultative health care , usually for inpatients and on referral from a primary or secondary health professional , in a facility that has personnel and facilities for advanced medical investigation and treatment , such as a tertiary referral hospital . Examples of tertiary care services are cancer management , neurosurgery , cardiac surgery , plastic surgery , treatment for severe burns , advanced neonatology services , palliative , and other complex medical and surgical interventions . # #Quaternary care# # The term quaternary care is sometimes used as an extension of tertiary care in reference to advanced levels of medicine which are highly specialized and not widely accessed . Experimental medicine and some types of uncommon diagnostic or surgical procedures are considered quaternary care . These services are usually only offered in a limited number of regional or national health care centres . This term is more prevalent in the United Kingdom , but just as applicable in the United States . A quaternary care hospital may have virtually any procedure available , whereas a tertiary care facility may not offer a sub-specialist with that training . # Home and community care # Many types of health care interventions are delivered outside of health facilities . They include many interventions of public health interest , such as food safety surveillance , distribution of condoms and needle-exchange programmes for the prevention of transmissible diseases . They also include the services of professionals in residential and community settings in support of self care , home care , long-term care , assisted living , treatment for substance use disorders and other types of health and social care services . Community rehabilitation services can assist with mobility and independence after loss of limbs or loss of function . This can include prosthesis , orthotics or wheelchairs . Many countries , especially in the west are dealing with aging populations , and one of the priorities of the health care system is to help seniors live full , independent lives in the comfort of their own homes . There is an entire section of health care geared to providing seniors with help in day-to-day activities at home , transporting them to doctors appointments , and many other activities that are so essential for their health and well-being . Although they provide home care for older adults in cooperation , family members and care workers may harbor diverging attitudes and values towards their joint efforts . This state of affairs presents a challenge for the design of ICT for home care . Results from health services research often form the basis of evidence-based policy in health care systems . Health services research is also aided by initiatives in the field of AI for the development of systems of health assessment that are clinically useful , timely , sensitive to change , culturally sensitive , low burden , low cost , involving for the patient and built into standard procedures . # Health care financing # There are generally five primary methods of funding health care systems : # general taxation to the state , county or municipality # social health insurance # voluntary or private health insurance # out-of-pocket payments # donations to health charities In most countries , the financing of health care services features a mix of all five models , but the exact distribution varies across countries and over time within countries . In all countries and jurisdictions , there are many topics in the politics and evidence that can influence the decision of a government , private sector business or other group to adopt a specific health policy regarding the financing structure . For example , social health insurance is where a nation 's entire population is eligible for health care coverage , and this coverage and the services provided are regulated . In almost every jurisdiction with a government-funded health care system , a parallel private , and usually for-profit , system is allowed to operate . This is sometimes referred to as two-tier health care or universal health care . E. g. in Poland ( former communist country ) the costs of health services borne by the National Health Fund ( financed by all that pay health insurance contributions ) in 2012 amounted to 60.8 billion PLN ( appr. 20 billion USD ) . The right to health services in Poland has about 99,9% of population ( also registered unemployed persons and their spouses ) . # Health care administration and regulation # The management and administration of health care is another sector vital to the delivery of health care services . In particular , the practice of health professionals and operation of health care institutions is typically regulated by national or state/provincial authorities through appropriate regulatory bodies for purposes of quality assurance . Most countries have credentialing staff in regulatory boards or health departments who document the certification or licensing of health workers and their work history . # Health information technology # Health information technology ( HIT ) is the application of information processing involving both computer hardware and software that deals with the storage , retrieval , sharing , and use of health care information , data , and knowledge for communication and decision making . Technology is a broad concept that deals with a species ' usage and knowledge of tools and crafts , and how it affects a species ' ability to control and adapt to its environment . However , a strict definition is elusive ; technology can refer to material objects of use to humanity , such as machines , hardware or utensils , but can also encompass broader themes , including systems , methods of organization , and techniques . For HIT , technology represents computers and communications attributes that can be networked to build systems for moving health information . Informatics is yet another integral aspect of HIT . # See also #  List of countries by quality of health care  Acronyms in healthcare  Catholic Church and health care  Healthcare system / Health care provider  Health center / Clinic / Hospital / Nursing Home  Health policy * Health insurance / Insurance / Right to health /Social health insurance /Subsidies * Health care reform / Health care reform in the United States * Healthy city / Alliance for Healthy Cities  Medical classification * ATC codes ( Anatomical Therapeutic Chemical classification system ) * Classification of Pharmaco-Therapeutic Referrals ( CPR ) * Diagnostic and Statistical Manual of Mental Disorders ( DSM ) / List of DSM-IV codes * ICD-10 ( International Classification of Diseases ) * International Classification of Primary Care ( ICPC-2 ) / ICPC-2 PLUS  Medicine / Doctor 's visit / Nursing  Philosophy of healthcare * Social service / Social determinants of health * Family medicine / Preventive medicine / Social medicine * Community health service / Community health centers in the United States * Direct primary care ( United States )  Universal health care * Health care in the United States as a private system * Healthcare in the United Kingdom * Healthcare in Cuba as a state owned system * Health in Germany as a private system under state controlled insurance * Primary Health Organisation ( New Zealand ) 
@@310484 Patent medicines are compounds promoted and sold as medical cures that do not work as promoted . Patent medicine is a misnomer since in most cases , although products might be trademarked , they are not patented ( the patent process requires proof that something new has been discovered ) . In ancient times , patent medicine was sometimes called nostrum remedium ( our remedy in Latin ) . The promotion of patent medicines was one of the first major products highlighted by the advertising industry , and many advertising and sales techniques were pioneered by patent medicine promoters . Patent medicine advertising often promoted the advantages of exotic ingredients , even though their actual effects came from more prosaic drugs . One group of patent medicines liniments that allegedly contained snake oil , supposedly a panacea made ' ' snake oil salesman ' ' a lasting synonym for a charlatan . # Patent medicines and advertising # The phrase patent medicine comes from the late 17th century marketing of medical elixirs , when those who found favour with royalty were issued ' ' letters patent ' ' authorising the use of the royal endorsement in advertising . Few if any of the nostrums were actually patented ; chemical patents did not come into use in the United States until 1925 . Furthermore , patenting one of these remedies would have meant publicly disclosing its ingredients , which most promoters sought to avoid . Instead , the compounders of such nostrums used a primitive version of branding to distinguish their products from the crowd of their competitors . Many familiar names from the era live on today in brands such as Luden 's cough drops , Lydia E. Pinkham 's vegetable compound for women , Fletcher 's Castoria and even Angostura bitters , which was once marketed as a stomachic . Though sold at high prices , many of these products were made from cheap ingredients . Their composition was well known within the pharmacy trade , and druggists manufactured and sold ( for a slightly lower price ) medicines of almost identical composition . To protect profits , the branded medicine advertisements emphasized brand names , and urged the public to , ... accept no substitutes . At least in the earliest days , the history of patent medicines is coextensive with scientific medicine . Empirical medicine , and the beginning of the application of the scientific method to medicine , began to yield a few orthodoxly acceptable herbal and mineral drugs for the physician 's arsenal . These few remedies , on the other hand , were inadequate to cover the bewildering variety of diseases and symptoms . Beyond these patches of evidence-based application , people used other methods , such as occultism ; the doctrine of signatures essentially , the application of sympathetic magic to pharmacology held that nature had hidden clues to medically effective drugs in their resemblances to the human body and its parts . This led medical men to hope , at least , that , say , walnut shells might be good for skull fractures . Given the state of the pharmacopoeia , and patients ' demands for something to take , physicians began making blunderbuss concoctions of various drugs , proven and unproven . These concoctions were the ancestors of the several nostrums . Touting these nostrums was one of the first major projects of the advertising industry . The marketing of nostrums under implausible claims has a long history . In Henry Fielding 's ' ' Tom Jones ' ' ( 1749 ) , allusion is made to the sale of medical compounds claimed to be universal panaceas : : ' ' As to Squire Western , he was seldom out of the sick-room , unless when he was engaged either in the field or over his bottle . Nay , he would sometimes retire hither to take his beer , and it was not without difficulty that he was prevented from forcing Jones to take his beer too : for no quack ever held his nostrum to be a more general panacea than he did this ; which , he said , had more virtue in it than was in all the physic in an apothecary 's shop . ' ' Within the English-speaking world , patent medicines are as old as journalism . Anderson 's Pills were first made in England in the 1630s ; the recipe was allegedly learned in Venice by a Scot who claimed to be physician to King Charles I. Daffy 's Elixir was invented about 1647 and remained popular in Britain and the USA until the late 19th century . The use of letters patent to obtain exclusive marketing rights to certain labelled formulas and their marketing fueled the circulation of early newspapers . The use of invented names began early . In 1726 a patent was also granted to the makers of Dr. Bateman 's Pectoral Drops ; at least on the documents that survive , there was no Dr. Bateman . This was the enterprise of a Benjamin Okell and a group of promoters who owned a warehouse and a print shop to promote the product . A number of American institutions owe their existence to the patent medicine industry , most notably a number of the older almanacs , which were originally given away as promotional items by patent medicine manufacturers . Perhaps the most successful industry that grew up out of the business of patent medicine advertisements , though , was founded by William H. Gannett in Maine in 1866 . There were few circulating newspapers in Maine in that era , so Gannett founded a periodical , ' ' Comfort ' ' , whose chief purpose was to propose the merits of ' ' Oxien ' ' , a nostrum made from the fruit of the baobab tree , to the rural folks of Maine . Gannett 's newspaper became the first publication of Guy Gannett Communications , which eventually owned four Maine dailies and several television stations . ( The family-owned firm is unrelated to the Gannett Corporation that publishes ' ' USA Today ' ' . ) An early pioneer in the use of advertising to promote patent medicine was New York businessman Benjamin Brandreth , whose Vegetable Universal Pill eventually became one of the best-selling patent medicines in the United States . A congressional committee in 1849 reported that Brandreth was the nations largest proprietary advertiser Between 1862 and 1863 Brandreths average annual gross income surpassed $600,000 For fifty years Brandreths name was a household word in the United States This statute did not ban the alcohol , narcotics , and stimulants in the medicines ; it required them to be labeled as such , and curbed some of the more misleading , overstated , or fraudulent claims that appeared on the labels . In 1936 the statute was revised to ban them , and the United States entered a long period of ever more drastic reductions in the medications available unmediated by physicians and prescriptions . Morris Fishbein , editor of the Journal of the American Medical Association , who was active in the first half of the 20th century , based much of his career on exposing quacks and driving them out of business . The patent medicine makers moved from selling nostrums to selling deodorants and toothpastes , which continued to be advertised using the same techniques that had proven themselves selling nostrums for tuberculosis and female complaints . One survival of the herbal exoticism that once characterized the patent medicine industry is the marketing of shampoos , which are often promoted as containing perfumes such as vetiver or ylang-ylang , and foods such as mangoes , bananas , or honey ; consumers are urged to put these ingredients in their hair despite lack of any evidence that these ingredients do anything other than make the hair smell like the ingredients . In more recent years , also , various herbal concoctions have been marketed as nutritional supplements . While their advertisements are careful not to cross the line into making explicit medical claims , and often bear a disclaimer that asserts that the products have not been tested and are not intended to diagnose or treat any disease , they are nevertheless marketed as remedies of various sorts . Weight loss while you sleep and similar claims are frequently found on these compounds ( cf. , Calorad , Relacore , etc . ) . One of the most notorious such elixirs , however , calls itself Enzyte , widely advertised for natural male enhancement that is , penis enlargement . Despite being a compound of herbs , minerals , and vitamins , Enzyte formerly promoted itself under a fake scientific name ' ' Suffragium asotas ' ' . Enzyte 's makers translate this phrase as better sex , but it is in fact ungrammatical Latin for refuge for the dissipated . # Surviving consumer products from the patent medicine era # A number of brands of consumer products that date from the patent medicine era are still on the market and available today . Their ingredients may have changed from the original formulas ; the claims made for the benefits they offer have typically been seriously revised . These brands include : 666 Cold Medicine Absorbine Jr . Anacin/Anadin Andrews Liver Salts Aspro aspirin tablets Bayer Aspirin BC Powder Bromo-Seltzer Carter 's Little Liver Pills ( Currently sold as Carter 's Little Pills ) Chlorodyne Doan 's Pills Fletcher 's Castoria Goody 's Powder Lobeila Cough Syrup Lormans Indian Oil Luden 's Throat Drops Lydia E. Pinkham 's Vegetable Compound Minard 's Liniment Phillips ' Milk of Magnesia Smith Brothers Throat Drops Vicks VapoRub A number of patent medicines are produced in China . Among the best known of these is Shou Wu Chih , a black , alcoholic liquid that the makers claimed turned gray hair black . # Products no longer sold under medicinal claims # Some consumer products were once marketed as patent medicines , but have been repurposed and are no longer sold for medicinal purposes . Their original ingredients may have been changed to remove drugs , as was done with Coca-Cola . The compound may also simply be used in a different capacity , as in the case of Angostura Bitters , now associated chiefly with cocktails . 7-Up Angostura Bitters Bovril Buckfast Tonic Wine Coca-Cola Dr Pepper Fernet Branca Hires Root Beer Moxie brand soda Pepsi Cola Tonic water 
@@314696 Environmental health is the branch of public health that is concerned with all aspects of the natural and built environment that may affect human health . Other terms referring to or concerning environmental health are environmental public health , and public health protection / environmental health protection and environmental protection . Environmental health and environmental protection are very much related . Environmental health is focused on the natural and built environments for the benefit of human health , whereas environmental protection is concerned with protecting the natural environment for the benefit of human health and the ecosystems . Environmental health addresses all the physical , chemical , and biological factors external to a person , and all the related factors impacting behaviours . It encompasses the assessment and control of those environmental factors that can potentially affect health . It is targeted towards preventing disease and creating health-supportive environments . This definition excludes behaviour not related to environment , as well as behaviour related to the social and cultural environment , as well as genetics . : : Scope of practice in environmental health means the practice of environmental health by registered environmental health specialists in the public and private sector within the meaning of this article and includes , but is not limited to , organization , management , education , enforcement , consultation , and emergency response for the purpose of prevention of environmental health hazards and the promotion and protection of the public health and the environment in the following areas : food protection ; housing ; institutional environmental health ; land use ; community noise control ; recreational swimming areas and waters ; electromagnetic radiation control ; solid , liquid , and hazardous materials management ; underground storage tank control ; onsite septic systems ; vector control ; drinking water quality ; water sanitation ; emergency preparedness ; and milk and dairy sanitation pursuant to Section 33113 of the Food and Agricultural Code . The environmental health profession had its modern-day roots in the sanitary and public health movement of the United Kingdom . This was epitomized by Sir Edwin Chadwick , who was instrumental in the repeal of the poor laws and was the founding president of the Association of Public Sanitary Inspectors in 1884 , which today is the Chartered Institute of Environmental Health . # Disciplines # Three basic disciplines generally contribute to the field of environmental health : environmental epidemiology , toxicology , and exposure science . Each of these disciplines contributes different information to describe problems in environmental health , but there is some overlap among them . : Environmental epidemiology studies the relationship between environmental exposures ( including exposure to chemicals , radiation , microbiological agents , etc. ) and human health . Observational studies , which simply observe exposures that people have already experienced , are common in environmental epidemiology because humans can not ethically be exposed to agents that are known or suspected to cause disease . While the inability to use experimental study designs is a limitation of environmental epidemiology , this discipline directly observes effects on human health rather than estimating effects from animal studies . : Toxicology studies how environmental exposures lead to specific health outcomes , generally in animals , as a means to understand possible health outcomes in humans . Toxicology has the advantage of being able to conduct randomized controlled trials and other experimental studies because they can use animal subjects . However there are many differences in animal and human biology , and there can be a lot of uncertainty when interpreting the results of animal studies for their implications for human health . : Exposure science studies human exposure to environmental contaminants by both identifying and quantifying exposures . Exposure science can be used to support environmental epidemiology by better describing environmental exposures that may lead to a particular health outcome , identify common exposures whose health outcomes may be better understood through a toxicology study , or can be used in a risk assessment to determine whether current levels of exposure might exceed recommended levels . Exposure science has the advantage of being able to very accurately quantify exposures to specific chemicals , but it does not generate any information about health outcomes like environmental epidemiology or toxicology . Information from these three disciplines can be combined to conduct a risk assessment for specific chemicals or mixtures of chemicals to determine whether an exposure poses significant risk to human health . This can in turn be used to develop and implement environmental health policy that , for example , regulates chemical emissions , or imposes standards for proper sanitation. # Concerns # Environmental health addresses all human-health-related aspects of both the natural environment and the built environment . Environmental health concerns include :  Air quality , including both ambient outdoor air and indoor air quality , which also comprises concerns about environmental tobacco smoke .  Body art safety , including tattooing , body piercing and permanent cosmetics .  Climate change and its effects on health .  Disaster preparedness and response .  Food safety , including in agriculture , transportation , food processing , wholesale and retail distribution and sale .  Hazardous materials management , including hazardous waste management , contaminated site remediation , the prevention of leaks from underground storage tanks and the prevention of hazardous materials releases to the environment and responses to emergency situations resulting from such releases .  Housing , including substandard housing abatement and the inspection of jails and prisons .  Childhood lead poisoning prevention .  Land use planning , including smart growth .  Liquid waste disposal , including city waste water treatment plants and on-site waste water disposal systems , such as septic tank systems and chemical toilets .  Medical waste management and disposal .  Noise pollution control .  Occupational health and industrial hygiene .  Radiological health , including exposure to ionizing radiation from X-rays or radioactive isotopes.  Recreational water illness prevention , including from swimming pools , spas and ocean and freshwater bathing places .  Safe drinking water .  Solid waste management , including landfills , recycling facilities , composting and solid waste transfer stations .  Toxic chemical exposure whether in consumer products , housing , workplaces , air , water or soil .  Vector control , including the control of mosquitoes , rodents , flies , cockroaches and other animals that may transmit pathogens . According to recent estimates , about 5 to 10% of disability adjusted life years ( DALYs ) lost are due to environmental causes in Europe . By far the most important factor is fine particulate matter pollution in urban air . Similarly , environmental exposures have been estimated to contribute to 4.9 million ( 8.7% ) deaths and 86 million ( 5.7% ) DALYs globally . In the United States , Superfund sites created by various companies have been found to be hazardous to human and environmental health in nearby communities . It was this perceived threat , raising the specter of miscarriages , mutations , birth defects , and cancers that most frightened the public . # Information # The Toxicology and Environmental Health Information Program ( TEHIP ) at the United States National Library of Medicine ( NLM ) maintains a comprehensive toxicology and environmental health web site that includes access to resources produced by the TEHIP and by other government agencies and organizations . This web site includes links to databases , bibliographies , tutorials , and other scientific and consumer-oriented resources . The TEHIP also is responsible for the Toxicology Data Network ( TOXNET ) , an integrated system of toxicology and environmental health databases that are available free of charge on the web . # Mapping # There are many environmental health mapping tools . TOXMAP is a geographic information system ( GIS ) from the Division of Specialized Information Services of the United States National Library of Medicine ( NLM ) that uses maps of the United States to help users visually explore data from the United States Environmental Protection Agency 's ( EPA ) Toxics Release Inventory and Superfund Basic Research Programs . TOXMAP is a resource funded by the US federal government . TOXMAP 's chemical and environmental health information is taken from the NLM 's Toxicology Data Network ( TOXNET ) and PubMed , and from other authoritative sources . 
@@319759 Albert Einstein College of Medicine ( Einstein ) is a graduate school of Yeshiva University . It is a not-for-profit , private , nonsectarian medical school located on the Jack and Pearl Resnick Campus in the Morris Park neighborhood of the Bronx in New York City . In addition to medical degrees , Einstein offers graduate biomedical degrees through the Sue Golding Graduate Division . Allen M. Spiegel , M.D. , has served as The Marilyn and Stanley M. Katz Dean since June 1 , 2006 . Einsteins main focal areas are medical education , basic research , and clinical investigation . During the 20132014 academic year , Einstein is home to more than 2,000 full-time faculty members , 734 M.D. students , 236 Ph.D . students attending the Sue Golding Graduate Division and 106 students in the combined M.D./Ph.D. program . In addition , there are 353 postdoctoral research fellows at the Belfer Institute for Advanced Biomedical Studies . The medical school is known for its humanistic approach to its curriculum and training and for the diversity of its student body . The class of 2017 includes 183 students from 24 different U.S. states , 16% were born outside the U.S. , and 11% identify themselves as belonging to groups considered underrepresented in medicine . Einstein is also a major biomedical and clinical research facility . Faculty members received more than $155 million in funding from the National Institutes of Health in 2013 . In addition , the NIH funds major research centers at Einstein in diabetes , cancer , liver disease , and AIDS. # History # Yeshiva University President Dr. Samuel Belkin began planning for a new medical school as early as 1945 . Six years later , Dr. Belkin and New York City Mayor Vincent Impellitteri entered into an agreement to begin construction . At the same time , world-renowned physicist and humanitarian Albert Einstein sent a letter to Dr. Belkin . He remarked that such an endeavor would be unique in that the school would welcome students of all creeds and races . Two years later , on his 74th birthday , March 14 , 1953 , Albert Einstein agreed to have his name attached to the medical school . The first classes began September 12 , 1955 , and had a total of 56 students . At the time , it was the first new medical school to be erected within New York City since 1897 . The Sue Golding Graduate Division was established in 1957 to offer Ph.D.s in biomedical disciplines . The Medical Scientist Training Program ( MSTP ) , a combined M.D./Ph.D. program , was first offered in 1964 . The C.R.T.P. ( Clinical Research Training Program ) , which confers M.S. degrees in clinical research methods , began classes in July 1998. # Notable research and achievements # Source : Einstein website. In 1964 , Einstein was the first medical school in the United States to establish a Department of Genetics . In 1965 , Einstein opened one of the first General Clinical Research Centers in the US , funded by the NIH. In 1974 , Einstein 's Liver Research Center now the Marion Bessin Liver Research Center was the first institute in the nation devoted to the study of liver disease and injury . In 1976 , researchers at Einstein identified the mechanism of action of Taxol , one of the most significant cancer-treatment drugs ever developed . ( Susan B. Horwitz , Ph.D. ) In 1978 , Einstein was designated a Diabetes Research and Training Center , one of 7 such comprehensive centers in the US . The Center has been home to the foremost diabetes investigators involved in seminal work on the insulin receptor , the mechanism of diabetes complications , on glucose toxicity , on brain control of metabolism , and on hypoglycemia as well as landmark studies such as the Diabetes Control and Complications Trial and the Diabetes Prevention Program . In 1988 , one of the first NIH-funded Centers for AIDS Research ( CFARs ) in the country was created at Einstein . Researchers at the center were the first to identify pediatric AIDS as a distinct disease and established the first day-care center in the world for children with AIDS . ( Arye Rubinstein , M.D. ) In 1994 , Einstein became the only New York City medical school selected by the NIH to participate in the Women 's Health Initiative , the largest research study of women 's health ever undertaken . ( Sylvia Wassertheil-Smoller , Ph.D. , principal investigator ) In 2006 , Einstein became the only medical institution in the Northeast to serve as a research site for the Hispanic Community Health Study , the largest research study of Hispanic health ever conducted . ( Sylvia Wassertheil-Smoller , Ph.D. , principal investigator ) Einstein researchers demonstrated the association between reduced levels of high-density lipoproteins ( HDL ) , or good cholesterol , and heart disease . Einstein researchers identified a key missing neurotransmitter in the brains of patients with Alzheimer 's disease , a finding that influenced all subsequent Alzheimer 's disease research . ( Peter Davies , Ph.D. ) Researchers at Einstein discovered structural abnormalities of brain cells that explain deficiencies in cognitive development , greatly contributing to our understanding of mental retardation . ( Dominick P. Purpura , M.D. ) Einstein researchers helped discover the mechanisms responsible for the extraordinary diversity of antibodies and their remarkable precision in mounting an immune response . ( Matthew D. Scharff , M.D. ) Scientists at Einstein pioneered research that has led to improved methods of avoiding organ transplant rejection . ( Stanley G. Nathenson , M.D. ) Einstein researchers are leaders in epidemiologic research in migraine and other types of headache . ( Richard B. Lipton , M.D. ) # Leadership # Allen M. Spiegel , M.D. , The Marilyn and Stanley M. Katz Dean , June 1 , 2006present . Dr. Spiegel was previously the director of the National Institute of Diabetes &amp; Digestive Diseases &amp; Kidney Diseases ( NIDDK ) at the National Institutes of Health ( NIH ) , where he worked for over 30 years . Dominick P. Purpura , M.D. , The Marilyn and Stanley M. Katz Dean , 19842006 . His 22 years as dean are a record for the head of a medical school . Ernst R. Jaff , M.D. , acting dean , 197274 , 198384. Ephraim Friedman , M.D. , dean , 197483. Labe C. Scheinberg , M.D. , dean , 197072. Harry H. Gordon , M.D. , dean , 196770. Marcus D. Kogel , M.D. , founding dean , 195367. # Academic programs # The school offers M.D. and Ph.D . degrees and has a Medical Scientist Training Program that awards a combined M.D./Ph.D. degree . Students pursuing the Ph.D or M.D./Ph.D. degree are offered full tuition remission and a stipend of $31,300 . At any given time there are approximately 724 medical students , 248 Ph.D . students , and 117 students pursuing a combined M.D./Ph.D . The College of Medicine also offers M.S. degrees in clinical research methods and in bioethics , as well as a Master of Public Health ( MPH ) program that focuses on community-based participatory research . The school is known for its medical community promoting awareness , and humanism in social , ethical , and medical realms through its hospital affiliations , free ECHO health clinic , and Bronx community health fairs . It is currently ranked nationwide by U.S. News &amp; World Report at #34 in research ( out of 153 medical schools ) . # Affiliations # Albert Einstein College of Medicine is affiliated with seven medical centers : Montefiore Medical Center , the University Hospital and academic medical center for Einstein ; Jacobi Medical Center , Einsteins founding hospital and first affiliate , and five other affiliates including Bronx Lebanon Hospital and St. Barnabas Hospital , North Shore-LIJ Health System on Long Island and Maimonides Medical Center in Brooklyn . The broad geographical reach of Einsteins residency programs is a distinction not shared by all New York medical schools . Through its affiliation network , Einstein runs the largest postgraduate medical training program in the US , offering some 155 residency and fellowship programs to more than 2,200 physicians in training . Einstein 's Department of Family and Social Medicine ( DFSM ) offers the Residency Program in Social Medicine ( RPSM , est. 1970 ) , created to address the shortage of primary care clinicians trained to work in underserved communities . Additionally , Einstein runs the Rose Kennedy Center . The Rose Kennedy Center for research and treatment to help persons who have developmental disabilities is considered a premier center in this type of work . Of particular note are the occupational and physical therapy departments considered cutting edge in this area . # Departments # Einstein has many departments working in the fields of academic medicine and basic science . A Ph.D . or an M.D./Ph.D degree can be pursued in biomedical sciences in any of the following departments : Anatomy and Structural Biology Anesthesiology Biochemistry Cardiothoracic Surgery Cell Biology Dentistry Developmental and Molecular Biology Emergency Medicine Epidemiology and Population Health Family and Social Medicine Genetics Medicine ( Divisions ) *Allergy and Immunology *Cardiology *Critical Care Medicine *Dermatology *Endocrinology *Gastroenterology *General Internal Medicine *Geriatrics *Hematology *Hepatology *Infectious Diseases *Nephrology *Oncology *Pulmonary Medicine *Rheumatology Microbiology and Immunology Molecular Pharmacology Leo M. Davidoff Department of Neurological Surgery The Saul R. Korey Department of Neurology Dominick P. Purpura Department of Neuroscience Nuclear Medicine Obstetrics &amp; Gynecology and Women 's Health Ophthalmology and Visual Sciences Orthopedic Surgery Otorhinolaryngology Head &amp; Neck Surgery Pathology Pediatrics Physiology and Biophysics Psychiatry and Behavioral Sciences Radiation Oncology Radiology The Arthur S. Abramson Department of Rehabilitation Medicine Surgery Systems &amp; Computational Biology Urology  ( DoSA ) is the largest addiction treatment program in Bronx County , second largest public treatment program in New York State , and largest in the world operating under the auspices of a medical school . Serving over 3600 persons , with primary residence or work site in The Bronx , the Division provides comprehensive opioid addiction treatment at nine ( 9 ) community-based outpatient facilities located throughout the borough , as well as ambulatory services for all substances of abuse at the Divisions Chemical Dependency Wellness Services program located in North and South Bronx facilities . : The Divisions continuum of care includes : : # Addiction screening , assessment and diagnosis . : # Primary health care and behavioral health care . : # Medication-assisted treatment for opioid addiction , including methadone and buprenorphine. : # Medically supervised ambulatory chemical dependency wellness services to treat opioid drugs , cocaine , crystal meth , and other abused substances. : # HIV and Hepatitis C testing , primary care and case management . : # Vaccinations for Hepatitis A and B : # Directly observed preventive therapy for tuberculosis : # Specialized case management services for women and families , including prenatal and gynecological care . : # Intensive vocational services that promote self-sufficiency . Sound View Throgs Neck Community Mental Health Center # Centers and Institutes # Children 's Evaluation and Rehabilitation Center ( CERC ) is the main clinical arm of the Rose F. Kennedy University Center for Excellence in Developmental Disabilities ( RFK UCEDD ) , one of 67 UCEDDs in the United States . Composed of 10 interdisciplinary teams ( Early Childhood Center , Infant and Toddler Team , Infant Preschool Unit , School Age Unit , Adolescent Unit , Adult Team , Special Care Dentistry Program , Rehab Team , Children 's Hearing Program , and Developmental and Family Support Unit ) , CERC provides care for approximately 8,000 children and adults with developmental and other disabilities each year . Under the direction of Robert W. Marion , M.D. , a medical geneticist , CERC 's mission is to provide outstanding care to children with disabilities and their families , provide training to the next generation of leaders in the field of neurodevelopmental disabilities , and to perform research into the causes and potential treatments of the conditions that affect our patients . The research arm of CERC is headed by Dr. John J. Foxe . CERC is home to one of 36 LEND ( Leadership in Neurodevelopmental Disabilities ) programs in the US , offering hands-on training to professionals in developmental and behavioral pediatrics , special care and general dentistry , medical genetics and genetic counseling , psychiatry , psychology , social work , nursing , and other specialties . Each year , more than 1,000 professionals receive long-term , intermediate-term , or short-term training at our centers . In 2007 , CERC has also developed a substantial clinical research program , investigating the causes and treatments of such conditions as autism and autism spectrum disorder , sensorineural hearing loss and cerebral palsy . The Center for Ethics at Yeshiva University and the Institute for Public Health Sciences are affiliated with the medical school . Albert Einstein Cancer Center Center for AIDS Research ( CFAR ) Diabetes Research and Training Center ( DRTC ) Hispanic Center of Excellence Institute for Aging Research Institute for Clinical and Translational Research See all centers # Student life # Einstein is located in Morris Park , a residential neighborhood in the northeast Bronx . Within a 15-minute drive of campus are the Wildlife Conservation Park ( better known as the Bronx Zoo ) and the New York Botanical Garden and its Haupt Conservatory . Also nearby is the fishing community of City Island , which features marinas and a broad selection of seafood restaurants . There are more than 50 student clubs organized around a variety of activities , medical specialties , and a wide range of religious , political , and ethnic affiliations . Offerings include dance and movie clubs , an arts and literary magazine , and the Einstein Community Health Outreach ( ECHO ) , which launched the states first student-coordinated free clinic . Manhattan is a 3045 minute ride by car , express bus , or mass transit from Einsteins campus . # The Jack and Pearl Resnick Campus # The Michael F. Price Center for Genetic and Translational Medicine is a $220 million research building , officially opened and dedicated on June 12 , 2008 . It is 201000 sqft and will house 40 new laboratories . It is a state of the art research facility and contains a BSL-3 laboratory for infectious disease research .  The Arthur B. and Diane Belfer Educational Center for Health Sciences ( 1972 ) is the school 's main educational building and houses the 1st year medical students ' lecture hall ( Riklis Auditorium ) along with instructional labs and various conference rooms . The administrative offices are also located here .  The Leo Forchheimer Medical Sciences Building ( 1953 ) is the school 's first building . It contains the Robbins auditorium ( the 2nd year medical student lecture hall ) , Max and Sadie lounge , various biological research labs and anatomy labs , and other lecture rooms for graduate courses . In 2007 , the building caught on fire twice , severely disrupting classes and research . This building is also home to the D. Samuel Gottesman Library , located on the 1st floor of the building .  The D. Samuel Gottesman Library serves the needs of the Einstein community . ( during peak exam periods the library will have extended study hours on Friday night and Saturday , the weekend before exams . ) The library is open Sunday through Friday ; it is closed in observance of the Sabbath on Saturdays . In June 2006 , the library embarked on a year-long renovation project of its main floor .  Ullmann Research Center for Health Sciences ( 1964 ) .  The Irwin B. and Sylvia Chanin Institute for Cancer Research ( 1978 ) is devoted exclusively to basic investigations into malignant processes .  Mazer Building contains , among other things , the Lubin Student Center , which is the school 's kosher dining hall .  Gruss Magnetic Resonance Research Center  The Samuel H. and Rachel Golding Building ( 1996 ) is a 10-story biomedical research facility that is an addition to the original Forchheimer building .  Falk Recreation Center , which houses a gym , pool , indoor track , in addition to basketball , squash and racquetball courts .  Morris Park Avenue bisects the campus , separating the majority of academic and research buildings from the residential buildings and new construction .  The Eastchester Road Residence Complex , a 634-apartment complex comprising three 28 story apartment buildings , provides housing to all MD and PhD students ( including some post-doctoral fellows ) and their families .  The Rhinelander Hall Residence Complex houses mostly post-docs and the occasional med student .  The Jack D. Weiler Hospital of the Albert Einstein College of Medicine . Weiler is a division of Montefiore Medical Center .  The Rose F. Kennedy Center for Research in Mental Retardation and Human Development lies on the adjacent campus of the Bronx Municipal Hospital Center ( Jacobi Medical Center ) . The Van Etten Building ( soon to be fully renovated ) , home to the now finished Ruth L. Gottesman Clinical Skills Center , a 22700sqft m2 space of classrooms and 23 fully equipped exam rooms for the clinical instruction of first and second year medical students . Beginning in 2007 with the construction of the Michael F. Price Center , EE&amp;K Architects have been working closely with Albert Einstein College of Medicine on a comprehensive master plan of the future long-term development and renovation of The Jack and Pearl Resnick Campus . # Notable alumni #  Lynda Chin ( M.D , 1993 ) , Department chair and professor of genomic medicine at the University of Texas MD Anderson Cancer Center and scientific director of the MD Anderson Institute for Applied Cancer Science .  Raymond Vahan Damadian ( M.D. , Class of 1960 ) , Pioneer of Magnetic Resonance Imaging ( MRI ) ; founder , president , and chairman , FONAR Corporation ; professor of medicine and radiology , SUNY Health Science Center at Brooklyn . Howard Dean ( M.D. , 1978 ) , a former Vermont governor and chairman of the Democratic National Committee , and 2004 presidential candidate . Dean met his wife , Judith Steinberg Dean , while they were both students at Einstein .  Ronald A. DePinho , a cancer biologist  Sankar Ghosh , Silverstein &amp; Hutt Family Professor and Chairman of Department of Microbiology and Immunology at Columbia University . Noted luminary in study of transcription factor NF-KB.  Baruch Goldstein , perpetrator of the Cave of the Patriarchs Massacre  Ronald Hoffman ( M.D. , 1983 ) , a champion of holistic medicine , an author and a radio talk show host .  Harvey Karp ( M.D. , Class of 1976 ) , assistant professor of pediatrics , David Geffen School of Medicine at UCLA ; author of The Happiest Baby on the Block .  Rudolph Leibel , ( M.D. , Class of 1967 ) , awarded the Distinguished Alumnus Award of Albert Einstein College of Medicine ( 2005 ) , Scientist at Columbia University whose co-discovery at Rockefeller University of the hormone leptin , and cloning of the leptin and leptin receptor genes , has had a major role in the area of understanding human obesity.  Ken Shubin Stein , Founder &amp; Portfolio Manager , Spencer Capital Management ; Healthcare investor  Jonathan Zizmor ( M.D. , 1969 ) , is a dermatologist and renowned personality amongst New York City Subway riders .  Allison O'Neill ( M.D. , 2005 ) , is a pediatric oncologist who specializes in pediatric hepatic malignancies at the Dana-Farber/Boston Children 's Cancer and Blood Disorders Center .  Gary Hartstein , is Clinical Professor of Anesthesia and Emergency Medicine at University of Lige Hospital , Lige , Belgium and former FIA Medical Delegate for the Formula One World Championship . # Notable faculty #  Leo M. Davidoff , dean  Gertie Marx , pioneer of obstetric anesthesiology # Allegations of discrimination # The College of Medicine has been the center of several allegations of discrimination . In 1994 , the College was sued by Heidi Weissmann , a researcher in nuclear medicine and former associate professor of radiology , for sexual discrimination for not promoting her due to gender bias . The College settled the case for $900,000 . In 1998 , Yeshiva University and the College of Medicine was sued by the American Civil Liberties Union for discrimination of two medical students over their sexual orientation by not allowing their non-student , non-married partners to live with them in student housing . 
@@347838 Nuclear medicine is a medical specialty involving the application of radioactive substances in the diagnosis and treatment of disease . In nuclear medicine procedures , radionuclides are combined with other elements to form chemical compounds , or else combined with existing pharmaceutical compounds , to form radiopharmaceuticals . These radiopharmaceuticals , once administered to the patient , can localize to specific organs or cellular receptors . This property of radiopharmaceuticals allows nuclear medicine the ability to image the extent of a disease process in the body , based on the cellular function and physiology , rather than relying on physical changes in the tissue anatomy . In some diseases , nuclear medicine studies can identify medical problems at an earlier stage than other diagnostic tests . Nuclear medicine , in a sense , is radiology done inside out , or endo-radiology , because it records radiation emitting from within the body rather than radiation that is generated by external sources like X-rays . Treatment of diseased tissue , based on metabolism or uptake or binding of a particular ligand , may also be accomplished , similar to other areas of pharmacology . However , the treatment effects of radiopharmaceuticals rely on the tissue-destructive power of short-range ionizing radiation . In the future , nuclear medicine may provide added impetus to the field known as molecular medicine . As understanding of biological processes in the cells of living organisms expands , specific probes can be developed to allow visualization , characterization , and quantification of biologic processes at the cellular and subcellular levels . Nuclear medicine is a possible specialty for adapting to the new discipline of molecular medicine because of its emphasis on function and its utilization of imaging agents that are specific for a particular disease process . The global market is expected to reach US$ 24 billion in 2030 , showing an annual average growth of 11% , mostly driven by the therapeutic radiopharmaceutical market which is expected to increase annually by 30% between 2013 and 2030 . The diagnostic radiopharmaceutical market is expected to grow by 5% a year , mainly driven by volume increases . The global nuclear medicine market is fragmented , with more than 60 companies selling radiopharmaceuticals on a regular basis ; however , three companies take more than half of the world market share whereas more than 50 companies share 14% of this same world market . # Diagnostic medical imaging # # Diagnostic # In nuclear medicine imaging , radiopharmaceuticals are taken internally , for example , intravenously or orally . Then , external detectors ( gamma cameras ) capture and form images from the radiation emitted by the radiopharmaceuticals . This process is unlike a diagnostic X-ray , where external radiation is passed through the body to form an image . There are several techniques of diagnostic nuclear medicine .  2D : ' ' Scintigraphy ' ' ( scint ) is the use of internal radionuclides to create two-dimensional images . <gallery> File:Nl bone scan2.jpgA nuclear medicine whole body bone scan . The nuclear medicine whole body bone scan is generally used in evaluations of various bone-related pathology , such as for bone pain , stress fracture , nonmalignant bone lesions , bone infections , or the spread of cancer to the bone . File:nl mpi2.jpgNuclear medicine myocardial perfusion scan with thallium-201 for the rest images ( bottom rows ) and Tc-Sestamibi for the stress images ( top rows ) . The nuclear medicine myocardial perfusion scan plays a pivotal role in the noninvasive evaluation of coronary artery disease . The study not only identifies patients with coronary artery disease ; it also provides overall prognostic information or overall risk of adverse cardiac events for the patient . File:parathyroid subtraction.jpgA nuclear medicine parathyroid scan demonstrates a parathyroid adenoma adjacent to the left inferior pole of the thyroid gland . The above study was performed with Technetium-Sestamibi ( 1st column ) and iodine-123 ( 2nd column ) simultaneous imaging and the subtraction technique ( 3rd column ) . File:HIDA.jpgNormal hepatobiliary scan ( HIDA scan ) . The nuclear medicine hepatobiliary scan is clinically useful in the detection of the gallbladder disease . File:ventperf.jpgNormal pulmonary ventilation and perfusion ( V/Q ) scan . The nuclear medicine V/Q scan is useful in the evaluation of pulmonary embolism . File:thyroid scan.jpgThyroid scan with iodine-123 for evaluation of hyperthyroidism. </gallery>  3D : ' ' SPECT ' ' is a 3D tomographic technique that uses gamma camera data from many projections and can be reconstructed in different planes . ' ' Positron emission tomography ' ' ( PET ) uses coincidence detection to image functional processes . <gallery> File:hemangioma scan.jpgA nuclear medicine SPECT liver scan with technetium-99m labeled autologous red blood cells . A focus of high uptake ( arrow ) in the liver is consistent with a hemangioma . *29;1176923;TOOLONG intensity projection ( MIP ) of a whole-body positron emission tomography ( PET ) acquisition of a 79 kg female after intravenous injection of 371 MBq of 18F-FDG ( one hour prior measurement ) . </gallery> Nuclear medicine tests differ from most other imaging modalities in that diagnostic tests primarily show the physiological function of the system being investigated as opposed to traditional anatomical imaging such as CT or MRI . Nuclear medicine imaging studies are generally more organ- or tissue-specific ( e.g. : lungs scan , heart scan , bone scan , brain scan , etc. ) than those in conventional radiology imaging , which focus on a particular section of the body ( e.g. : chest X-ray , abdomen/pelvis CT scan , head CT scan , etc . ) . In addition , there are nuclear medicine studies that allow imaging of the whole body based on certain cellular receptors or functions . Examples are whole body PET scans or PET/CT scans , gallium scans , indium white blood cell scans , MIBG and octreotide scans . While the ability of nuclear metabolism to image disease processes from differences in metabolism is unsurpassed , it is not unique . Certain techniques such as fMRI image tissues ( particularly cerebral tissues ) by blood flow and thus show metabolism . Also , contrast-enhancement techniques in both CT and MRI show regions of tissue that are handling pharmaceuticals differently , due to an inflammatory process . Diagnostic tests in nuclear medicine exploit the way that the body handles substances differently when there is disease or pathology present . The radionuclide introduced into the body is often chemically bound to a complex that acts characteristically within the body ; this is commonly known as a tracer . In the presence of disease , a tracer will often be distributed around the body and/or processed differently . For example , the ligand methylene-diphosphonate ( MDP ) can be preferentially taken up by bone . By chemically attaching technetium-99m to MDP , radioactivity can be transported and attached to bone via the hydroxyapatite for imaging . Any increased physiological function , such as due to a fracture in the bone , will usually mean increased concentration of the tracer . This often results in the appearance of a hot spot , which is a focal increase in radio accumulation or a general increase in radio accumulation throughout the physiological system . Some disease processes result in the exclusion of a tracer , resulting in the appearance of a cold spot . Many tracer complexes have been developed to image or treat many different organs , glands , and physiological processes . # Hybrid scanning techniques # In some centers , the nuclear medicine scans can be superimposed , using software or hybrid cameras , on images from modalities such as CT or MRI to highlight the part of the body in which the radiopharmaceutical is concentrated . This practice is often referred to as image fusion or co-registration , for example SPECT/CT and PET/CT . The fusion imaging technique in nuclear medicine provides information about the anatomy and function , which would otherwise be unavailable or would require a more invasive procedure or surgery . <gallery> File:nl petct.jpgNormal whole body PET/CT scan with FDG-18 . The whole body PET/CT scan is commonly used in the detection , staging and follow-up of various cancers . File:abnl petct.jpgAbnormal whole body PET/CT scan with multiple metastases from a cancer . The whole body PET/CT scan has become an important tool in the evaluation of cancer . </gallery> # Practical concerns in nuclear imaging # Although the risks of low-level radiation exposures are not well understood , a cautious approach has been universally adopted that all human radiation exposures should be kept As Low As Reasonably Practicable , ALARP . ( Originally , this was known as As Low As Reasonably Achievable ( ALARA ) , but this has changed in modern draftings of the legislation to add more emphasis on the Reasonably and less on the Achievable . ) Working with the ALARP principle , before a patient is exposed for a nuclear medicine examination , the benefit of the examination must be identified . This needs to take into account the particular circumstances of the patient in question , where appropriate . For instance , if a patient is unlikely to be able to tolerate a sufficient amount of the procedure to achieve a diagnosis , then it would be inappropriate to proceed with injecting the patient with the radioactive tracer . When the benefit does justify the procedure , then the radiation exposure ( the amount of radiation given to the patient ) should also be kept as low as reasonably practicable . This means that the images produced in nuclear medicine should never be better than required for confident diagnosis . Giving larger radiation exposures can reduce the noise in an image and make it more photographically appealing , but if the clinical question can be answered without this level of detail , then this is inappropriate . As a result , the radiation dose from nuclear medicine imaging varies greatly depending on the type of study . The effective radiation dose can be lower than or comparable to or can far exceed the general day-to-day environmental annual background radiation dose . Likewise , it can also be less than , in the range of , or higher than the radiation dose from an abdomen/pelvis CT scan . Some nuclear medicine procedures require special patient preparation before the study to obtain the most accurate result . Pre-imaging preparations may include dietary preparation or the withholding of certain medications . Patients are encouraged to consult with the nuclear medicine department prior to a scan . # Analysis # The end result of the nuclear medicine imaging process is a dataset comprising one or more images . In multi-image datasets the array of images may represent a time sequence ( i.e. cine or movie ) often called a dynamic dataset , a cardiac gated time sequence , or a spatial sequence where the gamma-camera is moved relative to the patient . SPECT ( single photon emission computed tomography ) is the process by which images acquired from a rotating gamma-camera are reconstructed to produce an image of a slice through the patient at a particular position . A collection of parallel slices form a slice-stack , a three-dimensional representation of the distribution of radionuclide in the patient . The nuclear medicine computer may require millions of lines of source code to provide quantitative analysis packages for each of the specific imaging techniques available in nuclear medicine . Time sequences can be further analysed using kinetic models such as multi-compartment models or a Patlak plot . # Interventional nuclear medicine # Radionuclide therapy can be used to treat conditions such as hyperthyroidism , thyroid cancer , and blood disorders . In nuclear medicine therapy , the radiation treatment dose is administered internally ( e.g. intravenous or oral routes ) rather from an external radiation source . The radiopharmaceuticals used in nuclear medicine therapy emit ionizing radiation that travels only a short distance , thereby minimizing unwanted side effects and damage to noninvolved organs or nearby structures . Most nuclear medicine therapies can be performed as outpatient procedures since there are few side effects from the treatment and the radiation exposure to the general public can be kept within a safe limit . Common nuclear medicine ( unsealed source ) therapies In some centers the nuclear medicine department may also use implanted capsules of isotopes ( brachytherapy ) to treat cancer . Commonly used radiation sources ( radionuclides ) for brachytherapy # History # The history of nuclear medicine is rich with contributions from gifted scientists across different disciplines in physics , chemistry , engineering , and medicine . The multidisciplinary nature of nuclear medicine makes it difficult for medical historians to determine the birthdate of nuclear medicine . This can probably be best placed between the discovery of artificial radioactivity in 1934 and the production of radionuclides by Oak Ridge National Laboratory for medicine related use , in 1946 . The origins of this medical idea date back as far as the mid-1920s in Freiburg , Germany , when George de Hevesy made experiments with radionuclides administered to rats , thus displaying metabolic pathways of these substances and establishing the tracer principle . Possibly , the genesis of this medical field took place in 1936 , when John Lawrence , known as the father of nuclear medicine , took a leave of absence from his faculty position at Yale Medical School , to visit his brother Ernest Lawrence at his new radiation laboratory ( now known as the Lawrence Berkeley National Laboratory ) in Berkeley , California . Later on , John Lawrence made the first application in patients of an artificial radionuclide when he used phosphorus-32 to treat leukemia . Many historians consider the discovery of artificially produced radionuclides by Frdric Joliot-Curie and Irne Joliot-Curie in 1934 as the most significant milestone in nuclear medicine . In February 1934 , they reported the first artificial production of radioactive material in the journal ' ' Nature ' ' , after discovering radioactivity in aluminum foil that was irradiated with a polonium preparation . Their work built upon earlier discoveries by Wilhelm Konrad Roentgen for X-ray , Henri Becquerel for radioactive uranium salts , and Marie Curie ( mother of Irne Curie ) for radioactive thorium , polonium and coining the term radioactivity . Taro Takemi studied the application of nuclear physics to medicine in the 1930s . The history of nuclear medicine will not be complete without mentioning these early pioneers . Nuclear medicine gained public recognition as a potential specialty on December 7 , 1946 when an article was published in the Journal of the American Medical Association by Sam Seidlin . The article described a successful treatment of a patient with thyroid cancer metastases using radioiodine ( I-131 ) . This is considered by many historians as the most important article ever published in nuclear medicine . Although the earliest use of I-131 was devoted to therapy of thyroid cancer , its use was later expanded to include imaging of the thyroid gland , quantification of the thyroid function , and therapy for hyperthyroidism . Widespread clinical use of nuclear medicine began in the early 1950s , as knowledge expanded about radionuclides , detection of radioactivity , and using certain radionuclides to trace biochemical processes . Pioneering works by Benedict Cassen in developing the first rectilinear scanner and Hal O. Anger 's scintillation camera ( Anger camera ) broadened the young discipline of nuclear medicine into a full-fledged medical imaging specialty . In these years of nuclear medicine , the growth was phenomenal . The Society of Nuclear Medicine was formed in 1954 in Spokane , Washington , USA . In 1960 , the Society began publication of the Journal of Nuclear Medicine , the premier scientific journal for the discipline in America . There was a flurry of research and development of new radionuclides and radiopharmaceuticals for use with the imaging devices and for in-vitro studies5 . Among many radionuclides that were discovered for medical-use , none were as important as the discovery and development of Technetium-99m . It was first discovered in 1937 by C. Perrier and E. Segre as an artificial element to fill space number 43 in the Periodic Table . The development of a generator system to produce Technetium-99m in the 1960s became a practical method for medical use . Today , Technetium-99m is the most utilized element in nuclear medicine and is employed in a wide variety of nuclear medicine imaging studies . By the 1970s most organs of the body could be visualized using nuclear medicine procedures . In 1971 , American Medical Association officially recognized nuclear medicine as a medical specialty . In 1972 , the American Board of Nuclear Medicine was established , and in 1974 , the American Osteopathic Board of Nuclear Medicine was established , cementing nuclear medicine as a stand-alone medical specialty . In the 1980s , radiopharmaceuticals were designed for use in diagnosis of heart disease . The development of single photon emission computed tomography ( SPECT ) , around the same time , led to three-dimensional reconstruction of the heart and establishment of the field of nuclear cardiology . More recent developments in nuclear medicine include the invention of the first positron emission tomography scanner ( positron emission tomography PET and PET/CT imaging experienced slower growth in its early years owing to the cost of the modality and the requirement for an on-site or nearby cyclotron . However , an administrative decision to approve medical reimbursement of limited PET and PET/CT applications in oncology has led to phenomenal growth and widespread acceptance over the last few years , which also was facilitated by establishing 18F-labelled tracers for standard procedures , allowing work at non-cyclotron-equipped sites . PET/CT imaging is now an integral part of oncology for diagnosis , staging and treatment monitoring . A fully integrated MRI/PET scanner is on the market from early 2011. # Source of radionuclides , with notes on a few radiopharmaceuticals # About a third of the world 's supply , and most of North America 's supply , of medical isotopes are produced at the Chalk River Laboratories in Chalk River , Ontario , Canada . ( Another third of the world 's supply , and most of Europe 's supply , are produced at the Petten nuclear reactor in the Netherlands . ) The Canadian Nuclear Safety Commission ordered the NRU reactor to be shut down on November 18 , 2007 for regularly scheduled maintenance and an upgrade of the safety systems to modern standards . The upgrade took longer than expected and in December 2007 , a critical shortage of medical isotopes occurred . The Canadian government unanimously passed emergency legislation , allowing the reactor to restart on 16 December 2007 , and production of medical isotopes to continue . The Chalk River reactor is used to irradiate materials with neutrons which are produced in great quantity during the fission of U-235 . These neutrons change the nucleus of the irradiated material by adding a neutron , or by splitting it in the process of nuclear fission . In a reactor , one of the fission products of uranium is molybdenum-99 which is extracted and shipped to radiopharmaceutical houses all over North America . The Mo-99 radioactively beta decays with a half-life of 2.7 days , turning initially into Tc-99m , which is then extracted ( milked ) from a moly cow ( see technetium-99m generator ) . The Tc-99m then further decays , while inside a patient , releasing a gamma photon which is detected by the gamma camera . It decays to its ground state of Tc-99 , which is relatively non-radioactive compared to Tc-99m . The most commonly used radioisotope in PET F-18 , is not produced in any nuclear reactor , but rather in a circular accelerator called a cyclotron . The cyclotron is used to accelerate protons to bombard the stable heavy isotope of oxygen O-18 . The O-18 constitutes about 0.20% of ordinary oxygen ( mostly O-16 ) , from which it is extracted . The F-18 is then typically used to make FDG ( see this link for more information on this process ) . A typical nuclear medicine study involves administration of a radionuclide into the body by intravenous injection in liquid or aggregate form , ingestion while combined with food , inhalation as a gas or aerosol , or rarely , injection of a radionuclide that has undergone micro-encapsulation . Some studies require the labeling of a patient 's own blood cells with a radionuclide ( leukocyte scintigraphy and red blood cell scintigraphy ) . Most diagnostic radionuclides emit gamma rays , while the cell-damaging properties of beta particles are used in therapeutic applications . Refined radionuclides for use in nuclear medicine are derived from fission or fusion processes in nuclear reactors , which produce radionuclides with longer half-lives , or cyclotrons , which produce radionuclides with shorter half-lives , or take advantage of natural decay processes in dedicated generators , i.e. molybdenum/technetium or strontium/rubidium . The most commonly used intravenous radionuclides are :  Technetium-99m ( technetium-99m )  Iodine-123 and 131  Thallium-201  Gallium-67  Fluorine-18 Fluorodeoxyglucose  Indium-111 Labeled Leukocytes The most commonly used gaseous/aerosol radionuclides are :  Xenon-133  Krypton-81m  Technetium-99m a radioaerosol invented in Australia by Dr Bill Burch and Dr Richard Fawdry  Technetium-99m DTPA # Radiation dose # A patient undergoing a nuclear medicine procedure will receive a radiation dose . Under present international guidelines it is assumed that any radiation dose , however small , presents a risk . The radiation doses delivered to a patient in a nuclear medicine investigation , though unproven , is generally accepted to present a very small risk of inducing cancer . In this respect it is similar to the risk from X-ray investigations except that the dose is delivered internally rather than from an external source such as an X-ray machine , and dosage amounts are typically significantly higher than those of X-rays . The radiation dose from a nuclear medicine investigation is expressed as an effective dose with units of sieverts ( usually given in millisieverts , mSv ) . The effective dose resulting from an investigation is influenced by the amount of radioactivity administered in megabecquerels ( MBq ) , the physical properties of the radiopharmaceutical used , its distribution in the body and its rate of clearance from the body . Effective doses can range from 6 Sv ( 0.006 mSv ) for a 3 MBq chromium-51 EDTA measurement of glomerular filtration rate to 37 mSv ( 37,000 Sv ) for a 150 MBq thallium-201 non-specific tumour imaging procedure . The common bone scan with 600 MBq of technetium-99m-MDP has an effective dose of approximately 3.5 mSv ( 3,500 Sv ) ( 1 ) . Formerly , units of measurement were the curie ( Ci ) , being 3.7E10 Bq , and also 1.0 grams of Radium ( Ra-226 ) ; the rad ( radiation absorbed dose ) , now replaced by the gray ; and the rem ( Rntgen equivalent man ) , now replaced with the sievert . The rad and rem are essentially equivalent for almost all nuclear medicine procedures , and only alpha radiation will produce a higher Rem or Sv value , due to its much higher Relative Biological Effectiveness ( RBE ) . Alpha emitters are nowadays rarely used in nuclear medicine , but were used extensively before the advent of nuclear reactor and accelerator produced radionuclides . The concepts involved in radiation exposure to humans are covered by the field of Health Physics ; the development and practice of safe and effective nuclear medicinal techniques is a key focus of Medical Physics . 
@@349340 ' ' Men 's Health ' ' ( ' ' MH ' ' ) , published by Rodale Inc. in Emmaus , Pennsylvania , United States , is the world 's largest men 's magazine brand , with 40 editions in 47 countries . It is also the best-selling men 's magazine on U.S. newsstands . Although originally started as a men 's health magazine , it currently covers various men 's lifestyle topics such as fitness , nutrition , fashion , and sexuality . The magazine 's website , MensHealth.com , averages 38 million page views a month . # History # Launched by Mark Bricklin in 1987 as a health-oriented service magazine , ' ' Men 's Health ' ' has evolved into a lifestyle magazine for men , covering areas such as health , fitness , nutrition , relationships , travel , technology , fashion and finance . Bricklin , along with Rodale editors Larry Stains and Stefan Bechtel , initially produced three newsstand test issues . The results led Rodale to launch ' ' Men 's Health ' ' as a quarterly magazine in 1988 and begin to sell subscriptions . Bricklin , who was editor-in-chief of ' ' Prevention ' ' magazine , appointed Mike Lafavore as editor of ' ' Men 's Health ' ' that year . In his subsequent 12 years as editor-in-chief , Lafavore grew the circulation from 100,000 to more than 1.5 million , took the publishing frequency to 10 times a year , and expanded the magazine 's brand to a number of countries , including the UK , France , Germany , Australia , South Africa , Mexico and Russia . He created the editorial formula still in use today , brought aboard Steven Slon , a veteran of the service journalism category , imported Greg Gutfeld from Rodale 's ' ' Prevention ' ' title and worked with longtime staff editor Denis Boyles , a former ' ' Playboy ' ' contributing editor , to develop the magazine 's influential and distinctive regular guy voice . Lafavore left ' ' Men 's Health ' ' in 2000 , the same year Capell 's Circulation Report named the magazine Circulation Performer of the Decade . He appointed Greg Gutfeld as his successor . After a year , Gutfeld was replaced by David Zinczenko . ' ' Men 's Health ' ' publishes 40 foreign editions across 47 countries , up from 20 editions in 2001 . The magazine does not run ads for tobacco or liquor companies ; they also do not run ads for supplements and herbal remedies . David Zinczenko became the editor-in-chief of ' ' Men 's Health ' ' in 2000 . Ronan Gardiner is the publisher . During this period , the magazine 's circulation grew 30 percent , and ad pages grew 80 percent , from 700 pages to 1150 . In 2000 , the brand had 21 international editions . In 2001 the title was consistently selling 400,000 copies at newsstands and overall circulation was 1.6 million . In 2001 , the magazine started the annual list of cities with the healthiest men based on twenty live-long parameters , including death rates ( both homicide and disease ) ; illness rates ( high blood pressure , heart disease , stroke , etc. ) ; body-mass index ; fitness training ; even environmental factors like number of parks , golf courses , etc . In 2003 , the circulation was 1.7 million . In 2006 , the circulation was close to 1.8 million . As of June 2011 , the circulation was 1.89 million . ' ' Men 's Health ' ' magazine has been criticized for its focus on physical health , which can increase men 's anxieties about their bodies , making them more prone to eating disorders and compulsive over-exercising . Says ' ' The New York Times ' ' , Since its debut in the late 1980 's , the magazine has surpassed traditional men 's books like Esquire and GQ by following the formula of best-selling women 's magazines by catering to men 's anxieties about their bodies and sexual performance . ' ' Columbia Journalism Review ' ' stated the magazine deals overwhelmingly with self-care and , in fact , exaggerates the possibilities for autonomous personal transformation . Then Editor-In-Chief Zinczenko argued that the magazine works towards overcoming the resistance of the 86-percent male audience to health as a subject and redefining health as inclusive of everything that could improve a man 's life . Great sex . Great food . Endorphin-boosting exercise . Looking and feeling your best . We turned health into a concept every guy would want to embrace , starting with the healthy guy on the cover . The magazine has also been criticized for reusing cover taglines . In response , Zinczenko explained that the majority of magazine sales80 percentare subscription and those covers vary from the newsstand version . Said Zinczenko , Twenty years of ' ' Men 's Health ' ' has certainly produced several lines that have proven themselves effective at newsstand , which makes up about 20 percent of our print run . We plan to keep using the most effective marketing tools to reach the largest market we possibly can . In July 2010 , the magazine was criticized for including tiny credit lines on the cover rather than inside as a possible quid-pro-quo for advertisers . Zinczenko explained the lines were a service to readers , saving them the need to dig for the information , and that Men 's Health had been including the lines across the board for over a year , regardless of advertiser status . A spokesperson for American Society of Magazine Editors confirmed that no rules were broken and the director for print strategy at a media planning and buying firm said the mention was too small of a plug to get brands excited . In 2004 , the magazine began putting celebrities and athletes on the cover , and with their shirts ona big departure from the cover look of the 1990s . In 2004 , Rodale filed suit against ' ' Men 's Fitness ' ' for its redesign which makes it a copycat version--one that is obviously intended to confuse consumers . In May 2006 , the magazine published a limited edition color cover of Josh Holloway . In the first half of 2006 , newsstand sales for Men 's Health rose from 492,000 to 544,000 during a price increase from $3.95 to $4.50 . In 2006 , the magazine and the Rodale 's other properties made extensive efforts to increase online content including adding video to each section , enlisting every major section editor to blog , and adding an online ad sales director . In fall 2007 , ' ' Men 's Health ' ' launched the FitSchools initiative to combat childhood obesity . The magazine sends health , fitness , and nutrition experts to selected schools each year to remake the physical education programs and school lunch offerings . Gettys Middle School , in Easley , South Carolina , was the first FitSchool . In spring 2008 , the magazine launched The FitSchools Foundation , a nonprofit organization with the mission to help end childhood obesity and get America 's kids interested in healthy , active living . The January/February 2008 The Year of You edition became the all-time single-copy sales issue in the magazine 's history with 750,650 copies . Also in 2008 , the magazine partnered with Google to make back issues available . In July 2008 , Men 's Health became the first to create the first fully interactive advertising magazine in America , where users snap a picture of an ad and an immediate promotional bounce-back will be sent to their phone . For its 20th Anniversary issue in November 2008 , ' ' Men 's Health ' ' featured an interview and photo shoot with future President-elect Barack Obama . In 2010 , Obama was again featured in reference to the health-care debates of the time and his proposed health plans . In 2011 , another politician , Congressman Aaron Schock of Illinois , graced the cover baring his chest to promote fitness . The cover was released on May 9 on the Today Show with Matt Lauer where Congressman Schock encouraged people to form healthy eating and fitness habits , and join the ' ' Men 's Health ' ' to shed pounds . Within minutes , the Congressman 's 6-pack abs caught the attention of multiple publications and went viral . In 2009 , ' ' Men 's Health ' ' published the ' ' Belly Off ! Diet ' ' book , based on the popular weight-loss testimonial column in the magazine . The popular column , Eat This , Not That ! ( ETNT ) , also became a book series in 2007 and later developed different versions ( children , supermarket , restaurant , diet book ) and free iPhone applications . EatThis.MensHealth.com was the most highly trafficked section of MensHealth.com in 2009 with 1 million unique visitors and 15 million page views a month . In September 2009 , the column Ask Jimmy the Bartender was turned into an iPhone and iPad application . In 2010 , ' ' Men 's Health ' ' became one of the first consumer magazines to enter the iPad market . The magazine 's first application , Men 's Health Workouts , has maintained a position at or near the Top 10 in the Health &amp; Fitness category since its debut . In 2012 , David Zinczenko was replaced by Bill Phillips . # Spin-offs # In 2000 ' ' MH-18 ( magazine ) ' ' , a youth-oriented version of ' ' Men 's Health ' ' covering teen lifestyle , was spun-off but ceased publication in November 2001 . In 2004 under Zinczenko 's direction , ' ' Men 's Health ' ' spun off ' ' Best Life . ' ' May 2009 was ' ' Best Life s last issue . ' ' Best Life ' ' was published 10 times a year and had a circulation of more than 500,000 . Stephen Perrine , the former editorial creative director at ' ' Men 's Health ' ' , was the editor-in-chief . David Zinczenko was editorial director . In March 2008 , ' ' Best Life ' ' finished #2 on Adweek 's prestigious 10 under 50 Hot List , which recognizes magazines with fewer than $50 million in ad revenue . In 2005 , ' ' Men 's Health ' ' spun off ' ' Women 's Health ' ' . The test-issue team was headed by Bill Stump , a former ' ' Men 's Health ' ' editor who was then the head of Rodale Inc. ' s New Product Development department . Within a year the circulation was at 750,000 . ' ' Women 's Health ' ' magazine is now published 10 times a year . In January 2009 , Michele Promaulayko was named editor-in-chief of ' ' Women 's Health . ' ' In March 2008 , ' ' Women 's Health ' ' finished #1 on Adweek 's 10 under 50 Hot List . The magazine was named #2 on Advertising Age 's 2008 A List . ' ' Women 's Health ' ' has a circulation of 1.1 million . In 2007 , ' ' Men 's Health ' ' spun off ' ' Men 's Health Living ' ' , a newsstand special which was named one of the 30 most notable launches of 2007 by Samir Husni . Samir Husni stated that ' ' Men 's Health Living ' ' is a new genre of men 's magazines that cater to non-woman related issues in a man 's life - that has gone unfulfilled for years : interior design and home that meets the needs of the affluent man . The test issue of ' ' Men 's Health Living ' ' was edited by Bill Phillips , executive editor of ' ' Men 's Health ' ' . The first issue sold around 200,000 copies at $4.99 each out of 375,000 sent to newsstands . In January 2009 , a second ' ' Men 's Health Living ' ' issue was at newsstands , 450,000 copies at $5.99 each . In 2007 , they also spun off ' ' Men 's Health on Campus ' ' as a test with a goal for quarterly publication thereafter . In 2009 , ' ' Men 's Health ' ' spun off ' ' Children 's Health ' ' , a special issue that was part of a Rodale publishing idea to work with President and First Lady Obama to show support for the Patient Protection and Affordable Care Act . The magazine published how-to stories about fitness and nutrition for children . # Awards and recognition # In March 1994 , Advertising Age magazine named Mike Lafavore its Editor of the Year . March 6 , 1994 . Four years later he won the International Herald Tribune Award for International Editor of the Year for his work on ' ' Men 's Health s foreign editions . The magazine was also nominated for several National Magazine Awards , including General Excellence under his editorship . Since 2000 , ' ' Men 's Health ' ' has been nominated for 15 National Magazine Awards or Ellies , which are administrated by Columbia University 's Graduate School of Journalism and presented by the American Society of Magazine Editors ( ASME ) . ' ' Men 's Health ' ' won in the category of Personal Service in 2004 , the first win for the magazine , and for parent company Rodale . In 2010 , ' ' Men 's Health ' ' took home the General Excellence award . Menshealth.com 's ' ' Eat This , Not That ! ' ' portion of their Web site took home the 2010 Digital Ellies award , also sponsored by the ASME , for best Interactive Tool , an award honoring the outstanding use of interactive tools that enable users to create or share content , participate in communities , improve the quality of their lives or enjoy recreational activities . In 2010 , Minonline.com deemed menshealth.com 's personal trainer channel , the Best Premium Site , an award recognizing subscription sites oriented around service . And in 2011 , Men 's Health won an Ellie in the category of Personal Service for an article , I Want My Prostate Back by Larry Stains. # Global editions # Although ' ' Men 's Health ' ' was founded in the U.S. , its international editions have made it the world 's largest men 's magazine brand . The magazine 's worldwide monthly circulation including all editions has reached 1.85 million and over 20 million readers worldwide . ' ' Men 's Health ' ' is currently published in 39 editions . International editions account for over 80% of the magazine 's trade volume . In each market , local editors commission or purchase articles for their own market and share content with US and other editions . The selected articles are then translated and edited by local staffers to make them match the well-educated informal style of the American edition . Usually , these editions started out as translations of the US version of the magazine , but over time many non-US editions became unique , providing material more pertinent to local readers .  Australia : see Men 's Health ( Australian magazine )  Brazil  Bulgaria  China  Croatia  France  Germany  Greece  Hungary  India  Indonesia  Italy  Kazakhstan  Malaysia  Mexico  Netherlands  Philippines  Poland  Portugal  Romania  Russia  Serbia  Singapore  South Africa  South Korea  Spain  Thailand  Turkey  Ukraine  United Kingdom : see ' ' Men 's Health ' ' ( British magazine ) 
@@353792 Folk medicine consists of the healing practices and ideas of body physiology and health preservation known to some in a culture , transmitted informally as general knowledge , and practiced or applied by anyone in the culture having prior experience . Folk medicine may also be referred to as traditional medicine , alternative medicine , indigenous medicine , complementary medicine , or natural medicine . These terms are often considered interchangeable , even though some authors may prefer one or the other because of certain overtones they may be willing to highlight . In fact , out of these terms perhaps only ' ' indigenous medicine ' ' and ' ' traditional medicine ' ' have the same meaning ' ' folk medicine ' ' , while the others should be understood rather in a modern or modernized context . # Background # All cultures and societies have knowledge best described as folk medicine . Although there is large overlap , the denotative and connotative definitions differ . Folk medicine often coexists with formalized , education-based , and institutionalized systems of healing such as Western medicine or Great traditional medicine systems like Ayurvedic , Unani medicine , and Chinese medicine , but is distinguishable from formalized or institutionalized healing systems . Some examples of strong informal and to some degree institutionalized folk medicine traditions are : Traditional Korean medicine , Arabic indigenous medicine ( source of Unani medicine , along with Ancient Greek medicine ) , Haitian folk medicine , Uyghur traditional medicine , Various African herbal folk remedies , Celtic traditional medicine ( in part practiced by the Irish medical families ) , Japanese Kamp medicine , Traditional Aboriginal Bush medicine , Georgian folk medicine , and other . Use of folk medicine knowledge is not restricted within the society to those who have served an apprenticeship , undergone some sort of training or testing , or have achieved a specific social status . Theories and practices of folk medicine may influence , or be influenced by , the formalized medicine systems of the same culture . # History # 3000 BC - 18th century Folk medicine has been traced back as early as ancient Egypt in 3000 BC , though much of modern medicine stems from Greece . The Greek documents were later translated to Arabic and medicine had then continued to undergo further study in the Islamic world . # Use in Western culture # At the turn of the century , folk medicine was viewed as a practice used by poverty stricken communities and quacks . However the rejection of synthetic or biomedical products has become a growing trend in Western society and allowed for a rise in the demand for natural medicines . When less developed countries are taken into account it is estimated that over 50% of the worlds population relies on folk medicine practices . The prevalence of folk medicine in certain areas of the world will vary based on cultural norms . Chinese herbology , for instance , has very much taken traction in the NY area . Much of today 's modern medicine though is previously based on plants that had been long used in folk medicine . Some researchers point out a significant factor , however , that many of the alternative treatments that they test are statistically indistinguishable from placebo treatments . # Safety concerns # Although over 100 countries have regulations on folk medicines there are still some risks associated with the use of them , especially when they are used without supervision . It is often assumed that because the medicines are herbal or natural , that they are completely safe . One type of folk medicine commonly used along with Ayurvedic medicine is Rasa Shastra and practice involves the use of heavy metals in herbal remedies . When taken without supervision there is a risk of overdosing resulting in mineral toxicity in the body . Many of these herbal medicines are available through online resources and do not require a prescription and run the risk of overdosing . As well there is the possibility of the herbal medicines interfering with prescription medicines that patients may be taking under their doctors orders . It is also true that fraud and unscrupulousness of self declared healers may be a substantial risk factor in resorting to folk medicine remedies , especially in an unregulated environment . 
@@356531 Her Majesty 's Principal Secretary of State for Health is a UK cabinet position responsible for the Department of Health . Since devolution in 1999 , the position holder 's responsibility for the health service is mainly restricted to England , with the holder 's counterparts in Scotland and Wales responsible for the NHS in those countries . Prior to devolution the Secretaries of State for Scotland and Wales had those respective responsibilities but the Department of Health had a larger role than now in the co-ordination of health policy across Great Britain . Health services in Northern Ireland have always had separate arrangements from the rest of the UK , and are currently the responsibility of the Health Minister in the Northern Ireland Executive . The first Boards of Health were created by Orders in Council dated 21 June 14 November , and 21 November 1831 . In 1848 a General Board of Health was created with the First Commissioner of Woods and Forests as its President . In 1854 this Board was reconstituted and the President appointed separately . However , the Board was abolished in 1858 and its function of overseeing the local boards was transferred to a new Local Government Act Office within the Home Office . From 1871 that function was transferred to the new Local Government Board . The Ministry of Health was created in 1919 as a reconstruction of the Local Government Board . Local government functions were eventually transferred to the Minister of Housing and Local Government , leaving the Health Ministry in charge of Health proper . From 1968 it was amalgamated with the Ministry of Social Security under the Secretary of State for Social Services , until a de-merger of the Department of Health and Social Security on 25 July 1988. # List of Ministers # Colour key ( for political parties ) : *6;19295;br 
@@361308 The Health and Safety Executive ( HSE ) is a non-departmental public body of the United Kingdom with its headquarters in Liverpool , England . It is the body responsible for the encouragement , regulation and enforcement of workplace health , safety and welfare , and for research into occupational risks in England and Wales and Scotland . Responsibility in Northern Ireland lies with the Health and Safety Executive for Northern Ireland . The HSE was created by the Health and Safety at Work etc . Act 1974 , and has since absorbed earlier regulatory bodies such as the Factory Inspectorate and the Railway Inspectorate though the Railway Inspectorate was transferred to the Office of Rail Regulation in April 2006 . The HSE is sponsored by the Department for Work and Pensions . As part of its work HSE investigates industrial accidents , small and large , including major incidents such as the explosion and fire at Buncefield in 2005 . Though it formerly reported to the Health and Safety Commission , on 1 April 2008 , the two bodies merged . s duties are to : Assist and encourage persons concerned with matters relevant to the operation of the objectives of the Health and Safety at Work etc . Act 1974. Make arrangements for and encourage research and publication , training and information in connection with its work . Make arrangements for securing government departments , employers , employees , their respective representative organisations , and other persons are provided with an information and advisory service and are kept informed of , and adequately advised on such matters . Propose regulations . The Executive is further obliged to keep the Secretary of State informed of its plans and ensure alignment with the policies of the Secretary of State , giving effect to any directions given to it . The Secretary of State can give directions to the Executive . On 1 April 2006 , the Executive ceased to have responsibility for railway safety . The Executive is responsible for the Employment Medical Advisory Service , which operates as part of its Field Operations Directorate . the site is a good place for help # Structure and responsibilities # Local authorities are responsible for the enforcement of health and safety legislation in shops , offices , and other parts of the service sector . Agencies belonging to the HSE include # Explosives Inspectorate # HSE 's Explosives Inspectorate enforces the legislation for the classification and transport of explosives . It licenses manufacturing and larger storage sites . # The Health and Safety Laboratory # Based in Buxton , Derbyshire , the Health and Safety Laboratory ( HSL ) employs over 350 people including scientists , engineers , psychologists , social scientists , health professionals and technical specialists . It was established in 1921 under the Safety in Mines Research Board to carry out large-scale tests related to mining hazards . Following the formation of the HSE , in 1975 the facilities became a Safety Engineering Laboratory and an Explosion and Flame Research Laboratory , operating as part of the Research Laboratories Service Division of the HSE . In 1995 the HSL was formed , including the Buxton site and laboratories in Sheffield . In 2004 the Sheffield activities moved to Buxton , and the University of Sheffield took over the Sheffield laboratory site . It now operates as an agency carrying out scientific research and investigations ( e.g. on the Buncefield fire ) for the HSE , other government agencies and the private sector . # HM Inspectorate of Mines # HM Inspectorate of Mines is responsible for the correct implementation and inspection of safe working procedures within all UK mine workings . It is based in Sheffield , South Yorkshire . # Nuclear Directorate # The Nuclear Directorate was one of the bodies merged into the Office for Nuclear Regulation on 1 April 2011 . Largely based in Bootle , the Nuclear Directorate had four main functions :  nuclear safety and radioactive waste management of civilian and defence sites - Nuclear Installations Inspectorate  security of civilian nuclear sites and nuclear transport - The Office for Nuclear Security ( transferred to HSE April 2007 )  safeguarding civilian nuclear material to prevent diversion to weapons - UK Safeguards Office ( transferred to HSE April 2007 )  a nuclear safety research programme # OSHCR ( Occupational Safety &amp; Health Consultants Register ) # The HSE currently administrates the Occupational Safety &amp; Health Consultants Register ( OSHCR ) , a central register of registered safety consultants within the United Kingdom and Northern Ireland . The intention of the HSE is to pass responsibility of operating the register to the relevant trade &amp; professional bodies once the register is up and running . # Criticism # The HSE has been criticised . Some of the criticism has been that its procedures are inadequate to protect safety . For example , the public enquiry by Lord Gill into the Stockline Plastics factory explosion criticised the HSE for inadequate appreciation of the risks associated with buried LPG pipework .. and a failure properly to carry out check visits . However , most criticism of the HSE is that their regulations are over-broad , suffocating , and part of a nanny state . The Daily Telegraph has claimed that the HSE is part of a compensation culture , that it is undemocratic and unaccountable , and that its rules are costing jobs . However , the HSE denies this , saying that much of the criticism is misplaced because it relates to matters outside the HSE 's remit . The HSE also responded to criticism by publishing a Myth of the Month section on its website between 2007 and 2010 , which it described as exposing the various myths about health and safety . This has become a political issue in the UK . The Lord Young report , published in October 2010 , recommended various reforms aiming to free businesses from unnecessary bureaucratic burdens and the fear of having to pay out unjustified damages claims and legal fees . # Areas of regulation # The HSE focuses regulation of health and safety in the following sectors of industry : Agriculture Air transport Armed forces Catering and hospitality Construction industries Crown establishments Chemical manufacture and storage industries Professional diving Dockwork Education sector e.g. schools Engineering sector Entertainment and leisure industry Fire service Food and drink manufacture Footwear and leather industries Haulage Health Services e.g. hospitals Gas supply and installation ; Gas Safe Register Laundries and dry-cleaning Mining Motor vehicle repair Nuclear installations ; Nuclear Installations Inspectorate ( aka NII ) Office work Offshore Oil and Gas Installations Paper and board manufacturing industry Pesticides Police force Printing industries Public services The quarry industry Recycling and waste management industries Textiles industries 
@@373579 The Department of Health ( DH ) is the department of the United Kingdom government responsible for government policy on health and adult social care matters in England , along with a few elements of the same matters which are not otherwise devolved to the Scottish Government , Welsh Government or Northern Ireland Executive . It oversees the English National Health Service ( NHS ) . The Department is led by the Secretary of State for Health with a Minister of State and three Parliamentary Under-Secretaries of State . The Department of Health develops policies and guidelines to improve the quality of care and to meet patient expectations . The Department carries out some of its work through arms length bodies , including non-departmental public bodies such as NHS England , and executive agencies such as Public Health England and the Medicines and Healthcare Products Regulatory Agency ( MHRA ) . # History # The Department of Health was formally created in 1988 , through The Transfer of Functions ( Health and Social Security ) Order . Like many others , the Department with responsibility for the nation 's health has had different names and included other functions over time . In the 19th century , several bodies were formed for specific consultative duties and dissolved when they were no longer required . There were two incarnations of the Board of Health ( in 1805 and 1831 ) and a General Board of Health ( 1854 to 1858 ) that reported directly into the Privy Council . Responsibility for health issues was also at times , and in part , vested in local health boards and , with the emergence of modern local government , with the Local Government Act Office , part of the Home Office . In the early part of the 20th century , medical assistance was provided through National Health Insurance Commissions . The first body which could be called a department of government was the Ministry of Health , created in 1919 through the Ministry of Health Act , consolidating under a single authority the medical and public health functions of central government . The co-ordination of local medical services was expanded in connection with emergency and wartime services , from 1935 to 1945 , and these developments culminated in the establishment of the NHS in 1948 . In 1968 , the Ministry of Health was dissolved and its functions transferred ( along with those of the similarly dissolved Ministry of Social Security ) to the newly created Department of Health and Social Security ( DHSS ) . Twenty years later , these functions were split back into two government departments , forming the Department of Social Security ( DSS ) and the current Department of Health . # Location # The Department 's headquarters and ministerial offices are in Richmond House ( Whitehall , London ) . Its other principal offices are Skipton House ( Elephant and Castle ) , Wellington House near Waterloo station and Quarry House in Leeds . Wellington House is now mainly occupied by staff from the Department 's Arms Length Bodies . New King 's Beam House near Blackfriars Bridge was formerly a Department of Health office prior to the expiry of its lease in October 2011 . Alexander Fleming House and Hannibal House were previously used by the department . The archives are at Nelson , Lancashire . Contact details for the Department can be found on the gov.uk website. # Ministers # The Department of Health Ministers are as follows : # Permanent Secretary # The Permanent Secretary at the Department of Health is Una O'Brien CB , who was appointed in 2010 . Following the resignation of the previous Permanent Secretary , Sir Nigel Crisp in March 2006 , a separate post of Chief Executive of the NHS in England was recreated , held by Sir David Nicholson . Following the Health and Social Care Act 2012 and the creation of the independent NHS Commissioning Board , known as NHS England , this post has evolved into Chief Executive of the new organisation . As of 1 April 2014 , the incumbent is Simon Stevens . Previous permanent secretaries :  Sir Hugh Taylor KCB 2006-2010  Sir Nigel Crisp KCB 2000-2006  Sir Christopher Kelly KCB 1997-2000  Sir Graham Hart KCB 1992- ?  Sir Christopher France , ( DHSS including social security : 1987-1988 , DH : 1987-1992 )  Sir Kenneth Stowe GCB CVO 1981-1987 ( DHSS ) # Chief professional officers # The Department has six chief professional officers who provide it with expert knowledge and also advise the Ministers , other government departments and the Prime Minister . The Chief Medical Officer and Chief Nursing Officer are also directors of the department 's board . Chief Medical Officer for England ( CMO ) -- Professor Dame Sally Davies , appointed in 2011. Chief Nursing Officer ( CNO ) -- Jane Cummings , appointed in 2010 , although she is now part of NHS England ( NHS Commissioning Board )  Director of Nursing -- Viv Bennett Chief Scientific Officer ( CSO ) -- Professor Sue Hill OBE , appointed in 2002. Chief Dental Officer for England ( CDO ) -- Barry Cockcroft , appointed in 2006. Chief Health Professions Officer ( CHPO ) -- Karen Middleton , appointed in 2007. Chief Pharmaceutical Officer -- Dr Keith William Ridge , appointed in 2006. # Arms Length Bodies # The Department acts as ' steward ' for the health and adult social care system in England and oversees number of arms length bodies : # Executive Agencies # The Department has two executive agencies :  The Medicines and Healthcare products Regulatory Agency has the specialist role of assessing , licensing and regulating medicines and medical devices for use in the United Kingdom .  Public Health England is responsible for delivering public health improvement , through prevention and awareness raising and protection and infection control . # Non-Departmental Public Bodies # There are seven NDPBs under the DH Umbrella :  The Care Quality Commission has the primary function of inspecting providers of health and adult social care in England , ensuring that they meet essential standards of safety and quality .  The Health and Social Care Information Centre , which provides statistical information and informatics support to the health and care system .  The Human Tissue Authority regulates the use of human tissue in research and therapeutic treatments .  The Human Fertilisation and Embryology Authority , which regulates and inspects in vitro fertilisation , artificial insemination and the storage of human eggs , sperm or embryos . It also regulates Human Embryo research .  Monitor , which oversees Foundation Trusts and applications from NHS Trusts seeking foundation trust status . It also has the new role of examining pricing and competition in the NHS .  NHS England oversees the NHS in England , commissions specialised healthcare services and primary care services and oversees Clinical Commissioning Groups .  The National Institute for Health and Care Excellence , ' NICE ' , which provides advice on treatment procedures and assesses healthcare interventions for cost-effectiveness. # Special Health Authorities # There are currently six Special Health Authorities :  Health Education England is responsible for ensuring enough high-quality training is available to develop the healthcare workforce .  NHS Blood and Transplant , which is responsible for the supply of blood , organs , tissues and stem cells ; their donation , storage and transportation .  The NHS Business Services Authority provides business support services to NHS organisations , including the administration of the NHS pension scheme .  The NHS Health Research Authority protects and promotes the interests of patients and the public in health research .  The NHS Litigation Authority , handles negligence claims and helps the NHS learn lessons from claims to improve patient and staff safety .  The NHS Trust Development Authority has the function of helping NHS Trusts achieve successful applications for Foundation Trust status . # Criticism # # Introduction of user charges for NHS services # The publication of Professor Lord Darzi 's review of the NHS prompted criticism of the government and the department of health for paving the way for user charging , and so contradicting the NHS Plan 2000 which stated that user charges are unfair and inequitable in they increase the proportion of funding from the unhealthy , old and poor compared with the healthy , young and wealthy . The report also introduces the concept of ' personal budgets ' . # Fragmentation of NHS services # Darzi 's report splits previously integrated services into ' core ' , ' additional ' and ' enhanced ' services , which critics say will lead to abandoning the open-ended duty of care on which the NHS was founded . # Superbugs and PFI # Fatal outbreaks of antibiotic-resistant bacteria ( superbugs ) , such as Methicillin-resistant ' ' Staphylococcus aureus ' ' ( MRSA ) and ' ' Clostridium difficile ' ' , in NHS hospitals has led to criticism of the DH 's decision to outsource cleaning via private finance initiative contracts as cutting corners on cleaning . A Deep Clean initiative announced by the Department of Health was criticised by infection control experts and by the Lancet as a gimmick which failed to address the causes of in-hospital infections , by the firms doing the work as an attempt to avoid paying for regular better cleaning , and by NHS managers as ineffective . It also attracted criticism because only a quarter of the 60m funding for the scheme actually went to hospitals , and because a number of hospitals missed the completion target , and as of June 2008 one in four NHS trusts was not meeting the government 's standards on hygiene . # Prescribing # Its advice to primary care on prescribing drugs such as proton pump inhibitors has been criticised as wasteful . # Medical Training # The DH has attracted criticism for its disastrous handling of the outcome of Modernising Medical Careers , in particular in the changes it made to the specialist training of doctors and the Medical Training Application Service ( MTAS ) . These changes left 29,193 junior doctors from the UK and overseas .. chasing 15,600 posts .. and resulted in accusations that the DH had broken the law by refusing to reveal scores to candidates . Ultimately there was a judicial review and a boycott of the system by senior doctors across the country . MTAS was eventually scrapped and Patricia Hewitt , the then Secretary of State for Health , resigned following accusations that she had lied to the House of Commons over the system . Even after the abolition of MTAS , anger among the medical profession continued , with the British Medical Association commenting of the DH response that Not only is this response too late , it does not go far enough . The official government inquiry into MMC recommended that the responsibility for medical training be removed from the DH . # Recurrent NHS Reorganisation # Successive DH ministerial teams have been criticised for repeated reorganisations of the NHS in England , where primary care commissioning responsibility in particular has been allocated to four different sets of organisations in the last ten years : PCGs , small area PCTs ( e.g. covering a rural local authority district or part of a city ) , larger-area PCTs ( e.g. covering a whole County ) , PCT clusters ( e.g. quarter of London or South of Tyne and Wear ) and the currently unspecified Clinical Commissioning Groups . The tendency to introduce each reorganisation before its predecessor has had time to settle down and generate improved performance has attracted censure amongst healthcare professions in the UK and beyond , including reference to the ironic concept of ' redisorganization ' . Andrew Lansley 's promise before the 2010 general election not to impose top-down reorganisation , followed by the instigation from ministerial level of one of the most fundamental NHS reorganisations yet envisaged , has generated especially widespread opprobrium , although some commentators have also suggested that this is to some extent completing the job started under the Blair administration . The NHS as of 1 April 2013 is no longer situated within the DH , as NHS England also went ' live ' at the same time . Therefore the DH has a further scrunity role of NHS services and commissioning . ( See Arms Length Bodies section ) . # Information technology # In recent years the Department of Health and the NHS have come under considerable scrutiny for its use of IT . Since being elected to power in 1997 the Labour government had sought to modernise the NHS through the introduction of IT . Although the policy is correct in aim , many claim its execution is lacking . In September 2008 a new leadership team was established , CIO for Health , Christine Connelly , and director of programme and system delivery Martin Bellamy . Previous CIO Richard Granger was believed to have been the most highly paid civil servant in the UK and was a controversial figure . Connelly left the DH for a position in the Cabinet Office in June 2009 and was replaced by Tim Donohoe and Carol Clarke . Connelly 's role is to deliver the Department 's overall information strategy and integrating leadership across the NHS , according to the DH 's website . That strategy , known as the National Programme for IT , is intended to do nothing less than revolutionise NHS information workflow and is costed at about 12.7bn . The success or otherwise of Connelly 's reign will be based on her promise to end delays of electronic medical records . She has said that if there is not clear progress by November 2009 , a new plan could be hatched . On the eve of the departure of Fujitsu as an outsourcing partner , Connelly said in April 2009 that she would open up sourcing to competition at acute sights in the south of England and offer toolkits by March 2010 to allow more local configuration of systems . In January 2009 , MPs criticised DH for its confidentiality agreement with key supplier CSC and in March the Department was admonished by the Information Commissioner for its records management . In May 2011 , Prime Minister David Cameron announced that he was considering scrapping the project . # 2010-11 Staffing cuts # In response to Government spending reduction targets following the 2008-9 international financial crisis and subsequent recession , DH in common with several other Government Departments resorted to large-scale staffing reductions . In order to minimise redundancy costs , the predominant impact was upon DH staff not employed through a traditional civil service ' headcount ' contract , with a resultantly emphasised effect upon more recent or innovative work-streams dependent upon seconded or externally hosted staff . This has attracted criticism from several of the professional and patient communities of interest concerned , for instance as regards the impact upon Improving Access to Psychological Therapies ( IAPT ) and the withdrawal of the practical assistance available to the NHS and local authorities via the National Support Teams . # Devolution # Most health policy in Scotland , Wales and Northern Ireland is devolved to the department 's counterparts :  the Scottish Government Health and Wellbeing Directorate  the Welsh Government  the Department of Health , Social Services and Public Safety , Northern Ireland Executive A number of health issues are , however , wholly or partly reserved to Westminster : Scotland  regulation of the health professions  abortion  xenotransplantation  embryology , surrogacy and human genetics  medicines , medical supplies and poisons Northern Ireland  xenotransplantation  surrogacy  human fertilisation and embryology  human genetics In Northern Ireland , abortion law is a criminal justice matter and is devolved . Wales Under the Welsh devolution settlement , specific policy areas are transferred to the Welsh Government rather than reserved to Westminster . As the distinction between Government and actual health services is seen as less pronounced than in England , the main source of information about current developments is NHS Wales . 
@@384064 acts amended = introducedby = Bill Archer ( D-TX ) conferencedate = July 31 , 1996 The Health Insurance Portability and Accountability Act of 1996 ( HIPAA ; ) was enacted by the United States Congress and signed by President Bill Clinton in 1996 . It has been known as the KennedyKassebaum Act or Kassebaum-Kennedy Act after two of its leading sponsors . Title I of HIPAA protects health insurance coverage for workers and their families when they change or lose their jobs . Title II of HIPAA , known as the Administrative Simplification ( AS ) provisions , requires the establishment of national standards for electronic health care transactions and national identifiers for providers , health insurance plans , and employers . # Title I : Health Care Access , Portability , and Renewability # Title I of HIPAA regulates the availability and breadth of group health plans and certain individual health insurance policies . It amended the Employee Retirement Income Security Act , the Public Health Service Act , and the Internal Revenue Code . Title I requires the coverage of and also limits restrictions that a group health plan can place on benefits for preexisting conditions . Group health plans may refuse to provide benefits relating to preexisting conditions for a period of 12 months after enrollment in the plan or 18 months in the case of late enrollment . Title I allows individuals to reduce the exclusion period by the amount of time that they had creditable coverage prior to enrolling in the plan and after any significant breaks in coverage . Creditable coverage is defined quite broadly and includes nearly all group and individual health plans , Medicare , and Medicaid . A significant break in coverage is defined as any 63 day period without any creditable coverage . Title I also requires insurers to issue policies without exclusion to those leaving group health plans with creditable coverage ( see above ) exceeding 18 months , and renew individual policies for as long as they are offered or provide alternatives to discontinued plans for as long as the insurer stays in the market without exclusion regardless of health condition . Some health care plans are exempted from Title I requirements , such as long-term health plans and limited-scope plans such as dental or vision plans that are offered separately from the general health plan . However , if such benefits are part of the general health plan , then HIPAA still applies to such benefits . For example , if the new plan offers dental benefits , then it must count creditable continuous coverage under the old health plan towards any of its exclusion periods for dental benefits . An alternate method of calculating creditable continuous coverage is available to the health plan under Title I. That is , 5 categories of health coverage can be considered separately , including dental and vision coverage . Anything not under those 5 categories must use the general calculation ( e.g. , the beneficiary may be counted with 18 months of general coverage , but only 6 months of dental coverage , because the beneficiary did not have a general health plan that covered dental until 6 months prior to the application date ) . Since limited-coverage plans are exempt from HIPAA requirements , the odd case exists in which the applicant to a general group health plan can not obtain certificates of creditable continuous coverage for independent limited-scope plans such as dental to apply towards exclusion periods of the new plan that does include those coverages . Hidden exclusion periods are not valid under Title I ( e.g. , The accident , to be covered , must have occurred while the beneficiary was covered under this exact same health insurance contract ) . Such clauses must not be acted upon by the health plan and also must be re-written so that they comply with HIPAA . To illustrate , suppose someone enrolls in a group health plan on January 1 , 2006 . This person had previously been insured from January 1 , 2004 until February 1 , 2005 and from August 1 , 2005 until December 31 , 2005 . To determine how much coverage can be credited against the exclusion period in the new plan , start at the enrollment date and count backwards until a significant break in coverage is reached . So , the five months of coverage between August 1 , 2005 and December 31 , 2005 clearly counts against the exclusion period . But the period without insurance between February 1 , 2005 and August 1 , 2005 is greater than 63 days . Thus , this is a significant break in coverage , and any coverage prior to it can not be deducted from the exclusion period . So , this person could deduct five months from his exclusion period , reducing the exclusion period to seven months . Hence , Title I requires that any preexisting condition begin to be covered on August 1 , 2006. # Title II : Preventing Health Care Fraud and Abuse ; Administrative Simplification ; Medical Liability Reform # Title II of HIPAA defines policies , procedures and guidelines for maintaining the privacy and security of individually identifiable health information as well as outlining numerous offenses relating to health care and sets civil and criminal penalties for violations . It also creates several programs to control fraud and abuse within the health care system . However , the most significant provisions of Title II are its Administrative Simplification rules . Title II requires the Department of Health and Human Services ( HHS ) to draft rules aimed at increasing the efficiency of the health care system by creating standards for the use and dissemination of health care information . These rules apply to covered entities as defined by HIPAA and the HHS . Covered entities include health plans , health care clearinghouses , such as billing services and community health information systems , and health care providers that transmit health care data in a way that is regulated by HIPAA . Per the requirements of Title II , the HHS has promulgated five rules regarding Administrative Simplification : the Privacy Rule , the Transactions and Code Sets Rule , the Security Rule , the Unique Identifiers Rule , and the Enforcement Rule . # Privacy Rule # The effective compliance date of the Privacy Rule was April 14 , 2003 with a one-year extension for certain small plans . The HIPAA Privacy Rule regulates the use and disclosure of Protected Health Information ( PHI ) held by covered entities ( generally , health care clearinghouses , employer sponsored health plans , health insurers , and medical service providers that engage in certain transactions . ) By regulation , the Department of Health and Human Services extended the HIPAA privacy rule to independent contractors of covered entities who fit within the definition of business associates . PHI is any information held by a covered entity which concerns health status , provision of health care , or payment for health care that can be linked to an individual . This is interpreted rather broadly and includes any part of an individual 's medical record or payment history . Covered entities must disclose PHI to the individual within 30 days upon request . They also must disclose PHI when required to do so by law such as reporting suspected child abuse to state child welfare agencies . Covered entities may disclose protected health information to law enforcement officials for law enforcement purposes as required by law ( including court orders , court-ordered warrants , subpoenas ) and administrative requests ; or to identify or locate a suspect , fugitive , material witness , or missing person . A covered entity may disclose PHI ( Protected Health Information ) to facilitate treatment , payment , or health care operations without a patient 's express written authorization . Any other disclosures of PHI ( Protected Health Information ) require the covered entity to obtain written authorization from the individual for the disclosure . However , when a covered entity discloses any PHI , it must make a reasonable effort to disclose only the minimum necessary information required to achieve its purpose . The Privacy Rule gives individuals the right to request that a covered entity correct any inaccurate PHI . It also requires covered entities to take reasonable steps to ensure the confidentiality of communications with individuals . For example , an individual can ask to be called at his or her work number instead of home or cell phone numbers . The Privacy Rule requires covered entities to notify individuals of uses of their PHI . Covered entities must also keep track of disclosures of PHI and document privacy policies and procedures . They must appoint a Privacy Official and a contact person responsible for receiving complaints and train all members of their workforce in procedures regarding PHI . An individual who believes that the Privacy Rule is not being upheld can file a complaint with the Department of Health and Human Services Office for Civil Rights ( OCR ) . However , according to the ' ' Wall Street Journal ' ' , the OCR has a long backlog and ignores most complaints . Complaints of privacy violations have been piling up at the Department of Health and Human Services . Between April of 2003 and November 2006 , the agency fielded 23,886 complaints related to medical-privacy rules , but it has not yet taken any enforcement actions against hospitals , doctors , insurers or anyone else for rule violations . A spokesman for the agency says it has closed three-quarters of the complaints , typically because it found no violation or after it provided informal guidance to the parties involved . However , in July 2011 , UCLA agreed to pay $865,500 in a settlement regarding potential HIPAA violations . An HHS Office for Civil Rights investigation showed that from 2005 to 2008 unauthorized employees repeatedly and without legitimate cause looked at the electronic protected health information of numerous UCLAHS patients . # #2013 Final Omnibus Rule Update# # In January 2013 , HIPAA was updated via the Final Omnibus Rule . Included in changes were updates to the Security Rule and Breach Notification portions of the HITECH Act . The greatest changes relate to the expansion of requirements to include business associates , where only covered entities had originally been held to uphold these sections of the law . Additionally , the definition of ' significant harm ' to an individual in the analysis of a breach was updated to provide more scrutiny to covered entities with the intent of disclosing more breaches which had been previously gone unreported . Previously an organization needed proof that harm had occurred whereas now they must prove the counter , that harm had not occurred . Protection of PHI was changed from indefinite to 50 years after death . More severe penalties were also approved for violation of PHI privacy . # #Unintended Consequences# # One consequence of HIPAA is hospitals will not reveal any information on people that may have been admitted under emergency conditions or even if that person is a patient in the hospital . This makes it difficult or impossible to locate a person who might be missing . In the case of the Asiana Airlines Flight 214 San Francisco crash , Asiana was unable to locate many passengers after the accident . Injured passengers were sent to 13 different area hospitals , and there was no list prepared at the time to help the airline track passengers . Hospitals also were reluctant to release information to the airline due to privacy laws , the airline said . # Transactions and Code Sets Rule # HIPAA was intended to make the health care system in the United States more efficient by standardizing health care transactions . HIPAA added a new Part C titled Administrative Simplification to Title XI of the Social Security Act . This is supposed to simplify health care transactions by requiring all health plans to engage in health care transactions in a standardized way . The HIPAA/EDI provision was scheduled to take effect from October 16 , 2003 with a one-year extension for certain small plans . However , due to widespread confusion and difficulty in implementing the rule , CMS granted a one-year extension to all parties . On January 1 , 2012 newer versions , ASC X12 005010 and NCPDP D.0 become effective , replacing the previous ASC X12 004010 and NCPDP 5.1 mandate . The ASC X12 005010 version provides a mechanism allowing the use of ICD-10-CM as well as other improvements . After July 1 , 2005 most medical providers that file electronically did have to file their electronic claims using the HIPAA standards in order to be paid . Under HIPAA , HIPAA-covered health plans are now required to use standardized HIPAA electronic transactions . See , 42 USC 1320d-2 and 45 CFR Part 162 . Information about this can be found in the final rule for HIPAA electronic transaction standards ( 74 Fed . Reg. 3296 , published in the Federal Register on January 16 , 2009 ) , and on the CMS website here : Key EDI ( X12 ) transactions used for HIPAA compliance are : EDI Health Care Claim Transaction set ( 837 ) is used to submit health care claim billing information , encounter information , or both , except for retail pharmacy claims ( see EDI Retail Pharmacy Claim Transaction ) . It can be sent from providers of health care services to payers , either directly or via intermediary billers and claims clearinghouses . It can also be used to transmit health care claims and billing payment information between payers with different payment responsibilities where coordination of benefits is required or between payers and regulatory agencies to monitor the rendering , billing , and/or payment of health care services within a specific health care/insurance industry segment . For example , a state mental health agency may mandate all healthcare claims , Providers and health plans who trade professional ( medical ) health care claims electronically must use the 837 Health Care Claim : Professional standard to send in claims . As there are many different business applications for the Health Care claim , there can be slight derivations to cover off claims involving unique claims such as for Institutions , Professionals , Chiropractors , and Dentists etc . EDI Retail Pharmacy Claim Transaction ( NCPDP Telecommunications Standard version 5.1 ) is used to submit retail pharmacy claims to payers by health care professionals who dispense medications , either directly or via intermediary billers and claims clearinghouses . It can also be used to transmit claims for retail pharmacy services and billing payment information between payers with different payment responsibilities where coordination of benefits is required or between payers and regulatory agencies to monitor the rendering , billing , and/or payment of retail pharmacy services within the pharmacy health care/insurance industry segment . EDI Health Care Claim Payment/Advice Transaction Set ( 835 ) can be used to make a payment , send an Explanation of Benefits ( EOB ) , send an Explanation of Payments ( EOP ) remittance advice , or make a payment and send an EOP remittance advice only from a health insurer to a health care provider either directly or via a financial institution . EDI Benefit Enrollment and Maintenance Set ( 834 ) can be used by employers , unions , government agencies , associations or insurance agencies to enroll members to a payer . The payer is a healthcare organization that pays claims , administers insurance or benefit or product . Examples of payers include an insurance company , health care professional ( HMO ) , preferred provider organization ( PPO ) , government agency ( Medicaid , Medicare etc. ) or any organization that may be contracted by one of these former groups . EDI Payroll Deducted and other group Premium Payment for Insurance Products ( 820 ) is a transaction set which can be used to make a premium payment for insurance products . It can be used to order a financial institution to make a payment to a payee . EDI Health Care Eligibility/Benefit Inquiry ( 270 ) is used to inquire about the health care benefits and eligibility associated with a subscriber or dependent . EDI Health Care Eligibility/Benefit Response ( 271 ) is used to respond to a request inquiry about the health care benefits and eligibility associated with a subscriber or dependent . EDI Health Care Claim Status Request ( 276 ) This transaction set can be used by a provider , recipient of health care products or services or their authorized agent to request the status of a health care claim . EDI Health Care Claim Status Notification ( 277 ) This transaction set can be used by a health care payer or authorized agent to notify a provider , recipient or authorized agent regarding the status of a health care claim or encounter , or to request additional information from the provider regarding a health care claim or encounter . This transaction set is not intended to replace the Health Care Claim Payment/Advice Transaction Set ( 835 ) and therefore , is not used for account payment posting . The notification is at a summary or service line detail level . The notification may be solicited or unsolicited . EDI Health Care Service Review Information ( 278 ) This transaction set can be used to transmit health care service information , such as subscriber , patient , demographic , diagnosis or treatment data for the purpose of request for review , certification , notification or reporting the outcome of a health care services review . EDI Functional Acknowledgement Transaction Set ( 997 ) this transaction set can be used to define the control structures for a set of acknowledgments to indicate the results of the syntactical analysis of the electronically encoded documents . Although it is not specifically named in the HIPAA Legislation or Final Rule , it is necessary for X12 transaction set processing . The encoded documents are the transaction sets , which are grouped in functional groups , used in defining transactions for business data interchange . This standard does not cover the semantic meaning of the information encoded in the transaction sets . # #Brief 5010 Transactions and Code Sets Rules Update Summary# # 1 ) Transaction Set ( 997 ) will be replaced by Transaction Set ( 999 ) acknowledgement report . <br/> 2 ) The size of many fields segment elements will be expanded , causing a need for all IT providers to expand corresponding fields , element , files , GUI , paper media and databases . <br/> 3 ) Some segments have been removed from existing Transaction Sets . <br/> 4 ) Many segments have been added to existing Transaction Sets allowing greater tracking and reporting of cost and patient encounters . <br/> 5 ) Capacity to use both International Classification of Diseases versions 9 ( ICD-9 ) and 10 ( ICD-10-CM ) has been added . # Security Rule # The Final Rule on Security Standards was issued on February 20 , 2003 . It took effect on April 21 , 2003 with a compliance date of April 21 , 2005 for most covered entities and April 21 , 2006 for small plans . The Security Rule complements the Privacy Rule . While the Privacy Rule pertains to all Protected Health Information ( PHI ) including paper and electronic , the Security Rule deals specifically with Electronic Protected Health Information ( EPHI ) . It lays out three types of security safeguards required for compliance : administrative , physical , and technical . For each of these types , the Rule identifies various security standards , and for each standard , it names both required and addressable implementation specifications . Required specifications must be adopted and administered as dictated by the Rule . Addressable specifications are more flexible . Individual covered entities can evaluate their own situation and determine the best way to implement addressable specifications . Some privacy advocates have argued that this flexibility may provide too much latitude to covered entities . The standards and specifications are as follows : Administrative Safeguards policies and procedures designed to clearly show how the entity will comply with the act *Covered entities ( entities that must comply with HIPAA requirements ) must adopt a written set of privacy procedures and designate a privacy officer to be responsible for developing and implementing all required policies and procedures . *The policies and procedures must reference management oversight and organizational buy-in to compliance with the documented security controls . *Procedures should clearly identify employees or classes of employees who will have access to electronic protected health information ( EPHI ) . Access to EPHI must be restricted to only those employees who have a need for it to complete their job function . *The procedures must address access authorization , establishment , modification , and termination . *Entities must show that an appropriate ongoing training program regarding the handling of PHI is provided to employees performing health plan administrative functions . *Covered entities that out-source some of their business processes to a third party must ensure that their vendors also have a framework in place to comply with HIPAA requirements . Companies typically gain this assurance through clauses in the contracts stating that the vendor will meet the same data protection requirements that apply to the covered entity . Care must be taken to determine if the vendor further out-sources any data handling functions to other vendors and monitor whether appropriate contracts and controls are in place . *A contingency plan should be in place for responding to emergencies . Covered entities are responsible for backing up their data and having disaster recovery procedures in place . The plan should document data priority and failure analysis , testing activities , and change control procedures . *Internal audits play a key role in HIPAA compliance by reviewing operations with the goal of identifying potential security violations . Policies and procedures should specifically document the scope , frequency , and procedures of audits . Audits should be both routine and event-based. *Procedures should document instructions for addressing and responding to security breaches that are identified either during the audit or the normal course of operations . Physical Safeguards controlling physical access to protect against inappropriate access to protected data *Controls must govern the introduction and removal of hardware and software from the network . ( When equipment is retired it must be disposed of properly to ensure that PHI is not compromised. ) *Access to equipment containing health information should be carefully controlled and monitored . *Access to hardware and software must be limited to properly authorized individuals . *Required access controls consist of facility security plans , maintenance records , and visitor sign-in and escorts . *Policies are required to address proper workstation use . Workstations should be removed from high traffic areas and monitor screens should not be in direct view of the public . *If the covered entities utilize contractors or agents , they too must be fully trained on their physical access responsibilities . Technical Safeguards controlling access to computer systems and enabling covered entities to protect communications containing PHI transmitted electronically over open networks from being intercepted by anyone other than the intended recipient . *Information systems housing PHI must be protected from intrusion . When information flows over open networks , some form of encryption must be utilized . If closed systems/networks are utilized , existing access controls are considered sufficient and encryption is optional . *Each covered entity is responsible for ensuring that the data within its systems has not been changed or erased in an unauthorized manner . *Data corroboration , including the use of check sum , double-keying , message authentication , and digital signature may be used to ensure data integrity . *Covered entities must also authenticate entities with which they communicate . Authentication consists of corroborating that an entity is who it claims to be . Examples of corroboration include : password systems , two or three-way handshakes , telephone callback , and token systems . *Covered entities must make documentation of their HIPAA practices available to the government to determine compliance . *In addition to policies and procedures and access records , information technology documentation should also include a written record of all configuration settings on the components of the network because these components are complex , configurable , and always changing . *Documented risk analysis and risk management programs are required . Covered entities must carefully consider the risks of their operations as they implement systems to comply with the act . ( The requirement of risk analysis and risk management implies that the acts security requirements are a minimum standard and places responsibility on covered entities to take all reasonable precautions necessary to prevent PHI from being used for non-health purposes. ) # Unique Identifiers Rule ( National Provider Identifier ) # HIPAA covered entities such as providers completing electronic transactions , healthcare clearinghouses , and large health plans , must use only the National Provider Identifier ( NPI ) to identify covered healthcare providers in standard transactions by May 23 , 2007 . Small health plans must use only the NPI by May 23 , 2008 . Effective from May 2006 ( May 2007 for small health plans ) , all covered entities using electronic communications ( e.g. , physicians , hospitals , health insurance companies , and so forth ) must use a single new NPI . The NPI replaces all other identifiers used by health plans , Medicare , Medicaid , and other government programs . However , the NPI does not replace a provider 's DEA number , state license number , or tax identification number . The NPI is 10 digits ( may be alphanumeric ) , with the last digit being a checksum . The NPI can not contain any embedded intelligence ; in other words , the NPI is simply a number that does not itself have any additional meaning . The NPI is unique and national , never re-used , and except for institutions , a provider usually can have only one . An institution may obtain multiple NPIs for different subparts such as a free-standing cancer center or rehab facility . # Enforcement Rule # On February 16 , 2006 , HHS issued the Final Rule regarding HIPAA enforcement . It became effective on March 16 , 2006 . The Enforcement Rule sets civil money penalties for violating HIPAA rules and establishes procedures for investigations and hearings for HIPAA violations . For many years there were few prosecutions for violations . : This may have changed with the fining of $50,000 to the Hospice of North Idaho ( HONI ) as the first entity to be fined for a potential HIPAA Security Rule breach affecting fewer than 500 people . Rachel Seeger , a spokeswoman for HHS , stated , HONI did not conduct an accurate and thorough risk analysis to the confidentiality of ePHI as part of its security management process from 2005 through Jan. 17 , 2012 . This investigation was initiated with the theft from an employees vehicle of an unencrypted laptop containing 441 patient records . As of March 2013 , the U.S. Dept. of Health and Human Resources ( HHS ) has investigated over 19,306 cases that have been resolved by requiring changes in privacy practice or by corrective action . If noncompliance is determined by HHS , entities must apply corrective measures . Complaints have been investigated against many different types of businesses such as national pharmacy chains , major health care centers , insurance groups , hospital chains and other small providers . There were 9,146 cases where the HHS investigation found that HIPAA was followed correctly . There were 44,118 cases that HHS did not find eligible cause for enforcement ; for example , a violation that started before HIPAA started ; cases withdrawn by the pursuer ; or an activity that does not actually violate the Rules . According to the HHS website ( www.hhs.gov ) , the following lists the issues that have been reported according to frequency : # Misuse and disclosures of PHI # No protection in place of health information # Patient unable to access their health information # Using or disclosing more than the minimum necessary protected health information # No safeguards of electronic protected health information . ( www.hhs.gov/enforcement , 2013 ) The most common entities found to be required to take corrective action in order to be in voluntary compliance according to HHS are listed by frequency : # Private Practices # Hospitals # Outpatient Facilities # Group plans such as insurance groups # Pharmacies ( hhs.gov/enforcement , 2013 ) # HITECH Act : Privacy Requirements # See the Privacy section of the Health Information Technology for Economic and Clinical Health Act ( HITECH Act ) . # Effects on research and clinical care # The enactment of the Privacy and Security Rules has caused major changes in the way physicians and medical centers operate . The complex legalities and potentially stiff penalties associated with HIPAA , as well as the increase in paperwork and the cost of its implementation , were causes for concern among physicians and medical centers . An August 2006 article in the journal ' ' Annals of Internal Medicine ' ' detailed some such concerns over the implementation and effects of HIPAA. # Effects on research # HIPAA restrictions on researchers have affected their ability to perform retrospective , chart-based research as well as their ability to prospectively evaluate patients by contacting them for follow-up . A study from the University of Michigan demonstrated that implementation of the HIPAA Privacy rule resulted in a drop from 96% to 34% in the proportion of follow-up surveys completed by study patients being followed after a heart attack . Another study , detailing the effects of HIPAA on recruitment for a study on cancer prevention , demonstrated that HIPAA-mandated changes led to a 73% decrease in patient accrual , a tripling of time spent recruiting patients , and a tripling of mean recruitment costs . In addition , informed consent forms for research studies now are required to include extensive detail on how the participant 's protected health information will be kept private . While such information is important , the addition of a lengthy , legalistic section on privacy may make these already complex documents even less user-friendly for patients who are asked to read and sign them . These data suggest that the HIPAA privacy rule , as currently implemented , may be having negative impacts on the cost and quality of medical research . Dr. Kim Eagle , professor of internal medicine at the University of Michigan , was quoted in the ' ' Annals ' ' article as saying , Privacy is important , but research is also important for improving care . We hope that we will figure this out and do it right . # Effects on clinical care # The complexity of HIPAA , combined with potentially stiff penalties for violators , can lead physicians and medical centers to withhold information from those who may have a right to it . A review of the implementation of the HIPAA Privacy Rule by the U.S. Government Accountability Office found that health care providers were uncertain about their legal privacy responsibilities and often responded with an overly guarded approach to disclosing information ... than necessary to ensure compliance with the Privacy rule . Reports of this uncertainty continue . # Costs of implementation # In the period immediately prior to the enactment of the HIPAA Privacy and Security Acts , medical centers and medical practices were charged with getting into compliance . With an early emphasis on the potentially severe penalties associated with violation , many practices and centers turned to private , for-profit HIPAA consultants who were intimately familiar with the details of the legislation and offered their services to ensure that physicians and medical centers were fully in compliance . In addition to the costs of developing and revamping systems and practices , the increase in paperwork and staff time necessary to meet the legal requirements of HIPAA may impact the finances of medical centers and practices at a time when insurance companies and Medicare reimbursement is also declining . # Education and Training # Education and training of healthcare providers is paramount to correct implementation of the HIPAA Privacy and Security Acts . Effective training must describe the statutory and regulatory background and purpose of HIPAA and a general summary of the principles and key provisions of the Privacy Rule . Explain and define the type of entities that are covered by the Privacy Rule . The term business associate is defined , as are the requirements of the Privacy Rule when they carry out health care activities and functions on behalf of covered entities . Describes Privacy Rule provisions that address how entity organization may affect privacy functions , Describes the health information that is protected by the Privacy Rule . The presentation extensively describes the required and permitted uses and disclosures of PHI by a covered entity or its business associate , including situations where PHI may be used or disclosed without the individuals authorization and when such authorization is required . The Rules minimum necessary provisions and its requirements are explained . Summarizes the Privacy Rules provisions and requirements related to research . Describes when a covered entity may use and disclose PHI for research purposes and what research is affected . The presentation illustrates the relationship of the Privacy Rules research provisions to other research rules , such as the Common Rule . Describes the Privacy Rules administrative requirements for covered entities , such as policies and procedures , data safeguards , documentation and record retention , prohibition on retaliation , complaints to the covered entity , workforce training and sanctions . # HIPAA and drug and alcohol rehabilitation organizations # Special considerations for confidentiality are needed for health care organizations that offer federally funded drug or alcohol rehabilitation services . Predating HIPAA by over a quarter century are the Comprehensive Alcohol Abuse and Alcoholism Prevention , Treatment and Rehabilitation Act of 1970 and language amended by the Drug Abuse Office and Treatment Act of 1972 . # Violations of HIPAA # According to the US Department of Health and Human Services Office for Civil Rights , between April 2003 and January 2013 they received 91,000 complaints of HIPAA violations , in which 22,000 led to enforcement actions of varying kinds ( from settlements to fines ) and 521 led to referrals to the US Dept of Justice ( criminal actions ) . The differences between civil and criminal penalties are summarized in the following table : # Title III : Tax-related health provisions governing medical savings accounts # Title III standardizes the amount that may be saved per person in a pre-tax medical savings account . Beginning in 1997 , medical savings account ( MSA ) are available to employees covered under an employer-sponsored high deductible plan of a small employer and self-employed individuals . # Title IV : Application and enforcement of group health insurance requirements # Title IV specifies conditions for group health plans regarding coverage of persons with pre-existing conditions , and modifies continuation of coverage requirements . It also clarifies continuation coverage requirements and includes COBRA clarification . # Title V : Revenue offset governing tax deductions for employers # Title V includes provisions related to company-owned life insurance for employers providing company-owned life insurance premiums , prohibiting the tax-deduction of interest on life insurance loans , company endowments , or contracts related to the company . It also repeals the financial institution rule to interest allocation rules . Finally , it amends provisions of law relating to people who give up United States citizenship or permanent residence , expanding the expatriation tax to be assessed against those deemed to be giving up their U.S. status for tax reasons , and making ex-citizens ' names part of the public record through the creation of the Quarterly Publication of Individuals Who Have Chosen to Expatriate . # Legislative information #   ; H. Rept. 104-469 , part 1 ; H. Rept. 104-736  ; ; S. Rept. 104-156 HHS Security Standards , , 162 , and 164 HHS Standards for Privacy of Individually Identifiable Health Information , and 
@@406118 Bright 's disease is a historical classification of kidney diseases that would be described in modern medicine as acute or chronic nephritis . It is typically denoted by the presence of serum albumin ( blood plasma protein ) in the urine , and frequently accompanied by edema and hypertension. # Symptoms # These common symptoms of kidney disease were first described in 1827 by the English physician Richard Bright . It is now known that the symptoms accompany various morbid kidney conditions . Thus , the term ' ' Bright 's disease ' ' is retained strictly for historical application . The formation of bilateral kidney stones often indicates underlying chronic kidney disease . These stones involve salt crystal formations such as calcium oxalate . Excess serum calcium can result from hypovitaminosis D , or vitamin D deficiency , that causes the body initially to lose serum calcium to the point where parathyroid hormone is produced to leach sufficient amounts of calcium from the bones , ( resulting in bone loss ) to more than make up the difference ( shutting down parathyroid hormone production ) . Oxalic acid is found in chocolate , peanuts , certain types of berries , and other foods , and when combined with calcium will form calcium oxalate crystal kidney stones that can drive up blood pressure like any other serum salt , block urinary flow within the kidneys , and cause physical kidney damage and pain . Researchers at Rockefeller University Hospital are studying arteriosclerosis in connection with this vitamin D deficiency , calcium plaque build-up , and kidney problems . The symptoms are usually severe . Back pain , phantom testicular pain in males , elevated blood pressure , vomiting and fever commonly signal an attack . Edema , varying in degree from slight puffiness of the face to an accumulation of fluid sufficient to distend the whole body , and sometimes severely restricted breathing , is very common . Urine is reduced in quantity , is of dark , smoky or bloody color , and has higher levels of albumin ( albuminuria ) . Under the microscope , blood corpuscles and urinary casts are found in abundance . This state of acute inflammation may severely limit normal daily activities , and if left unchecked , may lead to one of the chronic forms of Bright 's disease . In many cases though , the inflammation is reduced , marked by increased urine output and the gradual disappearance of its albumen and other abnormal by-products . A reduction in edema and a rapid recovery of strength usually follows . # Treatment # Acute Bright 's disease was treated with local depletion ( bleeding or blood-letting to reduce blood pressure ) , warm baths , diuretics , and laxatives . The disease was diagnosed often in diabetic patients . There was no successful treatment for chronic Bright 's disease , though dietary modifications were sometimes suggested . See Hay diet , named after William Howard Hay MD , who suffered from the illness and supposedly cured himself after accepted medical methods of the early 1900s failed to do so . The diet involves promoting alkali and acid balance through consuming various foods and beverages , thereby lowering the kidney 's involvement with blood pH balancing . Successful treatment for type II diabetes would reverse elevated glucose and insulin insensitivity problems throughout the body , especially in nerves and kidneys. # Notable people with Bright 's disease #  Isaac Albniz , Spanish composer  Alexander III , Tsar of Russia  Paul Edward Anderson , weightlifter and The Strongest Man in the World  Chester A. Arthur , 21st President of the United States  Harry Arundel , professional baseball player  Abu Bakar of Johor , Sultan of Johor ( died 1895 )  Washington Bartlett , Mayor of San Francisco and Governor of California  James Gillespie Blaine , U.S. Representative , Speaker of the United States House of Representatives , U.S. Senator from Maine , two-time Secretary of State and nominee for president in 1884 , developed Bright 's disease and died in 1893.  Madame Blavatsky , founder of the Theosophical Society and author of The Secret Doctrine  Isambard Kingdom Brunel , British engineer  Mikhail Bulgakov , Russian author of the novel ' ' The Master and Margarita ' ' as well as various other novels and plays  John Bunny , American vaudeville and silent film comedian , 1915  George-tienne Cartier , one of the fathers of the Canadian Confederation  Lydia Cassatt , older sister of the artist Mary Cassatt Lorne Chabot , professional ice hockey player  Ty Cobb , Hall of Fame baseball player  James Creelman , Canadian yellow journalist , died of the disease in February 1915 on his way to cover World War I from the German front  Louis Cyr , Canadian strongman , the strongest man ever to have lived , according to Wikipedia and history .  Marcus Daly , Butte Montana Copper King  Jessie Bartlett Davis , contralto ; mentor of Carrie Jacobs-Bond  Emily Dickinson , ( 1830- May 15 , 1886 ) American poet  Catherine Eddowes , fourth victim of the canonical five murdered by Jack the Ripper in 1888  Henry Edwards ( entomologist )  Arnold Ehret ( 18661922 ) a diet reformer , had cured himself of Bright 's disease after he had been given up by medical doctors and after a nature cure could bring him only temporary relief . He discovered that fasting and a diet free of mucus and albumin , consisting mainly of fruits cured not only his illness but other chronic disease .  Elizabeth F. Ellet ( 18181877 ) , American writer and poet  Father Frederick William Faber , C.O. , ( 1814-1863 ) English Catholic priest and noted hymn writer , founder of the Brompton Oratory  Andrew Hull Foote ( 1806-1863 ) , Federal naval officer during the American Civil War  May Agnes Fleming ( 18401880 ) , Canadian-American writer  Sydney Greenstreet ( 18791954 ) , English actor  Jean Harlow ( 1911-1937 ) , American actress and sex-symbol  Dean Hart , professional wrestler ( member of the Hart family )  Harry T. Hays , Confederate Army general and Louisiana politician  David B. Hill ( 1843-1910 ) , American politician and Governor of New York  Winifred Holtby ( 18981935 ) , English novelist and journalist  Robert Wood Johnson I ( 1845-1910 ) , one of the founders of Johnson &amp; Johnson and its first CEO  David Laamea Kamanakapuu Mahinulani Nalaiaehuokalani Lumialani Kalkaua ( 1836-1891 ) , King of Hawaii from 1874 to 1891  Kitty Kiernan , fiance of Irish revolutionary leader and chairman of the Provisional Government Michael Collins ( all of her five siblings also suffered from the disease )  Aldo Leopold , environmentalist  H. P. Lovecraft , science-fiction/horror author died from a combination of Bright 's disease and intestinal cancer  Sir Alexander Mackenzie ( 17641820 ) , Scottish explorer , first European to traverse North America and commercial partner in the North West Company  Rowland Hussey Macy , founder of RH Macy &amp; Company ( Macy 's department store )  Richard McBride , Premier of British Columbia ( 1903-1915 ) and founder of the British Columbia Conservative Party ; died of Bright 's disease 6 August 1917 ( aged 46 ) in London , England  Jervis McEntee , Hudson River School Painter ( 1828-1891 )  Abbot Gregor Mendel , O.S.A. , friar and scientist whose paper ' ' Experiments in Plant Hybridization ' ' showed that inheritance follows specific laws . His research led to the science of genetics  Father Edward McGlynn , Roman Catholic priest and social reformer from New York City , 1900  John Milne , British seismologist , father of modern seismology , died of Bright 's disease .  Billy Miske , American boxer ( 1894-1924 )  Elizabeth Mitchell-Smith ; first wife of John Cobb ( racing driver )  Helena Modjeska , Polish-American actress , real-estate investor , and philanthropist , 1909  Commodore Nutt , dwarf who became famous working for P T Barnum  Chief Ouray , Native American peacemaker , chief of the Ute nation ( 18331880 )  Isaac Parker , hanging judge of the American West  Linus Pauling , chemist and two-time Nobel laureate was successfully treated for a severe form of Bright 's disease by Thomas Addis .  Howard Pyle ( March 5 , 1853 November 9 , 1911 ) , American illustrator and writer  Bass Reeves , the first black commissioned United States deputy marshal west of the Mississippi River , 1910  David Wallis Reeves , composer , cornetist , and bandleader  Al Ringling , one of the five founders of the Ringling Brothers Circus  Henry Hobson Richardson , American architect , died of the disease in 1886  Alice Hathaway Lee Roosevelt , first wife of Theodore Roosevelt  Hannah de Rothschild , Jewish English countess and philanthropist  Richard Warren Sears , founder of Sears , Roebuck and Company  Jimmy Sebring , professional baseball player  Kate Shelley , Irish-American woman famous for crossing a damaged railroad bridge in a storm to save a train full of passengers  Father Edward Sorin , C.S.C. , founder of the University of Notre Dame and St Edward 's University  Effingham Brown Sutton , ( 1817-1891 ) , Shipping Magnet of Clipper ships during California Gold Rush , Sutton Place NYC  Charles Haddon Spurgeon , English Baptist pastor in London , nicknamed The Prince of Preachers  Bram Stoker ( 18471912 ) , writer of ' ' Dracula ' ' . Died having suffered from Bright 's disease and two separate strokes .  Victor Trumper , Australia 's legendary batsman , one of the best wet wicket cricketers Australia ever produced , 1915  George Tyrrell , modernist Roman Catholic priest  William Wynn Westcott , Supreme Magus of the Societas Rosicruciana in Anglia and co-founder of the Hermetic Order of the Golden Dawn  Ellen Wilson , first wife of US President Woodrow Wilson  Ross Youngs ( 18971927 ) , professional baseball player ; Giants outfielder and member of the Baseball Hall of Fame  Louis Van Zelst , a hunchback who was a mascot for University of Pennsylvania and The Philadelphia Athletics until his death from Bright 's disease in 1915  Karl Guthe Jansky ( 1905-1950 ) , discoverer of radio waves emanating from the Milky Way  Henry McCrea , captain of the USS Georgia ( BB-15 ) , during the time of the explosion in the aft turret , July 15 , 1907 and during the first leg of the Great White Fleet sailing  H.H. Bennett ( 1843-1908 ) , photographer , regarded as the Father of the Dells ( Wisconsin Dells 
@@408290 The United States National Library of Medicine ( NLM ) , operated by the United States federal government , is the world 's largest medical library . Located in Bethesda , Maryland , the NLM is a division of the National Institutes of Health . Its collections include more than seven million books , journals , technical reports , manuscripts , microfilms , photographs , and images on medicine and related sciences including some of the world 's oldest and rarest works . The current director of the NLM , since 1984 , is Donald A.B . Lindberg. # PubMed , Index Medicus , and NCBI # Since 1879 , the NLM has published the Index Medicus , a monthly guide to articles in nearly five thousand selected journals . The last issue of Index Medicus was printed in December 2004 , but this information is offered in the freely accessible PubMed amongst the more than fifteen million MEDLINE journal article references and abstracts going back to the 1960s and 1.5 million references going back to the 1950s . The NLM also runs the National Center for Biotechnology Information ( NCBI ) , which houses biological databases ( PubMed among them ) that are freely accessible on the Internet through the Entrez search engine . # Toxicology and Environmental Health Program # The Toxicology and Environmental Health Program was established at the NLM in 1967 and is charged with developing computer databases compiled from the medical literature and from the files of governmental and nongovernmental organizations . The program has implemented several information systems for chemical emergency response and public education , such as the Toxicology Data Network ( TOXNET ) , TOXMAP , Tox Town , Wireless Information System for Emergency Responders ( WISER ) , Toxmystery , and the Household Products Database . These resources are accessible without charge on the Web . # Radiation Exposure # The United States National Library of Medicine Radiation Emergency Management System ( REMM ) provides :  Guidance for health care providers , primarily physicians , about clinical diagnosis and treatment of radiation injury during radiological and nuclear emergencies  Just-in-time , evidence-based , usable information with sufficient background and context to make complex issues understandable to those without formal radiation medicine expertise  Web-based information that can be downloaded in advance , so that it would be available during an emergency if the internet is not accessible . REMM is produced by the United States Department of Health and Human Services , Office of the Assistant Secretary for Preparedness and Response , Office of Planning and Emergency Operations , in cooperation with the National Library of Medicine , Division of Specialized Information Services , with subject matter experts from the National Cancer Institute , the Centers for Disease Control and Prevention , and many US and international consultants . # Extramural Division # The Extramural Division provides grants to support research in medical information science and to support planning and development of computer and communications systems in medical institutions . Research , publications , and exhibitions on the history of medicine and the life sciences are also supported by the History of Medicine Division . In April 2008 the current exhibition Against the Odds : Making a Difference in Global Health was launched . # History # : ' ' For details of the pre-1956 history of the Library , see Library of the Surgeon General 's Office . ' ' The precursor of the NLM , established in 1836 , was the Library of the Surgeon General 's Office , a part of the office of the Surgeon General of the United States Army . The Armed Forces Institute of Pathology and its Medical Museum were founded in 1862 as the Army Medical Museum . Throughout their history the Library of the Surgeon General 's Office and the Army Medical Museum often shared quarters . From 1866 to 1887 , they were housed in Ford 's Theatre after production there was stopped after the assassination of President Abraham Lincoln . In 1956 , the library collection was transferred from the control of the U.S. Department of Defense to the Public Health Service of the Department of Health , Education and Welfare and renamed the National Library of Medicine , through the instrumentality of Frank Bradway Rogers , who was the Director from 1956 to 1963 . The library moved to its current quarters in Bethesda , Maryland , on the campus of the National Institutes of Health , in 1962 . *39;108053;gallery File:National Library of Medicine at night , 1972 .. JPGThe glowing facade of the National Library of Medicine at night . HMD Prints &amp; Photos , Z AD6 U56 C25 no . M298a box 57 ins . File:National Library of Medicines main reading room , ca. 1962 .. JPGView of the National Library of Medicines main reading room , with a Mondrian-influenced modernist design . HMD Prints &amp; Photos , PP059772.6 . File:National Library of Medicine , Main Reading Room , October 9 , 2008. jpgMain reading room File:History of Medicine Division , new reading room , ca. 1963 .. JPGThe gleaming new reading room of the History of Medicine Division , in the National Library of Medicine on the National Institutes of Health campus , Bethesda , Maryland . HMD Prints &amp; Photos , PP059772.5 . File:National Library of Medicine , History of Medicine Reading Room , October 9 , 2008. jpgHistory of Medicine reading room File:Binding section , National Library of Medicine , ca. 1963 .. JPGInterior view of the Binding Section . HMD Prints &amp; Photos , PP059772.4 . File:The new National Library of Medicine building under construction , ca. 1960 .. JPGView of front entrance of the new National Library of Medicine building under construction , in Bethesda , Maryland . HMD Prints &amp; Photos , Z AD6 U56 C32 no. 27 box 58 ins. </gallery> 
@@428966 Doctor of Medicine ( M.D. , from the Latin ' ' Medicinae Doctor ' ' meaning Teacher of Medicine ) is a terminal degree for physicians and surgeons . In some countries it is a professional doctorate where training is entered after obtaining between 90 and 120 credit hours of university level work ( see second entry degree ) and in most cases after obtaining a bachelor 's degree . In other countries , such as India , Ireland , and the United Kingdom , M.D. is a ' ' research ' ' degree which is equivalent to a Ph.D . In Britain , Ireland , Australia , New Zealand , Singapore , India , and many British Commonwealth nations , the medical degree is instead the MBBS ( MB BCh BAO , MBChB , MBBChir , BMBCh , MBBCh , BMBS , BMed , BM , etc. ) and , thus , the M.D. is a higher level of attainment in these countries . # History of the medical degree # According to Sir John Bagot Glubb , Syed Faride and S. M. Imamuddin , the first medical schools to issue academic degrees and diplomas were the teaching Bimaristan ( Hospitals ) of the medieval Islamic world . The first of these institutions was opened in Baghdad during the time of Harun al-Rashid . They then appeared in Egypt from 872 and then in Islamic Spain , Persia and the Maghreb thereafter . Physicians and surgeons at these hospital-universities gave lectures on Medicine to medical students and then a medical diploma or degree was issued to students who were qualified to be practicing physicians . # Academic degrees for physicians by country # # United States and Canada # The initial medical schools that granted the MD degree ( Doctor of Medicine ) were Columbia , Penn , Harvard , Maryland , and McGill . These first few North American medical schools that were established were ( for the most part ) founded by physicians and surgeons who had been trained in England and Scotland . University medical education in England culminated with the MB qualification , and in Scotland the M.D. , until in the mid-19th century the public bodies who regulated medical practice at the time required practitioners in Scotland as well as England to hold the dual Bachelor of Medicine and Bachelor of Surgery degrees ( MB BS/MBChB/MB BChir/BM BCh etc . ) . North American Medical schools switched to the tradition of the Ancient universities of Scotland and began granting the M.D. title rather than the MB beginning in the late 18th century . The Columbia University College of Physicians and Surgeons in New York ( which at the time was referred to as King 's College of Medicine ) was the first American University to grant the M.D. degree instead of the MB . In the United States , MDs are awarded by medical schools as Professional Doctorate and is accredited by the Liaison Committee on Medical Education ( LCME ) , an independent body sponsored by the Association of American Medical Colleges and the American Medical Association ( AMA ) . Admission to medical schools in the United States is highly competitive , with about 17,800 out of approximately 47,000 applicants receiving at least one acceptance to any medical school in recent application years . Before entering medical school , many schools require that students must complete a four-year undergraduate degree and take the Medical College Admission Test ( MCAT ) ; however , some medical schools require only a certain amount of undergraduate coursework ( but not degree completion ) before the start of the medical curriculum . Before graduating from a medical school and achieving the Doctor of Medicine degree , most schools require their students to take the United States Medical Licensing Examination ( USMLE ) Step 1 and both the Clinical Knowledge and Clinical Skills parts of Step 2 . The M.D. degree is typically earned in four years . Following the awarding of the M.D. , physicians who wish to practice in the United States are required to complete at least one internship year ( PGY-1 ) and pass the USMLE Step 3 . In order to receive Board Eligible or Board Accredited status in a specialty of medicine such as general surgery or internal medicine , then undergo additional specialized training in the form of a residency . Those who wish to further specialize in areas such as cardiology or interventional radiology then complete a fellowship . Depending upon the physician 's chosen field , residencies and fellowships involve an additional three to eight years of training after obtaining the M.D. This can be lengthened with additional research years , which can last one , two , or more years . The Doctor of Osteopathic Medicine or D.O . degree is the only other legal and professional equivalent to the M.D. degree in the United States and Canada . The differences between the M.D. and the D.O . degrees lie in the distinctive osteopathic philosophy and osteopathic manipulative treatment ( OMT ) . In Canada , the M.D. is the basic medical degree required to practice medicine . McGill University Faculty of Medicine is the only medical school in Canada to award M.D. , C.M. degrees ( abbreviated MDCM ) . MDCM is from the Latin Medicinae Doctorem et Chirurgiae Magistrum meaning Doctor of Medicine and Master of Surgery . Upon graduation , students enter into a residency phase of training . Prior to obtaining independent practicing license from a provincial regulatory body , students must complete the Medical Council of Canada Qualifying Examination to obtain the Licentiate of the Medical Council of Canada ( LMCC ) qualifications . # #Research physicians# # Even though the M.D. and D.O . are first professional degrees and not doctorates of research ( i.e. , a Ph.D. ) , many holders of the M.D. or D.O . degree conduct clinical and basic scientific research and publish in peer-reviewed journals during training and after graduation . Combined medical and research training is offered through programs granting MD/PhD or DO/Ph.D. degrees . The National Institutes of Health ( NIH ) through its Medical Scientist Training Program funds M.D./Ph.D. training programs at many universities . Some MDs and DOs choose a research career and receive funding from the NIH as well as other sources such as the Howard Hughes Medical Institute . A few even go on to become Nobel Laureates . The United States Department of Education and the National Science Foundation do not include the M.D. or other professional doctorates among the degrees that are equivalent to research doctorates. # UK , Ireland and some Commonwealth countries # The entry-level first professional degree in these countries for the practice of medicine is that of Bachelor of Medicine and Bachelor of Surgery ( MBBS , MB , MB BCh BAO , BMBS , MBBChir , or MBChB ) . This degree typically requires between four and six years of study and clinical training , and is equivalent to the North American MD degree . Due to the UK code for higher education , first degrees in medicine comprise an integrated programme of study and professional practice spanning several levels . These degrees may retain , for historical reasons , Bachelor of Medicine , Bachelor of Surgery and are abbreviated to MBChB or MBBS . In the UK , Ireland and many Commonwealth countries , the M.D. is a postgraduate research degree in medicine . At some universities , this takes the form of a first doctorate , analogous to the Ph.D. , awarded upon submission of a thesis and a successful ' ' viva ' ' . The thesis may consist of new research undertaken on a full- or part-time basis , with much less supervision ( in the UK ) than for a Ph.D. , or a portfolio of previously published work . <div> </div> In order to be eligible to apply for an M.D. degree from a UK or Commonwealth University one must hold either an MBBS , MBChB , or an equivalent US-MD degree and must usually have at least 5-years of postgraduate experience . Therefore graduates from the MBBS or MBChB degrees do not hold doctorates ; however , physicians holding these degrees are referred to as ' Doctor ' as they are fully licensed as medical practitioners . In some commonwealth nations these interns are designated as House Officers . At some other universities ( especially older institutions , such as Oxford , Dublin , Cambridge and St Andrews ) , the MD is a higher doctorate ( similar to a DSc ) awarded upon submission of a portfolio of published work representing a substantial contribution to medical research . The University of Cambridge is proposing to introduce a new degree of Med.Sc.D. ( more akin to the ScD degree ) awarded on the basis of a career 's contribution to the science or art of medicine , rather than a thesis , for which a candidate may be awarded the M.D. degree . In the case where the MD is awarded ( either as a first or higher doctorate ) for previously published research , the candidate is usually required to be either a graduate or a full-time member of staff , of several years ' standing of the university in question . # Denmark # In Denmark , basic medical education is given in four universities : University of Copenhagen , Aarhus University , University of Southern Denmark and Aalborg University . The duration of basic medical education is six years and the course leads to the degree of Candidate of Medicine ( rated equally to master degree ) . Students are qualified as ' ' Medical Doctor ( M.D. ) ' ' after swearing the Hippocratic Oath upon graduation . Medical school is usually followed by a year residency called clinical basic education ( Danish : Klinisk basisuddannelse or just KBU ) which upon completion grants the right to practices medicine without supervision . # France # Medical studies in France are organised as follow : Right after graduating from High School with a Baccalaureat , any student can register at a university of medicine ( there are about 30 of them throughout the country ) . At the end of first year , an internal ranking examination takes place in each of these universities in order to implement the numerus clausus . First year consists mainly of theoretical classes such as biophysics and biochemistry , anatomy , ethics or histology . Passing first year is commonly considered as challenging and requires hard and continuous work . Each student can only try twice . For example , the Universit Ren Descartes welcomes about 2000 students in first year and only 300 after numerus clausus . The second and third year are usually mainly quite theoretical although the teachings are often accompanied by placements in the field ( e.g. internships as nurses or in the emergency room , depending on the university ) . During 4th , 5th and 6th years , medical students get a special status called ' Externe ' ( In some universities , such as Pierre et Marie Curie , the ' Externe ' status is given starting in the 3rd year ) . They work as interns every morning at the hospital plus a few night shifts a month and study in the afternoon . Each internship lasts between 3 and 4 months and takes place in a different department . Med students get 5 weeks off a year . At the end of sixth year , they need to pass a national ranking exam , which will determine their specialty . Indeed , the first student gets to choose first , then the second et cetera . Usually students work pretty hard during 5th and 6th years in order to train properly for the national ranking exam . During these years , actual practice at the hospital and some theoretical courses are meant to balance the training . Such externs ' average wage stands between 100 and 300 euros a month . After that ranking exams , students can start as residents in the specialty they have been able to pick . That is the point from which they also start getting paid . Towards the end of the medical program , French medical students are provided with more responsibilities and are required to defend a thesis ; however , unlike a PhD thesis , no original research is actually necessary to write a MD thesis . At the conclusion of the thesis defense , French medical students receive a ' ' State Diploma of Doctor of Medicine ( MD ) ' ' or ' ' diplme d'Etat de docteur en mdecine ' ' . Every new doctor must then proceed to a ' ' Diploma of Specialised Studies ' ' ( Diplme d'Etudes Spcialises or DES ) to mark their specialty . Some students may also receive a ' ' Diploma of Complementary Specialized Studies ' ' ( Diplme d'Etudes Spcialises Complmentaires or DESC ) . # Germany # In Germany , admission to medical schools is currently administered jointly by the ' ' ' ' ( SfH ) , a centralized federal organization , and the universities themselves . The most important criterion for admission is the Numerus clausus , the final GPA scored by the applicant on the Abitur ( highest secondary school diploma ) . However , in light of the recent gain in influence of medical schools in regards to applicant selection , additional criteria are being used to select students for admission . These criteria vary among medical faculties and the final Abitur GPA is always a core indicator and strongly influences admission . Admission remains highly competitive . A very small number of slots per semester are reserved for selected applicants which already hold a university degree ( Zweitstudium ) and for medical officer candidates ( Sanittsoffizieranwrter ) . The first two years of medical school consist of the so-called pre-clinical classes . During this time , the students are instructed in the basic sciences ( e.g. physics , chemistry , biology , anatomy , physiology , biochemistry , etc. ) and must pass a federal medical exam ( ' ' ' ' ) , administered nationally . Upon completion , the students advance to the clinical stage , where they receive three years of training and education in the clinical subjects ( e.g. , internal medicine , surgery , obstetrics and gynecology , pediatrics , pharmacology , pathology , etc . ) . The last year of medical school consists of the so-called practical year ( ' ' ) ' ' . Students are required to spend three four-month clerkships , two of them in a hospital ( internal medicine and surgery ) as well as one elective , which can be one of the other clinical subjects ( e. g. family medicine , anesthesiology , neurology , pediatrics , radiology etc . ) . After at least six years of medical school , the students graduate with a final federal medical exam ( ' ' ' ' ) . Graduates receive the license to practice medicine and the professional title of physician ( ' ' ' ' ) . The academic degree Doctor of Medicine ( Dr. med. ) is a research doctorate degree and is awarded if the graduate has , in addition , successfully completed a scientific study and dissertation . Many medical students opt to perform their thesis during their studies at medical school , but only a fraction of them is able to finish the dissertation-process during their studies . If physicians wish to open up a doctor 's office , they are required to further complete residency in order to fulfill the federal requirements of becoming Facharzt ( specialized in a certain field of medicine like internal medicine , surgery , pediatrics etc . ) . There are 36 medical faculties in Germany . # Netherlands and Belgium # In the Netherlands and Belgium , medical students receive 6 years of university education prior to their graduation . In the Netherlands , students receive three years of preclinical training , followed by three years of clinical training ( ' ' co-assistentschappen ' ' , or ' ' co-schappen ' ' for short ) in hospitals . At one medical faculty , that of Utrecht University , clinical training already begins in the third year of medical school . After 6 years , students graduate as Basisartsen ( comparable to Doctors of Medicine ) . As a result of the Bologna process , medical students in the Netherlands now receive a bachelor 's degree after three years in medical school and a master 's degree upon graduation . Prospective students can apply for medical education directly after finishing the highest level of secondary school , vwo ; previous undergraduate education is not a precondition for admittance . The Belgian medical education is much more based on theoretical knowledge than the Dutch system . In the first 3 years , which are very theoretical and lead to a university bachelor degree , general scientific courses are taken such as chemistry , biophysics , physiology , biostatistics , anatomy , virology , etc . To enter the bachelor course in Flanders , prospective students have to pass an exam , as a result of the numerus clausus . In the French-speaking part of Belgium , only the best students that pass the first year of the bachelor course in medicine are admitted to the second and third year . After the bachelor courses , students are allowed to enter the ' master in medicine ' courses , which consist of 4 years of theoretical and clinical study . In general , the first 2 master years are very theoretical and teach the students in human pathology , diseases , pharmacology . The third year is a year full of internships in a wide range of specialities in different clinics . The seventh , final year serves as a kind of ' pre-specialization ' year in which the students are specifically trained in the specialty they wish to pursue after medical school . This contrasts with the Dutch approach , in which graduates are literally ' basic doctors ' ( ' ' basisartsen ' ' ) who have yet to decide on a specialty. # South Korea # In South Korea , there are two types of Medical Doctor(MD) licenses ( with two types of Medical Schools ) . One is Doctor of Western-medicine , and another is Doctor of Korean-medicine ( before 2012 , It was called Doctor of Oriental-medicine ) The medical educations in South Korea ( Republic of Korea ) are 6 or 4 years in duration , 6-year coures starting right after high schools , and 4-year course starting after 4-year 's university education ( To start 4-year course , the student needs bachelor 's degree ) . The first 2 years in the 6-year system is composed of basic sciences and liberal art courses . # Sweden # Medical education in Sweden begins with a five-and-a-half-year undergraduate university program leading to the degree Master of Science in Medicine ( ) . Following this , the National Board of Health and Welfare requires a minimum of 18 months of clinical internship ( ) before granting a medical license to be fully qualified as Medical Doctor ( MD ) . This internship consists of surgery ( 36 months ) , internal medicine ( 36 months ) , psychiatry ( three months ) and family medicine ( six months ) . Upon receiving a license to practice , a physician is able to apply for a post to start specialist training . There are currently 52 recognized medical specialties in Sweden . The specialist training has a duration of minimum five years , which upon completion grants formal qualification as a specialist . # Australia # Historically Australian medical schools have followed the British tradition by conferring MBBS degrees to medicine graduates . The notable exception is the Bachelor of Medicine ( BMed ) joint program of the University of Newcastle and the University of New England . Australian MBBS degrees are graduate-entry Bachelor 's degrees at Level 7 of the Australian Qualifications Framework ( AQF ) and take four years to complete . The Newcastle/New England BMed is again an exception , being a five-year undergraduate-entry Level 7 degree . A recent revision to the AQF permits certain Level 9 Master 's degree programs to use Doctor of in the degree title . As a result , several Australian universities are in the process of revising their Level 7 Bachelor 's degrees to become Level 9 Master 's degrees with the title Doctor of Medicine ( MD ) . The University of Melbourne was the first to introduce the MD degree in 2011 , and many other Australian universities are in the process of replacing their MBBS degrees with MDs . Many universities previously offered an MD as an AQF Level 10 doctoral degree akin to the PhD or as a higher doctorate . Since the introduction of the Master 's level MD , universities have renamed their previous medical research doctorates . For instance , the University of Melbourne renamed its research degree the Doctor of Medical Science ( DMedSci ) , whilst the University of Queensland has renamed its research degree to Doctor of Medicine ( Research ) ( DMed(Res) . # Malaysia # In Malaysia , M.D. are awarded by both private and public universities , mostly are trained as a 5 years course but recently with the establishment of Perdana University in collaboration with John Hopkins Medical School the 4 years graduate entry medical degree is beginning to replace the 5 years program . Example of universities in Malaysia offering M.D. are University Sains Malaysia , National University of Malaysia , University Putra Malaysia , UCSI University &amp; etc. # Argentina # In Argentina the First Degree of Physician or Physician Diplomate ' ' ( Ttulo de Mdico ) ' ' is equivalent to the North American M. D. Degree with six years of intensive studies followed by usually three or four years of ' ' residency ' ' as a major specialty in a particular empiric field , consisting of internships , social services and sporadic research . Only by holding a Medical Title can the postgraduate student apply for the Doctor degree through a Doctorate in Medicine program approved by the National Commission for University Evaluation and Accreditation . # India # The MBBS ( Bachelor of Medicine/Bachelor of Surgery ) degree represents the first ( graduation ) level of training required to be licensed as a physicians , and the MS or MD degree is a higher postgraduate degree , representative of specialty training . The equivalent training in the US or Canada would be completion of a medical ( post-graduate ) degree . Eligibility for the MS or MD course is restricted to medical graduates holding the MBBS degree . The MBBS course is for five and a half years , and training is obtained in medical disciplines ( e.g. : Internal Medicine , Radiology , Pathology , etc . ) . After three years of study and the successful completion of an examination , which includes both theoretical and practical elements , in a pre-clinical or clinical subject of a non-surgical nature the candidate receives MD degree , whereas in a pre-clinical or clinical subject of a surgical nature i.e. , anatomy , general surgery , orthopaedics and gynaecology the candidate receives the equivalent degree Master of Surgery ( MS ) . The research element is not very prominent in India , as this is primarily a clinical qualification resembling the professional doctorates of the USA . In general surgery , orthopaedics and gynaecology and in a pre-clinical subject like anatomy the equivalent degree is Master of Surgery ( MS ) . A second alternate qualification , termed DNB Diplomate of National Board , is considered equivalent to the MD and MS degrees . This can be obtained by passing the exam conducted by the National Board of Examinations after completing 3 years of post-MBBS residency training in teaching hospitals recognised by the board . The , India ( Established 1912 ) also awards higher postgraduate degrees in clinical and pre-clinical specialties , called FCPS ; it involves three years of study and the successful completion of an examination , which includes both theoretical and practical elements , and a research thesis and a viva . The FCPS is representative of specialty clinical training , and equivalent to MD/MS/DNB in India , or PhD or Professional Doctorates in other parts of the world . Till 2007 , the Government of India and the Medical Council of India recognised the FCPS qualification - since then , this is being done by State Medical Councils . After obtaining the first postgraduate degree , that is MD/MS/FCPS/DNB , one can go for further specialisation in medical or surgical fields . This involves a highly competitive entrance examination . Course has three years of additional training and study and then after passing an examination , both theory and practical , the degree awarded is DM ( Doctor of Medicine ) , like DM in Cardiology , Neurology , Nephrology , Gastroenterology , NeuroRadiology , Critical Care , Pulmonology , Hematology , Medical Oncology , Cardioanaesthesia , and Neuroanaesthesia . For surgical superspecialities the degree awarded is MCh ( Magister Chirurgiae ) , like MCh in Cardiac Thoracic and Vascular Surgery , Neurosurgery , Gastrosurgery , Urology , Plastic Surgery , Pediatric Surgery etc . DM and Mch are Doctorate degrees . A third alternate qualification is DNB ( superspecialties ) , offered by National Board of Examinations , like DNB in Cardiology , Neurology , Cardiac Surgery , Neurosurgery . The DM and MCh degrees are super-specialties and are very high ranked/prestigious . Following DM or Mch , one can further go for a third postdoctorate degree that is , postdoctoral fellowship programs of one year duration in specific subspecialities like Cardiac Electrophysiology , Invasive cardiology , Pediatric cardiology , Epilepsy , stroke , electroencephalography , movement disorders , neuromuscular disorders , cerebrovacular surgery , skull base surgery , pediatric cardiac surgery etc. offered by prestigious government institutes . In Ayurveda , B.A.M.S in Naturopathy and Yoga , Bachelor of Naturopathy and Yoga , B.N.Y.S in Unani , Bachelor of Unani Medicine and Surgery BUMS in Siddha BSMS in homoeopathy B.H.M.S are the basic qualification for practicing Ayurveda , Unani , Homoeo&amp;Sidha . The B.A.M.S , B.N.Y.S , B.U.M.S , B.S.M.S and B.H.M.S are 5 1/2-year degree ( including internship called house surgeonship ) course after 12 years of formal education at a C.C.I.M approved colleges . M.D ( Ayu ) ( Ayurveda vachaspati ) and other related M.D master degrees has to be done after B.A.M.S , B.N.Y.S. , B.U.M.S , B.S.M.S or B.H.M.S in a specialty , and it takes 3 years ( including submission of a thesis ) to complete the course . Ayurveda M.D ( Ayu ) ( Ayurveda vachaspati ) is a Master degree accepted by the C.C.I.M.After completion of M.D ( Ayu ) ( Ayurveda vachaspati ) can follow higher level PhD programmes . # Iran # In Iran , Medical education begins after high school . No pre-med course or BSc degree is required . The eligibility is determined through the rank applicants obtain in the public university entrance exam being held every year throughout the country . The entry to medical school is so competitive and only students with the highest rank are accepted into medical program . The primary medical degree is completed in 7-7.5 years . Medical graduates are awarded a certificate in general medicine , called Professional Doctorate in Medicine validated by the Ministry of health and Medical Education of Iran . All physicians will obtain licence and medical council registration number from the Medical Council of Iran before they officially begin to practice . They may subsequently specialize in a specific medical field at medical schools offering the necessary qualifications . # Israel # There are five university medical schools in Israel , including the Technion in Haifa , Ben Gurion University in Be'er Sheva , Tel Aviv University , the Hebrew University in Jerusalem and the Medical school of the Bar-Ilan University in Safed . They all follow the European 6-year model except Bar-Ilan University who has a four-year program similar to the US system . However , as of 2009 , Tel Aviv University has introduced a four-year program similar to the US system for students with a bachelor 's degree in certain biological sciences . The entrance requirements of the various schools of medicine are very strict . Israeli students require a high school Baccalaureate average above 100 and psychometric examination grade over 740 . The demand for medical education is strong and growing and there is a lack of doctors in Israel . The Technion Medical School , Ben Gurion University , and Tel Aviv University Sackler Faculty of Medicine offer 4-year MD programs for American students who have American college degrees and have taken the MCAT interested in completing rigorous medical education in Israel before returning to the US or Canada . The degree of Doctor of Medicine ( MD ) is legally considered to be equivalent to Master degree due to Israeli Educational System . # Pakistan # In Pakistan equivalent degree is MBBS ( bachelors of medicine and bachelors of surgery ) . MBBS is awarded as the basic medical qualification after completing five years of study . This comprises two years of basic science subjects including anatomy , physiology , and biochemistry , with a particular emphasis on human anatomy . Subsequently , there are three years of clinical internship and courses on medicine surgery and pharmacology . Finally , the student is required to work for one year under a professor , before one is awarded Degree of MBBS with license to practice . So the total duration of MBBS degree becomes Six years in Pakistan . For specialization , one has to pass Fellow of College of Physicians &amp; Surgeons Pakistan ( FCPS ) exam-1 in field in of specialization and obtain an internship in the field for 36 years . Next , one can take the FCPS exam part 2 , which includes intensive practical exams . Upon successful completion a fellow of the relevant specialty is awarded . Tough entry tests are passed successfully before entering into a medical college . Medical colleges and foreign medical qualifications are supervised by the Pakistan Medical and Dental Council ( PMDC ) . Specialized degrees are awarded by the Pakistan College of Physicians and Surgeons . In basic medical sciences such as Anatomy , Physiology , Biochemistry , Pathology etc. the research postgraduate degree awarded by many universities is M.Phil. , which has a mandatory pre-requirement of minimum two years of Demonstratorship in relevant subject in a recognized Medical College . The Mphil course is 24 years and is a research postgraduate degree , containing submission and defence of research thesis in basic sciences similar to MD degree program in India . Including two years of mandatory training period as demonstratorship total M. Phil duration in Pakistan for 6 years MBBS degree holders thus becomes 4 to 6 years . Many universities in conjunction with tertiary hospitals offer coursework MD and MS degrees as well . # Philippines # The Dominicans , under the Spanish Government , established the oldest Medical School in the Philippines in 1871 , known as the Faculty of Medicine and Surgery ( at that time was one with the University of Santo Tomas Faculty of Pharmacy , also considered the oldest school of Pharmacy in the Philippines ) of the Pontifical and Royal University of Santo Tomas in Intramuros , Manila . Medical education in the Philippines became widespread under the American administration . The Americans , led by the insular government 's Secretary of the Interior , Dean Worcester , built the University of the Philippines - College of Medicine and Surgery in 1905 . By 1909 , nursing instruction was also begun at the Philippine Normal School . At present there are a number of medical schools in the Philippines , notable examples include the University of the Philippines Manila , Our Lady of Fatima University , Far Eastern University - Nicanor Reyes Medical Foundation , Saint Louis University ( Baguio ) , De La Salle Health Sciences Institute , University of Santo Tomas , Pamantasan ng Lungsod ng Maynila , University of the East Ramon Magsaysay Memorial Medical Center , St. Luke 's College of Medicine-William H. Quasha Memorial , Cebu Doctors ' University , Cebu Institute of Medicine , Mindanao State University-College of Medicine , Southwestern University , West Visayas State University in Iloilo City , Davao Medical School Foundation in Davao City , Xavier University - Ateneo de Cagayan , Dr. Jose P. Rizal School of Medicine in Cagayan De Oro , Virgen Milagrosa University Foundation in San Carlos , Pangasinan , and University of Northern Philippines ( Vigan City ) . In 1994 , the Zamboanga Medical School Foundation was founded . Currently , it is now known as the . It is an innovative medical school which patterned its curriculum from the College of Medicine in the University of New Mexico and the University of Calgary in Canada yet , evolving it to be suitable and unique to the Philippine setting . It is the only medical school in the Philippines offering a 5-year program integrating degrees of Doctor of Medicine and Master of Public Health . On 2007 , the Ateneo School of Medicine and Public Health was established . It is the first medical school in the country to offer a double degree program leading to the degrees Doctor of Medicine and Masters in Business Administration . Any college graduate may apply for medical school given that they satisfy the requirements set by the institutions . There is also a test known as the National Medical Admission Test or NMAT . Scores are given on a percentile basis and a high ranking is a must to enter the top medical schools in the country . In most institutions , medical education lasts for four years . Basic subjects are taken up in the first and second years , while clinical sciences are studied in the second and third years . In their fourth year , students rotate in the various hospital departments , spending up to two months each in the fields of internal medicine , surgery , obstetrics and gynecology , and pediatrics , and several weeks in the other specialties . After this , students graduate with a Doctorate in Medicine ( MD ) and apply for postgraduate internship ( PGI ) in an accredited hospital of their choice . After PGI , the student is eligible to take the Medical Licensure Examination . Passing the examinations confers the right to practice medicine as well as to apply in a Residency Training Program . # Romania # Romanian medical schools lasts for 6 years ( including clinical practice ) and concludes with a final licensing examination ( licena ) , which is based on the dissertation of the student 's original research . The degree awarded is that of Doctor-medic ( Medical Doctor ) , abbreviated as MD , or more commonly Dr. ( although this is not correct , and should be written dr. ) . # Sri Lanka # In Sri Lanka , MBBS degree is the degree to be held for one to be licensed as a physicians by the Sri Lanka Medical Council . MD degree is a higher postgraduate degree and in Sri Lanka awarded by the Postgraduate Institute of Medicine after completion of a postgraduate course and examinations . The MD degree in Sri Lanka is representative of specialty training in clinical , para clinical and preventive medicine ( e.g. , General Medicine , Cardiology , Nephrology , Oncology , para clinical such as microbiology , haematology and preventive such as Community Medicne . ) . Entry for the MD course open only for medical graduates holding the MBBS degree ( with a duration of five and a half years ) , and training is obtained in medical disciplines that are non-surgical in nature ( e.g. , Internal Medicine , Radiology , Pathology , etc . ) . After three or four years of study and the successful completion of an examination with written as well as cases and viva examinations , the MD degree in the respective field of Study is awarded . In Community medicine and Medical Administration , part I examination consists of a theoretical exam while the degree is cofered after completion of a thesis as n PhD . This thesis has to be completed within a period of five years . After successfully defending the academic thesis , MD degree is conferred to the candidate , The MD degree holder is certified as a Board certified specialist by the respective board of study of the Postgraduate Institute of Medicine after he/she undergoes 24 years of local and foreign training depending on the specialty/subspecialty selected . In Ayurveda , Bachelor of Ayurveda , Medicine and Surgery B.A.M.S in Unani , Bachelor of Unani Medicine and Surgery BUMS in Sidha , Bachelor of Sidha Medicine and Surgery BSMS are the basic qualification for practicing Ayurveda , Unani , &amp;Sidha . The B.A.M.S , B.U.M.S , and B.S.M.S are 6-year degree ( including internship ) courses accepted by the University Grants Commission ( Sri Lanka ) . M.D ( Ayu ) ( Ayurveda vachaspati ) can be done after B.A.M.S , as a speciality , and it takes 3 years ( including submission of a thesis ) to complete the course . Ayurveda M.D ( Ayu ) ( Ayurveda vachaspati ) is a Master degree accepted by University Grants Commission ( Sri Lanka ) , after completion of MPhil can follow PhD level programmes in Sri Lanka . # Republic of China ( Taiwan ) # The medical education in the Republic of China ( Taiwan ) is usually 7 years ( 6-year learning plus 1-year internship ) in duration , starting right after high schools . The first 2 years in the 7-year system is composed of basic sciences and liberal art courses . Doctor-patient classes are emphasized , and most schools require compulsory amounts of volunteer hours . Clinical sciences are compressed into a two-year program in the 3rd and 4th years . The duration of clerkships and internships varies from school to school , but all of them end at the 7th grade . Taiwans medical education began in 1897 and is over 100 years old now . Students graduate with a Doctor of Medicine ( MD ) degree . Starting from the year 2013 , incoming students will have a 6+2 year curriculum , in which the first 6 years are oriented similarly as before and the last two years are Post Graduate Years ; this change aims to increase primary care capabilities of medical school graduates . # Singapore # The Yong Loo Lin School of Medicine at the National University of Singapore confers ' ' MB BS ' ' . The American Duke University also has a medical programme based in Singapore ( Duke-NUS Graduate Medical School ) , but it follows the North-American model of styling its degree Doctor of Medicine ( MD ) at masters degree level . # Thailand # The Thai medical education is 6 years system , consisting of 1 year in basic-science , 2 years in pre-clinical training , and 3 years for clinical training . Upon graduation , all medical students must pass national medical licensing examinations and a university-based comprehensive test . After medical school , newly graduated doctor are under contract to spend a year of internship and 2 years of tenure in rural areas before they are eligible for any other residency positions or specialized training . The students will receive Doctor of Medicine ( MD ) degree . However the degree is equivalent to Master 's degree in Thailand . # Tunisia # In Tunisia , education is free for all Tunisian citizens and for foreigners who have scholarships . The oldest Medical school is a faculty of the University of Tunis . There are four medicine faculties situated in the major cities of Tunis , Sfax , Sousse and Monastir . Admission is bound to the success and score in the baccalaureate examination . Admission score threshold is very high , based on competition among all applicants throughout the nation . Medical school curriculum consists of five years . The first two years are medical theory , containing all basic sciences related to medicine , and the last three years consists of clinical issues related to all medical specialties . During these last three years , the student gets the status of Externe . The student has to attend at the university hospital every day , rotating around all wards . Every period is followed by a clinical exam regarding the student 's knowledge in that particular specialty . After those five years , there are two years on internship , in which the student is a physician but under the supervision of the chief doctor ; the student rotates over the major and most essential specialties during period of four months each . After that , student has the choice of either passing the residency national exam or extending his internship for another year , after which he gains the status of family physician . The residency program consists of four to five years in the specialty he qualifies , depending on his score in the national residency examination under the rule of highest score chooses first . Whether the student choses to be a family doctor or a specialist , he has to make a doctorate thesis , which he will be defending in front of a jury , after which he gains his degree of Doctor of Medicine ( MD ) ' ' . # Cambodia # After 6 years of general medical education ( a foundation year + 5 years ) , all students will graduate with Bachelor of Medical Sciences ( BMedSc ) ' ' ' ' . This degree does not allow graduates to work independently as Physician , but it is possible for those who wish to continue to master 's degrees in other fields relating to medical sciences such as Public Health , Epidemiology , Biomedical Science , Nutrition ... Medical graduates , who wish to be fully qualified as physician must do as below : General Practitioner 's ( GP ) course is of 8 years ( BMedSc + 2-year internship ) . Clinical rotation in the internship is modulated within 4 main disciplines ( general medicine , surgery , gynecology , pediatrics ) . The medical degree awarded is Doctor of Medicine ( MD ) ' ' ' ' ( equivalent to master 's degree ) . After graduating with BMedSc ; students , who wish to enter Specialist Training Programs , are required to sit for a rigorous Contesting Entrance Exam . It lasts 9 to 10 years from the beginning of medical school ( BMedSc + 3 4 years of specialization ) that will lead to conferment of the degree of ( after thesis defense ) Doctor of Medicine with Specialization ( MD-DES ) ' ' ' ' which is officially rated as Professional Doctorate . All Medical graduates must complete ' ' Thesis Defense ' ' and pass the ' ' National Licensing Exam ' ' ' ' ' ' to become either GPs or Medical/Surgical Specialists . # Equivalent degrees in other countries # In Russia , medical schools in Russia offer a 6-year curriculum leading to award ' ' Doctor of Medicine ( MD ) ' ' Physician . In the Dominican Republic , it is known as Doctor en Medicina ( Doctor in Medicine ) . In 1511 the Spanish Catholic church founded the first university of the Americas in Santo Domingo present capital of modern day Dominican Republic and name it Universidad Santo Tomas de Aquino ( today Universidad Autonoma de Santo Domingo ) . In 1630 this university graduated the first medical doctors of the Americas and amongst the graduates some Native Americans included . In Guyana , Doctor of Medicine ( MD ) degree is awarded after the completion of 4 years or 5 years of study . Texila American University , Green heart university , American International School of Medicine provides Medicine programs In Bangladesh , the basic medical degree is the MBBS . After completing the intermediate level of education ( 12 years ) the candidate must undergo 5 years of medical training in any medical college to achieve the MBBS degree . After obtaining the degree , the candidate needs to undergo one year of internship to obtain BMDC ( Bangladesh medical and dental council ) accreditation in order to practice in the country . In Italy , the title of Dottore in Medicina e Chirurgia ( literally Doctor in Medicine and Surgery ) is awarded after completion of a Master 's course in Medicine and Surgery ( lasting six years ) in a University . After obtaining this degree , graduates have to pass a state examination ( called abilitazione ) through which they acquire the right to work as a medical doctor . All Doctors then must enroll to a specialization school for a specific medical field . The Czech and Slovak title MUDr . ( Medicinae Universae doctor or ' ' doktor medicny ' ' ) is a professional doctorate granted upon completion of six years pregraduate Master 's study at medical schools . The postgraduate academic research degree in medicine is a PhD degree . In Poland the title of ' ' lekarz ' ' ( physician , medic ) or lek . ( previously ' ' lekarz medycyny ' ' or lek . med. ) is granted after completing a 6-year Master 's medical program ( although students apply to it directly after graduating high school ) . In contrast , a higher doctoral academic research degree in medicine resembling a PhD is named dr n. med. or ' ' doktor nauk medycznych ' ' ( Doctor of Medical Sciences ) . Specialization is valued similarly to a specialization in the English system and is a pre-requisite for a dr. n. med. which is usually defined within the same field . The Danish and Norwegian Candidatus medicinae or Candidata medicinae degrees ( cand. med. ) is awarded after completing a six-year medical programme , to which students apply directly upon finishing secondary school . The programme usually includes a small thesis . However , the cand. med. degree must not be confused with the previous Danish and Norwegian Dr. Med. degree , which is a separate degree from the Ph.D . and represents a higher degree of medical research experience . It typically consists of at least 56 original publications . In Mexico , schools of medicine award the Ttulo de Mdico Cirujano degree after completing either six or seven years of study . This curriculum includes a rotating internship year and a year of social service providing care to an underserved community . In Nepal , a MBBS degree is awarded . In Greece , after a six-year study , a medical student acquires his medical degree and the right to use . , ( Dr. ) before his name . This is considered equivalent to the M.D. title . In mainland China , some medical schools award MBBS to foreign students while all medical schools award Bachelor of Medicine to nationals . MD is a higher academic research degree . In Colombia , the medicine faculties of the universities awards the title of Medico Cirujano after taking 10 semesters of studies on all clinic and surgery discipline a two semester on internship . After receiving the degree there is a mandatory year obliged social work were the doctors practice as GP in the countryside . Residency programs last between 34 years depends on the specialty. In Sudan the awarded degree in most of the medical schools is , Bachelor of Medicine and Basic Surgery ( MBBS ) . In schools that are based on the English system of medical teaching , the degree is granted after six years of studying . As for the schools that are adopting the American system , they grant their students the degree of MBBS in only five years . In Turkey , the title of Tp Doktoru ( literally Doctor of Medicine ) is awarded upon completion of six years continuous study started with five years university education include three years basic sciences , two years clinical courses followed by one year of internship in university hospitals . In Indonesia , the title of dokter ( dr. ) is awarded after a Medical student received their Bachelor in Medicine ( Sarjana Kedokteran ; S. Ked ) after 3-3.5 years of study ( at least ) and 1.52 years of clinical course in university hospitals . After a medical student finished those five years of study and take Hippocrates Oath , The title of Dokter ( dr. ) is entitled before their name . Then they need to take Ujian Kompetensi Dokter Indonesia ( UKDI , test to get license to practice medicine as general practitioner ) then take a year-long internship course in primary health care clinics ( also known as Puskesmas ) or primary hospitals all over the country to practice as general practitioner under supervision of senior doctors . Those who wished to further their study into specialties can take graduate course of medicine of their preference and will be entitled with Specialist of .. after their name ( e.g. : Sp.A for Spesialis Anak = Pediatrician ) . graduate course of medicine is equal with residency program which is required the candidates to study for four years and hospital internship . ( Note : dr. ( dokter ) is used for medical graduates , while Dr. ( Doktor ) is used for PhD holders .. In Serbia and Croatia , the title of doktor medicine ( abbreviated dr. med. ) is awarded upon completion of six years of study at a Faculty of Medicine ( medicinski fakultet ) directly after high school . In Japan , Doctor of Medicine ( MD ) is awarded from the government , after graduating a medical university or college with 6-year curriculum and passing the national examination . In Portugal , to practice Medicine , a Masters in Medicine ( awarded after a 6-year Integrated Masters Program in Medicine ) is mandatory . Before the 2007 Bologna Process , the same course was only a Licentiate Degree . After the 6-year program , students must go through the Specialty Exam ( which is not an evaluation ) , and then a year of Medical Internship . When the internship ends , the students are placed in their choice of Medical Specialty , according to their ranking in the formentioned Specialty Exam . Only when each student finishes the Medical Internship and the first year of their Specialty , will they be allowed to practice Medicine without supervision . Entry to the Integrated Masters Program in Medicine is done directly after High School , based on the student 's grade - each year there are about 1500 new Medical Students in Portugal , in 8 different Medical Schools . # Other postgraduate clinical degrees # There is also a similar advanced professional degree to the postgraduate MD : the Master of Surgery ( usually ChM or MS , but MCh in Scotland , Ireland , Wales and at Oxford and MChir at Cambridge ) . The equivalence of these degrees , but their differing names , prevents the need for surgeons ( addressed as Mr. in the UK ) having to revert to the title Dr. , which they once held as new MBBS graduates . In Ireland , where the basic medical qualification includes a degree in obstetrics , there is a similar higher degree of Master of the Art of Obstetrics ( MAO ) . A Master of Midwifery was formerly examined by the Worshipful Society of Apothecaries of London ( hence MMSA ) but fell into abeyance in the 1960s ; in this case the term Master referred not to a university degree but rather a professional rank that is common among craft guilds . In East Africa , the medical schools in Kenya , Tanzania and Uganda award the degree of Master of Medicine ( MMed ) degree in both surgical and medical specialty disciplines following a three-year period of instruction . In West Africa , the West African College of Physicians and the West African College of Surgeons award the Fellowship of the West African College of Physicians ( FWACP ) and the Fellowship of the West African College of Surgeons ( FWACS ) in medical and surgical disciplines respectively after a minimum of four-year residency training period . 
@@431259 The Institute of Medicine ( IOM ) is an American non-profit , non-governmental organization founded in 1970 , under the congressional charter of the National Academy of Sciences . The IOM is part of the United States National Academies , which also includes :  National Academy of Sciences ( NAS )  National Academy of Engineering ( NAE )  National Research Council ( NRC ) Its purpose is to provide national advice on issues relating to biomedical science , medicine , and health , and its mission to serve as adviser to the nation to improve health . It works outside the framework of the U.S. federal government to provide independent guidance and analysis and relies on a volunteer workforce of scientists and other experts , operating under a formal peer-review system . The Institute aims to provide unbiased , evidence-based , and authoritative information and advice concerning health and science policy to policy-makers , professionals , leaders in every sector of society , and the public at large . As a national academy , new members of the organization are elected annually by current members , based on their distinguished and continuing achievements in a field relevant to the IOM 's mission as well as for their willingness to participate actively in its work . The outgoing President of the IOM is Harvey V. Fineberg , M.D. , Ph.D. ; the Interim Leonard D. Schaeffer Executive Officer is Clyde J. Behney . The newly elected president is Victor Dzau , the chancellor for health affairs at Duke University and the CEO of the Duke University Health System . Dzau also serves on the board of PepsiCo as well as Alynlam Pharmaceuticals , Genzyme , and Medtronic. # Operations # The Institute and The National Academies use a unique process in the attempt to obtain authoritative , objective , and scientifically balanced answers to difficult questions of national importance . Their work is conducted by committees of volunteer scientistsleading national and international expertswho serve without compensation . Committees are composed in an attempt to assure the requisite expertise and to avoid bias or conflict of interest . Every report produced by IOM committees undergoes extensive review and evaluation by a group of external experts who are anonymous to the committee , and whose names are revealed only once the study is published . The majority of IOM studies and other activities are requested and funded by the federal government . Private industry , foundations , and state and local governments also initiate studies , as does the IOM itself . The IOM works in a broad range of categories , including : mental health , child health , food &amp; nutrition , aging , womens health , education , public policy , healthcare &amp; quality , diseases , global health , workplace , military &amp; veterans , health sciences , environment , treatment , public health &amp; prevention , and minority health . The reports of the IOM are made available online for free by the publishing arm of the United States National Academies , the National Academies Press , in multiple formats . # Membership # The Institute of Medicine is both an honorific membership organization and a policy research organization . The Institute 's members , elected on the basis of their professional achievement and commitment to service , serve without compensation in the conduct of studies and other activities on matters of significance to health . Election to active membership is both an honor and a commitment to serve in Institute affairs . The bylaws of IOM specify that no more than 70 new members shall be elected annually . The announcement of newly elected members occurs at the IOM Annual Meeting in October . As of October 22 , 2013 , the number of regular members plus foreign associates and emeritus members is 1,966 . An unusual diversity of talent among Institute members is assured by the charter stipulation that at least one-quarter be selected from outside the health professions , from such fields as the natural , social , and behavioral sciences , as well as law , administration , engineering , and the humanities . # Reception # ' ' The New York Times ' ' calls the IOM the United States ' most esteemed and authoritative adviser on issues of health and medicine , and its reports can transform medical thinking around the world . # Notable members , past and present #  Herbert Kleber , professor of psychiatry , Yale University .  Harold Amos , microbiologist and professor  Nancy Andrews , Dean of Duke University School of Medicine  Elizabeth Blackburn , biologist  Ben Carson , columnist and retired American neurosurgeon , former director of pediatric neurosurgery at Johns Hopkins Hospital  Dennis S. Charney , dean of the Mount Sinai School of Medicine in New York City  Jewel Plummer Cobb , cell biologist and President of California State University , Fullerton , 198190  Francis Collins , geneticist , leader in the Human Genome Project and NIH Director  Jim Collins , synthetic biology pioneer and MacArthur genius  Anthony Cerami , pioneering medical researcher  Kenneth L. Davis , author , medical researcher and CEO of Mount Sinai Medical Center  Margaret Hamburg , commissioner of the U.S. Food and Drug Administration  Maurice Hilleman , microbiologist  David Ho , pioneer in the use of protease inhibitors in treating HIV-infected patients  Leroy Hood , winner of the 2003 Lemelson-MIT Prize  Arthur Kellermann , professor and founding chairman of the department of Emergency Medicine at Emory University  Philip J. Landrigan , pediatrician and leading advocate of children 's health  Jeffrey Lieberman , chair of psychiatry , Columbia University ; president , American Psychiatric Association  Rudolph Leibel , MD , professor at Columbia University whose co-discovery at Rockefeller University of the hormone leptin , and cloning of the leptin and leptin receptor genes , has had a major role in the area of understanding human obesity.  Susan Lindquist , a molecular biologist and former Director of the Whitehead Institute  Howard Markel , George E. Wantz Distinguished Professor of the History of Medicine and Director of the Center for the History of Medicine at the University of Michigan  Maclyn McCarty , youngest member of the research team responsible for the Avery-MacLeod-McCarty experiment  Sherilyn S. McCoy , CEO of Avon Products and former Vice Chairman of Johnson &amp; Johnson  Ruslan Medzhitov , professor of immunobiology at Yale University , co-discoverer of human Toll Like Receptors ( TLRs ) and winner of the inaugural Else *26;235;TOOLONG award in 2013  Mario J. Molina , recipient of the 1995 Nobel Prize in Chemistry  Herbert Needleman , pediatrician and psychiatrist  Carl F. Nathan , Professor of Immunology and Microbial Pathogenesis at Weill Cornell Medical College . Winner of the inaugural Anthony Cerami Award in Translational Medicine  Peter R. Orszag , 37th Director of the Office of Management and Budget under President Barack Obama  Nicholas A. Peppas , pioneer of biomaterials and drug delivery  Samir M. Chebaro , Stanford Medical Center , Deans office Child Care Task Force  Patricia Flatley Brennan , professor of Nursing and Industrial Engineering at University of WisconsinMadison , and theme leader at the Wisconsin Institutes for Discovery .  Frederick Redlich , dean of the Yale School of Medicine from 1967 to 1972  James Rothman , winner of the 2002 Albert Lasker Award for Basic Medical Research  Jeffrey Sachs , economist and director of the Earth Institute at Columbia University  David A. Savitz , director of the Disease Prevention and Public Health Institute at the Mount Sinai Medical Center  Shirley M. Tilghman , former president of Princeton University  Douglas C. Wallace , geneticist and pioneer of human mitochondrial genetics  Sheldon Weinbaum , biomedical engineer , biofluid mechanician and Distinguished Professor , Emeritus , at The City College of New York  Kern Wildenthal , former president of the University of Texas Southwestern Medical School  William Julius Wilson , sociologist  Elias Zerhouni , former executive vice-dean of Johns Hopkins University School of Medicine and director of the National Institutes of Health under George W. Bush 
@@435330 Stanford University School of Medicine is the medical school of Stanford University . It is located at Stanford University Medical Center in Stanford , California . It is the successor to the Medical Department of the University of the Pacific , founded in San Francisco in 1858 and later named Cooper Medical College ; the medical school was acquired by Stanford in 1908 . Due to this descent it ranks as the oldest medical school in the Western United States . The medical school moved to the Stanford campus near Palo Alto , California in 1959 . Clinical rotations occur at several hospital sites . In addition to the Stanford University Medical Center ( Stanford Hospital and Clinics ) and Lucile Packard Children 's Hospital , Stanford has formal affiliations with Kaiser Permanente , Santa Clara Valley Medical Center and the VA Palo Alto Health Care System . Stanford medical students also manage two free clinics : Arbor Free Clinic in Menlo Park and Pacific Free Clinic in San Jose . Stanford is a cutting-edge center for translational and biomedical research ( both basic science and clinical ) and emphasizes medical innovation , novel methods , discoveries , and interventions in its integrated curriculum . The School of Medicine also has a Physician Assistant ( PA ) program that was added in 1971 , called the Primary Care Associate Program . It was one of the first accredited physician assistant programs in California . It is offered in association with Foothill College . The program has graduated more than 1,300 physician assistants since its opening . Most graduates fulfill the program 's mission of serving underserved medical communities . # Mission # The School of Medicine 's mission is to be a premier research-intensive medical school that improves health through leadership , diversity , collaborative discoveries and innovations in patient care , education and research . # Rankings and admissions # In the 2014 U.S. News &amp; World Report rankings , Stanford was ranked 2nd in the nation for research , behind Harvard Medical School . Admissions to Stanford is highly competitive . The acceptance rate is the second lowest in the country at 2.2% ( the Mayo Medical School is lower , with an acceptance rate of 1.9% ) . In 2008 , 6,567 people applied and 463 were interviewed for 86 spots . Matriculants had an average GPA of 3.76 and median MCAT score of 35 . Additionally , Stanford University Medical Center ( the medical school 's major teaching affiliate ) is ranked 17th out of 4,825 hospitals evaluated , making it the second highest ranked hospital in the San Francisco Bay Area , according to U.S. News ' Best Hospitals 2011-2012 . Along with the School of Humanities and Science , the Stanford School of Medicine also runs the Biosciences Ph.D . Program which was ranked 1st in 2009 among graduate programs in the Biological Sciences by the US News and World Report ; for the incoming class in 2009 , the program had an 11% acceptance rate . In specialties , according to U.S. News for 2011 , Stanford is #1 in genetics , genomics , and bioinformatics ; #2 in biochemistry , biophysics , and structural biology , immunology , cell biology , molecular biology and neuroscience , #3 in infectious disease , and microbiology. # History # In 1855 , Illinois physician Elias Samuel Cooper moved to San Francisco in the wake of the California Gold Rush . In cooperation with the University of the Pacific ( also known as California Wesleyan College ) , Cooper established the Medical Department of the University of the Pacific , the first medical school on the West Coast , in 1858 , on Mission Street near 3rd Street in San Francisco . The school underwent many changes until Cooper 's nephew , Levi Cooper Lane , established a new campus at the intersection of Webster and Sacramento Streets in 1882 ; at that time , the school was christened Cooper Medical College . Lane also built a hospital and a nursing school ( forerunner of the Stanford School of Nursing ) and made provision for the creation of Lane Medical Library . In 1908 , Stanford University adopted the Cooper Medical College as its affiliated medical institution , called the Stanford Medical Department and later the Stanford University School of Medicine . The school expanded and built up a reputation for excellence and providing cutting edge clinical care . In the 1950s , the Stanford Board of Trustees decided to move the school to the Stanford main campus near Palo Alto . The move was completed in 1959 . In the 1980s the Medical Center launched a major expansion program . A new hospital was added in 1989 with 20 new operating rooms , state of the art intensive care and inpatient units , and other technological additions . The Lucile Packard Children 's Hospital was completed in 1991 , adding even more diversity to the Center . The recently completed Clark Center ( Bio-X Program ) houses interdisciplinary research endeavors and serves to reinforce Stanford 's commitment to providing the best possible patient care through innovation . The focus of the program is to combine bioengineering , chemical engineering , physics , and entrepreneurship with medical research and clinical education to pioneer the future of medicine through translating discoveries . In the early years of the 21st century Stanford School of Medicine underwent rapid construction to further expand teaching and clinical opportunities . The Li Ka Shing Center for Learning and Knowledge opened in 2010 ; it serves as the gateway to the School of Medicine as well as providing a new model of medical education by combining biomedical research with clinical education and information technology . The Lorry I. Lokey Stem Cell Research Building also opened in 2010 ; it is the largest stem cell and regenerative medicine facility in North America . The Stem Cell Research Building is the first of the planned Stanford Institutes of Medicine . In addition to research facilities it houses offices for faculty from the Stanford Cancer Center and hotel space offices for visiting researchers . Furthermore , the Stanford University Medical Center is undergoing a renewal and expansion project which will rebuild Stanford Hospital &amp; Clinics and the Emergency Department , modernize and expand Lucile Packard Childrens Hospital , renovate the School of Medicine facilities to accommodate modern technology , and renovate Hoover Pavilion , the original Palo Alto Hospital , to accommodate community physicians . # Curriculum # A new medical school curriculum was implemented in fall 2003 . Classroom lectures were reduced from 30 hrs/week to 12-22 hrs/week , and there are no classes on Wednesdays . For the first two years , the grading scheme is completely pass/fail , and there is no AOA or other forms of an honor system as to encourage cooperation among students . In the clinical years , evaluation will be through a criterion-based system and just like the first two years using a pass/fail evaluation scheme . Each student can choose from one of twelve scholarly concentrations/majors. # Notable research/achievements #  1956 - First use in Western hemisphere of linear accelerator to treat cancer  1960 - First kidney transplant in California  1964 - Demonstration of electrical stimulation of auditory nerve in deaf patients , paving the way for cochlear implants  1968 - First adult human heart transplant in the United States  1970 - Leonard Herzenberg develops the fluorescence-activated cell sorter ( FACS ) which revolutionizes the study of cancer cells and will be essential for purification of adult stem cells  1974 - Isolation of genome of a virus that causes hepatitis B and a common form of liver cancer  1979 - Discovery of dynorphin , a brain chemical 200 times more powerful than morphine  1981 - First successful human combined heart/lung transplant in the world ( fourth attempted worldwide )  1984 - Isolation of a gene coding for part of the T-cell receptor , a key to the immune systems function  1988 - Isolation of pure hematopoietic stem cells from mice  1993 - First clinical trial testing methods for preventing eating disorders in adolescents  1996 - Discovery that the p53 protein , known to be involved in controlling cancerous tumors , works as an emergency brake on cancer development  2000 - Solution of the structure of the RNA polymerase protein , a pivotal molecule that copies genes from DNA to RNA  2005 - Discovery of obestatin , a hormone that suppresses appetite  2007 - Application and expansion of optogenetics , a technique to control brain cell activity with light  2009 - Discovery of a don't-eat-me signal that allows blood cancer stem cells to migrate safely through the body  2010 - For the first time , researchers use a healthy person 's complete genome sequence to predict his risk for dozens of diseases  2013 - Karl Deisseroth 's development of the CLARITY technique for rendering intact tissues transparent # Notable alumni #  John Baldwin - Former Dean of Dartmouth Medical School  Cheri Blauwet- professional cyclist , winner of Boston Marathon  William Brody - President of the Salk Institute and former President of The Johns Hopkins University  David D. Burns - Psychiatrist and author  Amy Chow - Olympic gold medalist.  Henry F. EpsteinCecil and Ida Green Distinguished Professor of Neuroscience , University of Texas Medical Branch  David A. Wood - President of the American Cancer Society , first director of the UCSF Cancer Research Institute  William Frist- Cardiothoracic Surgery Fellow ; United States Senator , former presidential candidate  Randall B. Griepp - cardiothoracic surgeon who collaborated with Norman Shumway in the development of the first successful heart transplant procedures in the U.S.  Milt McColl - Former NFL linebacker  John C. Handy - Physician and surgeon in Tucson , Arizona ( graduate of Medical College of the Pacific )  James Mongan - CEO of Partners HealthCare ( MGH and Brigham and Women 's Hospital , Harvard Medical School )  Scott Parazynski - NASA Astronaut , veteran of 5 Space Shuttle missions  Joshua Prager - pain medicine specialist and neuromodulator  Belding Scribner - Professor , University of Washington , inventor of the Scribner Shunt  Irving Weissman - Leading Stem Cell Biologist . Founder of Systemix and Stem Cells Inc.  Augustus White - Surgeon-in-Chief at Beth Israel Deaconess Medical Center  Ray Lyman Wilbur - President of American Medical Association , President of Stanford ( 19161943 ) , personal physician of President Harding  Val Murray Runge - John Sealy Distinguished Chair and Professor of Radiology University of Texas Medical Branch # Notable faculty #  John R. Adler - Professor of Neurosurgery . Inventor of CyberKnife.  Ben Barres - Professor of Neurobiology . Renowned for research on sex and intelligence .  George W. Beadle - Professor of Biology . Winner of the 1958 Nobel Prize in Physiology or Medicine .  Paul Berg - Biochemist . Winner of the 1980 Nobel Prize in Chemistry for discovery of recombinant-DNA.  Eugene C. Butcher - Professor of Pathology . Winner of the 2004 Crafoord Prize .  Gilbert Chu - Professor of Biochemistry and Medicine . Younger brother of Secretary of Energy Steven Chu .  Stanley Norman Cohen - Professor of Genetics and of Medicine , who accomplished the first transplantation of genes between cells . Winner of the National Medal of Science , National Medal of Technology , inducted into National Inventors Hall of Fame .  Frances K. Conley - Famed female neurosurgeon best known for advancing women in American medicine .  Karl Deisseroth - Professor of Bioengineering and of Psychiatry and Behavioral Sciences . Pioneer of optogenetics  William C. Dement - Professor of Psychiatry and Behavioral Sciences , pioneer in sleep research .  Andrew Z. Fire - Winner of the 2006 Nobel Prize in Physiology or Medicine .  Thomas J. Fogarty - Clinical Professor of Surgery . Member of National Inventors Hall of Fame . Owner of more than 100 surgical patents , including the Fogarty balloon catheter.  Philip Hanawalt - Hertzstein Professor of Biology and Dermatology , discovered transcription coupled repair of DNA .  Griffith R. Harsh - Vice Chair of the Stanford Department of Neurosurgery and the Director of the Stanford Brain Tumor Center . He is also the spouse of Meg Whitman .  Leonard Herzenberg - Winner of the Kyoto Prize for development of fluorescent-activated cell sorting .  Emile Holman - First Chair of General Surgery at Stanford . Rhodes scholar and considered to be last pupil of William Halsted.  Henry S. Kaplan - Pioneer in radiation therapy for cancer . Inventor of the first linear accelerator in the Western hemisphere .  Brian Kobilka - Professor of Molecular and Cellular physiology . Winner of the 2012 Nobel Prize in Chemistry  Arthur Kornberg - Winner of the 1959 Nobel Prize in Physiology or Medicine ( with Severo Ochoa ) for their discovery of the mechanisms of the biological synthesis of ribonucleic acid and deoxyribonucleic acid .  Roger Kornberg - Winner of the 2006 Nobel Prize in Chemistry . Son of Arthur Kornberg . Discoverer of nucleosome and transcriptional mediator . Member of National Academy of Sciences .  Michael Levitt - Winner of the 2013 Nobel Prize in Chemistry .  Joshua Lederberg - Founder of the Stanford department of genetics , co-recipient of 1958 Nobel Prize in Physiology or Medicine .  Donald Laub - Founder of Interplast , Inc.  Kate Lorig - Director of the Stanford Patient Education Research Center .  Norman Shumway - Heart transplant pioneer . Performed first heart transplant in the United States .  Bruce Reitz - Performed first combined adult human heart-lung transplant .  Robert Sapolsky - Famous neuroscientist and Professor of Neurology , most noted for his studies on stress  Lucy Shapiro - Professor of Developmental Biology . Winner of the National Medal of Science in biological sciences .  Vaughn Starnes - Performed first living double-lobar lung transplant .  Stephen Quake - Professor and co-chair of Bioengineering . Founder of Fluidigm Corp , Helicos Biosciences . Inventor of non-invasive prenatal diagnostics by sequencing . Winner of Lemelson-MIT Prize .  Lubert Stryer - National Medal of Science recipient , Winzer Professor of Neurobiology , and author of Biochemistry Textbook  Thomas Sdhof - Winner of 2013 Nobel Prize in Medicine  Edward L. Tatum - Co-winner of 1958 Nobel Prize in Physiology or Medicine .  Irving Weissman - Leading stem cell biologist and director of the Stanford Institute for Stem Cell Biology and Regenerative Medicine . Founder of Systemix and Stem Cells Inc.  Paul Yock - Inventor of the rapid exchange system for endovascular procedures .  Lucy S. Tompkins - Associate Dean for Academic Affairs . # References in popular culture #  Dr. Cristina Yang , a character on the popular medical television drama Grey 's Anatomy is a Stanford alumna and ' graduated first in her class ' , despite Stanford 's medical school not actually having grades or rankings  Nick Rubashkin- Stanford Alum and Co-Editor of ' ' What I Learned in Medical School ' ' -personal stories of young doctors  Bob Kelso , Chief of Medicine on the NBC comedy ' ' Scrubs ' ' graduated ' 12th in his class ' at Stanford .  At the end of ' ' Good Will Hunting ' ' , the character Skylar leaves Boston to enter medical school at Stanford . 
@@446404 Baylor College of Medicine ( BCM ) , located in the Texas Medical Center in Houston , Texas , US , is a health sciences university that creates and applies science and discoveries to further education , healthcare and community service locally and globally . It includes a medical school , Baylor College of Medicine , which is one of the leading research-intensive medical schools in the country ; the Baylor College of Medicine Graduate School of Biomedical Sciences ; the Baylor College of Medicine School of Allied Health Sciences ; and the Baylor College of Medicine National School of Tropical Medicine . The school , located in the middle of the world 's largest medical center , is part owner of Baylor St. Luke 's Medical Center , part of the CHI St. Luke 's Health system , and has hospital affiliations with : Harris Health System , Texas Children 's Hospital , The University of Texas MD Anderson Cancer Center , Memorial Hermann - The Institute for Rehabilitation and Research , Menninger Clinic , the Michael E. DeBakey Veterans Affairs Medical Center and Children 's Hospital of San Antonio . The medical school has been consistently considered in the top-tier of programs in the country , and is particularly noted for having the lowest tuition among all private medical schools in the US . Its Graduate School of Biomedical Sciences is among the top 30 graduate schools in the United States . Within the School of Allied Health Sciences , the nurse anesthesia ranks 5th ( U.S. News &amp; World Report ) and the physician assistant program ranks 6th . A program in Orthotics and Prosthetics began in 2013 , with 18 students in the first class . The National School of Tropical Medicine is the only school in the nation dedicated exclusively to patient care , research , education and policy related to neglected tropical diseases . On June 21 , 2010 , Dr. Paul Klotman was named as the new President and CEO of the Baylor College of Medicine . In January 2014 , the College and CHI St. Luke 's became joint owners of Baylor St. Luke 's Medical Center . # History # The school was formed in Dallas , Texas , by a small group of Baylor University alumni physicians who aimed to improve medical practice in North Texas . Originally called the University of Dallas Medical Department , the school opened its doors October 30 , 1900 , with 81 students . Dr. Albert Ferdinand Beddoe , A.B. , M.D. was a co-founder . He established the chair of Diseases of Children and became a professor . He built up the free clinic in connection with Baylor hospital . In 1903 , an alliance with Baylor University in Waco was formed and the name was changed to Baylor University College of Medicine . By 1918 , Baylor University College of Medicine was the only private medical school in Texas . The M.D. Anderson Foundation invited Baylor to join the newly formed Texas Medical Center in Houston in 1943 . The school opened in the medical center July 12 , 1943 , in a converted Sears , Roebuck &amp; Co. warehouse , with 131 students . Four years later , Baylor moved to its present site in the Roy and Lillie Cullen Building , the first building completed in the Texas Medical Center . In 1948 , Michael E. DeBakey joined the faculty as chair of the Department of Surgery , and the following year , the Graduate School of Biomedical Sciences was established . Baylor 's rise in prominence began in the 1950s when DeBakey 's surgical techniques garnered international attention . In the 1960s , the college underwent its first major expansion . In 1969 , the college separated from Baylor University and became an independent institution , which allowed it access to federal research funding , changing its name to Baylor College of Medicine . That same year , BCM negotiated with the Texas Legislature to double its class size in order to increase the number of physicians in Texas . In 2005 , Baylor College of Medicine began building a hospital and clinic , to be called the Baylor Clinic and Hospital , slated to open in 2011 . In 2009 , the college postponed construction for financial reasons , with the outer shell of the hospital completed but the interiors remaining unfinished . In March 2012 , BCM decided to convert the building to an outpatient clinic center . In 2009 , BCM entered into discussions with Rice University regarding a potential merger between the two Houston institutions . After extensive meetings , the boards at both institutions decided that each school would remain an independent . In 2010 , Baylor University entered into talks with BCM to strengthening ties to each other ; however , the merger did not occur . In January 2014 , the BCM and CHI St. Luke 's announced they would become joint owners of Baylor St. Luke 's Medical Center , a hospital at the Texas Medical Center ( formerly known as St. Luke 's Episcopal Hospital , then St. Luke 's Medical Center after it was purchased by Catholic Health Initiatives in 2013 ) . A partially completed hospital building on the BCM-McNair Campus is slated to open in 2015 and will become BCM 's acute care hospital and main medical teaching facility . # Medical school # Each year the medical school matriculates around 172 , around 75% of whom are Texas residents . Baylor College of Medicine is the least expensive private medical school in the country It is also one of the few medical schools in the United States that is structured with an accelerated 1.5 year preclinical curriculum ( the others are Columbia University College of Physicians and Surgeons in New York City , the University of Pennsylvania School of Medicine in Philadelphia , Pennsylvania , University of Virginia School of Medicine , Emory University School of Medicine in Atlanta , Georgia , and University of Texas Health Science Center at San Antonio in San Antonio , Texas ) . Baylor College of Medicine is also one of only 45 medical institutions in the United States to offer a Medical Scientist Training Program . This federally sponsored and highly competitive program allows exceptionally well qualified students to study for a combined MD and PhD in a medical science to be earned in 7&amp;ndash ; 9 total years . Typically , 8&amp;ndash ; 12 students matriculate into this program per year , and receive free tuition in addition to a stipend of $29,000 per academic year . # Graduate school # The Baylor College of Medicine Graduate School of Biomedical Sciences ranks 26th for best Ph.D . program in the biological sciences . Overall , in 2013 BCM ranked 19th in terms of research funding from the National Institutes of Health based on rankings done by the Blue Ridge Institute , . Baylor also ranked in the top 20 in eight specialty areas , including number one in the nation for Genetics . BCM 's research faculty includes seven members of the National Academy of Sciences , 14 members of the Institute of Medicine and three members of the Howard Hughes Medical Institute . About 100 students join the graduate program each year , of which one half were women and one third were graduates from foreign schools . Many departments of the graduate school collaborate with Rice University and other institutions within the Texas Medical Center . Currently , 615 graduate students are enrolled in one of the thirteen different PhD programs . These programs are :  Biochemistry &amp; Molecular Biology  Immunology  Molecular and Cellular Biology  Molecular and Human Genetics  Molecular Physiology &amp; Biophysics  Molecular Virology &amp; Microbiology  Neuroscience  Pharmacology  Integrative Molecular and Biomedical Sciences  Molecular and Cellular Biology  Developmental biology  Structural and Computational Biology &amp; Molecular Biophysics  Translational Biology &amp; Molecular Medicine  Clinical Scientist Training Program # School of Allied Health Sciences # Baylor College of Medicine School of Allied Health Sciences is focused on educating allied health professionals to be leaders in the delivery of high-quality patient care ; advancing the knowledge of allied health education , healthcare delivery , and health promotion through research ; fostering healthy lifestyles among adults and children through innovative health education programs ; and augmenting patient care services provided through Baylor College of Medicine and our affiliated hospitals . The School 's Physician Assistant Program which began in 1971 as a certificate program , was elevated to Bachelor of Science status in 1975 , and on to a Master of Science program in 1989 . Today , this program ranks 6th among the nations physician assistant programs according to U.S. News &amp; World Report . The 2012 graduates of the Graduate Program in Nurse Anesthesia Program were the first to earn their doctorate of nursing practice from the Program . Developed from a 1968 a certificate program that was offered by the Harris County Hospital District , now the Harris Health System , in 1983 , it became a Master of Science degree program under the auspices of Baylor . This program ranks 5th in the nation among training programs in nurse anesthesia according to U.S. News &amp; World Report . The Master of Orthotics and Prosthetics Program welcomed its first students in June 2013 . It is a 30 month program , where the first 12 months are dedicated to the didactic curriculum , and the following 18 months are spent on clinical rotations and research . It Is the only program in the country to integrate a series of full-time clinical rotations exposing students to six core areas of expertise designed to meet the requirements of the NCOPE-approved residency . # National School of Tropical Medicine # Baylor College of Medicine National School of Tropical Medicine is one of the first of its kind in North America devoted to education , healthcare delivery , research and policy related to the neglected diseases that disproportionately afflict the bottom billion , the world 's poorest people who live below the World Bank poverty level . The School currently offers a Diploma in Tropical Medicine program as well as several non-degree courses and seminars for undergraduates , graduate students and professionals . Plans are in development for masters and doctorate programs . The School provides clinical services at the Tropical Medicine Clinic at Harris Health System 's Smith Clinic , which opened on October 6 , 2011 . The mission of the Clinic is to prevent , diagnose , and treat common and neglected tropical diseases in the Houston metropolitan population and to improve occupational health for those working in regions where tropical diseases thrive . Baylor Travel Medicine , an affiliate of the National School of Tropical Medicine , opened in May 10 , 2012 , offers medications , immunizations , counseling , and information customized for each patients health needs . The National School of Tropical Medicine also conducts a comprehensive research and development program for producing a new generation of drugs , diagnostics and vaccines for the Neglected Tropical Diseases ( NTDs ) and Neglected Infections of Poverty ( NIoPs ) , as well as fundamental and applied research against these diseases . # Residency training # Baylor College of Medicine sponsors Graduate Medical Education in more than 80 ACGME-accredited , and 40 Texas Medical Board ( TMB ) -approved training programs . At Baylor College of Medicine residents and fellows learn from one of the most diverse patient populations anywhere in the country . This is partially due to the diversity found within the city of Houston , which has no single majority ethnic group . The hospitals of the Texas Medical Center and Houston 's status as a hub for international industry also draw patients from every corner of the globe . Adding to this diversity are the many and varied settings in which residents and fellows have the opportunity to train , including Baylor St. Luke 's Medical Center and Baylor 's many affiliated hospitals . # Biomedical research # In 2013 , Baylor College of Medicine ranked 19th in terms of research funding from the National Institutes of Health based on rankings done by the Blue Ridge Institute , . Baylor also ranked in the top 20 in eight specialty areas , including number one in the nation for Genetics . BCM 's research faculty includes seven members of the National Academy of Sciences , 14 members of the Institute of Medicine and three members of the Howard Hughes Medical Institute . The College has dedicated more than 800000sqft m2 of its space for laboratory research . Housed within this research space are a number of centers and facilities , such as :  BCM 's Human Genome Sequencing Center  The Human Neuroimaging Lab  The Dan L. Duncan Cancer Center  The Center for Cell and Gene Therapy  The Huffington Center on Aging  The Influenza Research Center  The National Center for Macromolecular Imaging  The W.M. Keck Center for Computational Biology  The Epigenomics Data Analysis and Coordination Center  Core facilities , including microscopy , DNA sequencing , microarray , and protein sequencing  One of the largest transgenic mouse facilities in the country # Hospital joint venture # BCM is a co-owner of Baylor St. Luke 's Medical Center , part of CHI St. Luke 's Health . It serves as the primary private adult teaching hospital for the College and ranks among the best hospitals in the nation for cardiology and heart surgery , diabetes and endocrinology , gastroenterology and GI surgery , and pulmonology in U.S. News &amp; World Report . # Hospital affiliation # BCM is affiliated with many of the hospitals of the Texas Medical Center and in 2013 , began an affiliation with Children 's Hospital of San Antonio . BCM 's affiliations include : Texas Children 's Hospital The University of Texas M. D. Anderson Cancer Center Michael E. DeBakey Veterans Affairs Medical Center Ben Taub General Hospital Memorial Hermann - The Institute for Rehabilitation and Research Menninger Clinic Children 's Hospital of San Antonio Cooperating Patient Care Institutions :  Community Health Centers  Cullen Bayou Place  DePelchin Children 's Center  Houston Child Guidance Center  Jewish Family Service Cancer Center  Kelsey-Seybold Clinic  Park Plaza Hospital  Quentin Mease Hospital  Seven Acres Jewish Geriatric Center  Houston Shriners Hospital ( orthopedic )  Thomas Street AIDS Clinic  Woman 's Hospital of Texas # Baylor International Pediatric AIDS Initiative # The Baylor International Pediatric AIDS Initiative ( BIPAI ) at Baylor College of Medicine and Texas Children 's Hospital was established in 1996 , and has rapidly become the world 's largest university-based program dedicated to global pediatric and family HIV/AIDS care and treatment , health professional training and clinical research . Baylor constructed and opened the world 's two largest centers for the care and treatment of HIV-infected children and families , the Romanian-American Children 's Center in Constanta , Romania in 2001 , and the Botswana-Baylor Children 's Clinical Center of Excellence in Gaborone , Botswana in 2003 , followed by Uganda , Lesotho , Swaziland , Malawi , and Tanzania , where it has entered into partnership with the Ministries of Health to scale up pediatric HIV/AIDS care and treatment , and build and open new Children 's Clinical Centers of Excellence . BIPAI also has created the Pediatric AIDS Corps , a model program to place up to 250 American pediatricians and infectious disease specialists in its African centers to vastly expand capacity for pediatric HIV/AIDS care and treatment and health professional training . Major funders of BIPAI 's activities include NIH , Centers for Disease Control and Prevention ( CDC ) , the Bristol-Myers Squibb Foundation , Abbott Laboratories , and numerous private and corporate foundations . # Notable physicians and researchers # Mohammad Athari , M.D. -- Neurologist and founder of Universal MRI and Diagnostics , Inc. Arthur L. Beaudet , M.D. -- Chairman of the Department of Molecular and Human Genetics , and a member of the National Academy of Sciences . John Barnhill -- Chief of the Consultation-Liaison Service at New York-Presbyterian Hospital/Weill Cornell Medical Center . Albert Ferdinand Beddoe , A.B . M.D. - co-founder . Robert Earl Beddoe , M.D. matriculated 1904 , Medical missionary to China 1909 - 1947. Hugo Bellen -- noted developmental biologist ; Howard Hughes Medical Institute investigator. Michael Glyn Brown ( graduate of academic program , former hand surgeon ) Malcolm Brenner Ph.D. , -- Director , Center for Cell and Gene Therapy William Bill R. Brinkley ; American cell biologist and early contributor to discovery of mitotic spindle apparatus F . Charles Brunicardi , MD -- Chair , DeBakey Department of Surgery and Editor-in-Chief of Schwartz 's Principles of Surgery Leroy Chiao , Astronaut and Commander of the International Space Station , Chairman of the National Space Biomedical Research Institute User Panel , and Co-investigator for the Advanced Diagnostic Ultrasound in Microgravity Project C . Thomas Caskey -- American internist and prominent medical geneticist and biomedical entrepreneur . Denton Cooley -- founder of the Texas Heart Institute and world-renowned cardiovascular surgeon . Carried out the first successful implantation of an artificial heart . Michael E. DeBakey -- award-winning cardiovascular surgeon David Eagleman -- neuroscientist and writer H . Tristram Engelhardt , Jr . -- American philosopher Ralph Feigin -- Former President , Baylor College of Medicine ; Chief of Pediatrics and President of Texas Children 's Hospital ; author , Textbook of Pediatric Infectious Diseases O . H. Frazier -- Heart surgeon who has performed over 1,000 transplants . Richard A. Gibbs , PhD -- pioneering geneticist. Leslie A. Geddes , PhD -- PhD , pioneering biomedical engineer and inventor. Brendan H Lee , MD , PhD -- Professor , Molecular and Human Genetics , Investigator , Howard Hughes Medical Institute . Roger Guillemin -- Nobel Prize laureate in Medicine ( 1977 ) Paul Randall Harrington -- inventor of the Harrington Rod , a device used to treat scoliosis. David C. Hilmers -- Former astronaut and current professor of medicine and pediatrics . Carolyn Huntoon ( Master of Science and Ph.D . ) , NASA researcher , first woman director of the Johnson Space Center Mark Kline , M.D -- Physician-in-Chief of Texas Children 's Hospital ; Chairman of the Department of Pediatrics ; President of the Baylor International Pediatric AIDS Initiative ( BIPAI ) William J. Klish -- influential pediatrician James Lovelock -- Former professor , chemist , proponent of Gaia hypothesis . John S. Meyer -- Chairman of Neurology Huntly D. Millar -- founder and owner of Millar Instruments , Inc. , worldwide distributor of catheter-tip pressure sensors . Bert W. O'Malley -- National Medal of Science winner , member National Academy of Sciences for advances in hormone action and gene expression David Poplack , MD -- Director , Texas Children 's Cancer Center , Professor of Pediatrics . Lorraine Potocki , M.D. -- Medical Geneticist and researcher , co-discoverer of the genetic disorder Potocki-Lupski syndrome ( PTLS ) . Michael J. Reardon -- Internationally known heart surgeon who developed first successful cardiac auto transplantation for cardiac sarcoma. Andrew W. Schally -- Nobel Prize laureate in Medicine ( 1977 ) Lars Georg Svensson -- Director of the Aorta Center and Director of the Marfan Syndrom and Connective Tissue Disorder Clinic and Cleveland Clinic Peter G. Traber -- President Emeritus of Baylor College of Medicine .  Michael D. West , founder of Geron , now CEO of BioTime ( ) Huda Zoghbi -- Member of National Academy of Sciences ; Investigator of Howard Hughes Medical Institute ; Award-winning neuropsychiatrist ; Director of Jan and Duncan Neurological Research Institute , Houston , Texas . # In culture # The male Asian elephant calf born to Shanti at the Houston Zoo on May 4 , 2010 was named Baylor in honor of the college and their research on elephant herpesvirus. # Affiliated schools #  Baylor College of Medicine Academy at Ryan 
@@455909 The National Institute of Mental Health ( NIMH ) is one of 27 institutes and centers that make up the National Institutes of Health ( NIH ) . The NIH , in turn , is an agency of the United States Department of Health and Human Services and is the primary agency of the United States government responsible for biomedical and health-related research . NIMH is the largest research organization in the world specializing in mental illness . Thomas R. Insel is the current Director of NIMH . The institute was first authorized by the U.S. Government in 1946 , when then President Harry Truman signed into law the National Mental Health Act , although the institute was not formally established until 1949 . NIMH is a $1.5 billion enterprise , supporting research on mental health through grants to investigators at institutions and organizations throughout the United States and through its own internal ( intramural ) research effort . The mission of NIMH is to transform the understanding and treatment of mental illnesses through basic and clinical research , paving the way for prevention , recovery , and cure . In order to fulfill this mission , NIMH ... must foster innovative thinking and ensure that a full array of novel scientific perspectives are used to further discovery in the evolving science of brain , behavior , and experience . In this way , breakthroughs in science can become breakthroughs for all people with mental illnesses . # Research priorities # NIMH has identified four overarching strategic objectives for itself : Promote discovery in the brain and behavioral sciences to fuel research on the causes of mental disorders Chart mental illness trajectories to determine when , where and how to intervene Develop new and better interventions that incorporate the diverse needs and circumstances of people with mental illnesses Strengthen the public health impact of NIMH-supported research # History # Mental health has traditionally been a state responsibility , but after World War II there was increased lobbying for a federal ( national ) initiative . Attempts to create a National Neuropsychiatric Institute failed . Robert H. Felix , then head of the Division of Mental Hygiene , orchestrated a movement to include mental health policy as an integral part of federal biomedical policy . Congressional subcommittees hearings were held and the National Mental Health Act was signed into law in 1946 . This aimed to support the research , prevention and treatment of psychiatric illness , and called for the establishment of a National Advisory Mental Health Council ( NAMHC ) and a National Institute of Mental Health . On April 15 , 1949 , the NIMH was formally established , with Felix as director . Funding for the NIMH grew slowly and then , from the mid-1950s , dramatically . The institute took on a highly influential role in shaping policy , research and communicating with the public , legitimizing the importance of new advances in biomedical science , psychiatric and psychological services , and community-based mental health policies . In 1955 the Mental Health Study Act called for an objective , thorough , nationwide analysis and reevaluation of the human and economic problems of mental health . The resulting Joint Commission on Mental Illness and Health prepared a report , Action for Mental Health , resulting in the establishment of a cabinet-level interagency committee to examine the recommendations and determine an appropriate federal response . In 1963 , Congress passed the Mental Retardation Facilities and Community Mental Health Centers Construction Act , beginning a new era in Federal support for mental health services . NIMH assumed responsibility for monitoring the Nation 's community mental health centers ( CMHC ) programs . During the mid-1960s , NIMH launched a campaign on special mental health problems . Part of this was a response to President Lyndon Johnson 's pledge to apply scientific research to social problems . The Institute established centers for research on schizophrenia , child and family mental health , suicide , as well as crime and delinquency , minority group mental health problems , urban problems , and later , rape , aging , and technical assistance to victims of natural disasters . Alcohol abuse and alcoholism did not receive full recognition as a major public health problem until the mid-1960s , when the National Center for Prevention and Control of Alcoholism was established as part of NIMH ; a research program on drug abuse was inaugurated within NIMH with the establishment of the Center for Studies of Narcotic and Drug Abuse . In 1967 , NIMH separated from NIH and was given Bureau status within PHS . However , NIMH 's intramural research program , which conducted studies in the NIH Clinical Center and other NIH facilities , remained at NIH under an agreement for joint administration between NIH and NIMH . Secretary of Health , Education , and Welfare John W. Gardner transferred St. Elizabeths Hospital , the Federal Government 's only civilian psychiatric hospital , to NIMH . In 1968 , NIMH became a component of PHS 's Health Services and Mental Health Administration ( HSMHA ) . In 1970 the Comprehensive Alcohol Abuse and Alcoholism Prevention , Treatment , and Rehabilitation Act ( P.L. 91-616 ) established the National Institute of Alcohol Abuse and Alcoholism within NIMH . In 1972 , the Drug Abuse Office and Treatment Act established a National Institute on Drug Abuse within NIMH . In 1973 , NIMH went through a series of organizational moves . The Institute temporarily rejoined NIH on July 1 with the abolishment of HSMHA . Then , the DHEW secretary administratively established the Alcohol , Drug Abuse , and Mental Health Administration ( ADAMHA ) composed of the National Institute on Alcohol Abuse and Alcoholism , the National Institute on Drug Abuse , and NIMH as the successor organization to HSMHA . ADAMHA was officially established in 1974 . The President 's Commission on Mental Health in 1977 reviewed the mental health needs of the nation and to make recommendations to the President as to how best meet these needs in 1978 . In 1980 The Epidemiologic Catchment Area ( ECA ) study , an unprecedented research effort that entailed interviews with a nationally representative sample of 20,000 Americans was launched . The field interviews and first wave analyses were completed in 1985 . Data from the ECA provided a picture of rates of mental and addictive disorders and services usage . The Mental Health Systems Act based on recommendations of the President 's Commission on Mental Health and designed to provide improved services for persons with mental disorders was passed . NIMH participated in development of the National Plan for the Chronically Mentally Ill , a sweeping effort to improve services and fine-tune various Federal entitlement programs for those with severe , persistent mental disorders . In 1987 , Administrative control of St. Elizabeth 's Hospital was transferred from the NIMH to the District of Columbia . NIMH retained research facilities on the grounds of the hospital . The NIMH Neuroscience Center and the NIMH Neuropsychiatric Research Hospital , located on the grounds of St. Elizabeth 's Hospital , were dedicated in 1989 . In 1992 , Congress passed the ADAMHA Reorganization Act , abolishing ADAMHA . The research components of NIAAA , NIDA and NIMH rejoined NIH , while the services components of each institute became part of a new PHS agency , the ( SAMHSA ) . The return to NIH and the loss of services functions to SAMHSA necessitated a realignment of the NIMH extramural program administrative organization . New offices were created for research on Prevention , Special Populations , Rural Mental Health and AIDS . In 1994 The House Appropriations Committee mandated that the director of NIH conduct a review of the role , size , and cost of all NIH intramural research programs ( IRP ) . NIMH and the National Advisory Mental Health Council ( NAMHC ) initiated a major study of the NIMH Intramural Research Program . The planning committee recommended continued investment in the IRP and recommended specific administrative changes ; many of these were implemented upon release of the committee 's final report ; other changes for example , the establishment of a major new program on Mood and Anxiety Disorders have been introduced in the years since . In 1996 NIMH , with the NAMHC , initiated systematic reviews of a number of areas of its research portfolio , including the genetics of mental disorders ; epidemiology and services for child and adolescent populations ; prevention research ; clinical treatment and services research . At the request of the National Institute for Mental Health director , the NAMH Council established programmatic groups in each of these areas . NIMH ( National Institute of Mental Health ) continued to implement recommendations issued by these Workgroups . In 1997 , NIMH realigned its extramural organizational structure to capitalize on new technologies and approaches to both basic and clinical science , as well as changes that had occurred in health care delivery systems , while retaining the Institute 's focus on mental illness . The new extramural organization resulted in three research divisions : Basic and Clinical Neuroscience Research ; Services and Intervention Research ; and Mental Disorders , Behavioral Research and AIDS . Between 1997 and 1999 NIMH refocused career development resources on early careers and added new mechanisms for clinical research . In 1999 The NIMH Neuroscience Center/Neuropsychiatric Research Hospital was relocated from St. Elizabeth 's Hospital in Washington , D.C. to the NIH Campus in Bethesda , Maryland , in response to the recommendations of the 1996 review of the NIMH ( National Institute of Mental Health ) Intramural Research Program by the IRP Planning Committee . The first White House Conference on Mental Health , held June 7 , in Washington , D.C. , brought together national leaders , mental health scientific and clinical personnel , patients , and consumers to discuss needs and opportunities . The National Institute on Mental Health developed materials and helped organize the conference . U.S. Surgeon General David Satcher released The Surgeon General 's Call To Action To Prevent Suicide , in July , and the first Surgeon General 's Report on Mental Health , in December . NIMH , along with other Federal agencies , collaborated in the preparation of both of these landmark reports . Since the appointment of Thomas R. Insel as Director of NIMH in 2002 , the institute has undergone organizational changes to better target mental health research needs ( the expansion from three extramural divisions to five divisions , with the two new divisions focusing on adult and child translational research ) . NIMH also weathered several years of controversy due to conflict of interest and ethics violations by some of its intramural investigators . This situation cast light on an area that affected all of NIH , and resulted in more stringent rules about conflict of interest for all of NIH . Recently , Congressional interest turned to ethics and conflict of interest concerns with external investigators who receive NIMH or other NIH support . Current federal law has responsibility for managing and monitoring conflict of interests for external investigators with their home *26;972;TOOLONG . NIH responded to these new concerns by initiating a formal process for seeking public input and advice that will likely result in a change to the rules for monitoring and managing conflict of interest concerns for externally supported investigators . Finally , the past decade has also been marked by exciting scientific breakthroughs and efforts in mental illness research , as new genetic advances and bioimaging methodologies have increased understanding of mental illnesses . Two notable consequences of these advances are the Institute 's collaboration with the Department of Army to launch the Study To Assess Risk and Resilience in Service Members ( STARRS ) , a Framingham-like effort scheduled to last until 2014 and the Research Domain Criteria ( RDoC ) effort , which seeks to define basic dimensions of functioning ( such as fear circuitry or working memory ) to be studied across multiple levels of analysis , from genes to neural circuits to behaviors , cutting across disorders as traditionally defined . A collection of interviews with directors and individuals significant in the foundation and early history of the institute conducted by Dr. Eli A. Rubenstein between 1975 and 1978 is held at the National Library of Medicine in Bethesda , Maryland . # Noted researchers # In 1970 , Julius Axelrod , a NIMH researcher , won the Nobel Prize in Physiology or Medicine for research into the chemistry of nerve transmission for discoveries concerning the humoral transmitters in the nerve terminals and the mechanisms for their storage , release and inactivation . He found an enzyme that terminated the action of the nerve transmitter , noradrenaline in the synapse and which also served as a critical target of many antidepressant drugs . In 1984 , Norman E. Rosenthal , a psychiatrist and NIMH researcher , pioneered seasonal affective disorder , coined the term SAD , and began studying the use of light therapy as a treatment . He received the Anna Monika Foundation Award for his research on seasonal depression . Louis Sokoloff , a NIMH researcher , received the Albert asker award in Clinical Medical Research for developing a new method of measuring brain function that contributed to basic understanding and diagnosis of brain diseases . Roger Sperry , a NIMH research grantee , received the Nobel Prize in Medicine or Physiology for discoveries regarding the functional specialization of the cerebral hemispheres , or the left and right brain . Eric Kandel and Paul Greengard , each of whom have received NIMH support for more than three decades , shared the Nobel Prize in Physiology or Medicine with Sweden 's Arvid Carlsson . Kandel received the prize for his elucidating research on the functional modification of synapses in the brain . Initially using the sea slug as an experimental model but later working with mice , he established that the formation of memories is a consequence of short and long-term changes in the biochemistry of nerve cells Greengard was recognized for his discovery that dopamine and a number of other transmitters can alter the functional state of neuronal proteins , and also that such changes could be reversed by subsequent environmental signals . Nancy Andreasen , a psychiatrist and long-time NIMH grantee , won the National Medal of Science for her groundbreaking work in schizophrenia and for joining behavioral science with neuroscience and neuroimaging . The Presidential Award is one of the nation 's highest awards in science . Aaron Beck , a psychiatrist , received the 2006 Albert Lasker Award for Clinical Medical Research . Often called Americas Nobels , the Laskers are the nations most distinguished honor for outstanding contributions to basic and clinical medical research . Beck developed cognitive therapya form of psychotherapywhich transformed the understanding and treatment of many psychiatric conditions , including depression , suicidal behavior , generalized anxiety , panic attacks and eating disorders . In 2010 , Mortimer Mishkin was awarded the National Medal of Science . Mishkin is chief of the NIMH 's Section on Cognitive Neuroscience , and acting chief of its Laboratory of Neuropsychology . He is the first NIMH intramural scientist to receive the medal . Due in part to work spearheaded by Mishkin , science now understands much about the pathways for vision , hearing and touch , and about how those processing streams connect with brain structures important for memory . # NIMH directors # # In popular culture # A children 's novel ' ' Mrs. Frisby and the Rats of NIMH ' ' by Robert C. O'Brien , published in 1971 , features a society of intelligent rats that had presumably escaped from a laboratory at NIMH . The novel was later adapted into a critically acclaimed animated feature film entitled ' ' The Secret of NIMH ' ' by animator and director Don Bluth. 
@@457857 Traditional medicine ( also known as indigenous or folk medicine ) comprises knowledge systems that developed over generations within various societies before the era of modern medicine . The World Health Organization ( WHO ) defines traditional medicine as : # Traditional medicine is the sum total of the knowledge , skills , and practices based on the theories , beliefs , and experiences indigenous to different cultures , whether explicable or not , used in the maintenance of health as well as in the prevention , diagnosis , improvement or treatment of physical and mental illness . # In some Asian and African countries , up to 80% of the population relies on traditional medicine for their primary health care needs . When adopted outside of its traditional culture , traditional medicine is often called complementary and alternative medicine . The WHO also notes , though , that inappropriate use of traditional medicines or practices can have negative or dangerous effects and that further research is needed to ascertain the efficacy and safety of several of the practices and medicinal plants used by traditional medicine systems . Core disciplines which study traditional medicine include herbalism , ethnomedicine , ethnobotany , and medical anthropology . Traditional medicine may include formalized aspects of folk medicine , i.e. longstanding remedies passed on and practiced by lay people . Practices known as traditional medicines include Ayurveda , Siddha medicine , Unani , Ancient Iranian Medicine # Classical history # In the written record , the study of herbs dates back 5,000 years to the ancient Sumerians , who described well-established medicinal uses for plants . Ancient Egyptian medicine of 1000 BC are known to have used various herbs for medicine . The Old Testament also mentions herb use and cultivation in regards to Kashrut . Many herbs and minerals used in Ayurveda were described by ancient Indian herbalists such as Charaka and Sushruta during the 1st millennium BC . The first Chinese herbal book was the ' ' Shennong Bencao Jing ' ' , compiled during the Han Dynasty but dating back to a much earlier date , which was later augmented as the ' ' Yaoxing Lun ' ' ( ' ' Treatise on the Nature of Medicinal Herbs ' ' ) during the Tang Dynasty . Early recognised Greek compilers of existing and current herbal knowledge include Pythagoreanism , Hippocrates , Aristotle , Theophrastus , Dioscorides and Galen . Roman writers included Pliny the Elder and Celsus . Pedanius Dioscorides included the writings of the herbalist Krateuas , physician to Mithridates VI King of Pontus from 120 to 63 BC in his ' ' De Materia Medica ' ' . ' ' De Materia Medica ' ' was translated into several languages , and Turkish , Arabic and Hebrew names were added to it over the centuries . Latin manuscripts of De Materia Medica were combined with a Latin herbal by Apuleius Platonicus ( ' ' Herbarium Apuleii Platonici ' ' ) and were incorporated into the Anglo-Saxon codex ' ' Cotton Vitellius C.III ' ' . These early Greek and Roman compilations became the backbone of European medical theory and were translated by the Persian Avicenna ( Ibn Sn , 980&amp;ndash ; 1037 ) , the Persian Rhazes ( Rzi , 865&amp;ndash ; 925 ) and the Jewish Maimonides . Translations of Greek medical handbooks and manuscripts into Arabic took place in the eighth and ninth centuries . Arabic indigenous medicine developed from the conflict between the magic-based medicine of the Bedouins and the Arabic translations of the Hellenic and Ayurvedic medical traditions . Spanish indigenous medicine was influenced by the Arabs from 711 to 1492 . Islamic physicians and Muslim botanists such as al-Dinawari and Ibn al-Baitar significantly expanded on the earlier knowledge of materia medica . The most famous Arabic medical treatise was Avicenna 's ' ' The Canon of Medicine ' ' , which was an early pharmacopoeia and introduced the method of clinical trials . The ' ' Canon ' ' was translated into Latin in the 12th century and remained a medical authority in Europe until the 17th century . The Unani system of traditional medicine is also based on the ' ' Canon ' ' . Translations of the early Roman-Greek compilations were made into German by Hieronymus Bock whose herbal published in 1546 was called ' ' Kreuter Buch ' ' . The book was translated into Dutch as ' ' Pemptades ' ' by Rembert Dodoens ( 1517&amp;ndash ; 1585 ) , and from Dutch into English by Carolus Clusius , ( 1526&amp;ndash ; 1609 ) , published by Henry Lyte in 1578 as ' ' A Nievve Herball ' ' . This became John Gerard 's ( 1545&amp;ndash ; 1612 ) ' ' Herball or General Hiftorie of Plantes ' ' . Each new work was a compilation of existing texts with new additions . Women 's folk knowledge existed in undocumented parallel with these texts . Forty-four drugs , diluents , flavouring agents and emollients mentioned by Discorides are still listed in the official pharmacopoeias of Europe . The Puritans took Gerard 's work to the United States where it influenced American Indigenous medicine . Francisco Hernndez , physician to Philip II of Spain spent the years 15711577 gathering information in Mexico and then wrote ' ' Rerum Medicarum Novae Hispaniae Thesaurus ' ' , many versions of which have been published including one by Francisco Ximnez . Both Hernandez and Ximenez fitted Aztec ethnomedicinal information into the European concepts of disease such as warm , cold , and moist , but it is not clear that the Aztecs used these categories . Juan de Esteyneffer 's ' ' Florilegio medicinal de todas las enfermedas ' ' compiled European texts and added 35 Mexican plants . Martn de la Cruz wrote an herbal in Nahuatl which was translated into Latin by Juan Badiano as ' ' Libellus de Medicinalibus Indorum Herbis ' ' or ' ' Codex Barberini , Latin 241 ' ' and given to King Carlos V of Spain in 1552 . It was apparently written in haste and influenced by the European occupation of the previous 30 years . Fray Bernadino de Sahagn 's used ethnographic methods to compile his codices that then became the ' ' Historia General de las Cosas de Nueva Espana ' ' , published in 1793 . Castore Durante published his ' ' Herbario Nuovo ' ' in 1585 describing medicinal plants from Europe and the East and West Indies . It was translated into German in 1609 and Italian editions were published for the next century . # Knowledge transmission and creation # Indigenous medicine is generally transmitted Oral tradition Elements in a specific culture are not necessarily integrated into a coherent system , and may be contradictory . In the Caribbean , indigenous remedies fall into several classes : certain well-known European medicinal herbs introduced by the early Spaniard colonists that are still commonly cultivated ; indigenous wild and cultivated plants , the uses of which have been adopted from the Amerindians ; and ornamental or other plants of relatively recent introduction for which curative uses have been invented without any historical basis . # See also #  ' ' African Journal of Traditional , Complementary and Alternative Medicines ' '  Ethnomedicine  Ethnoscience  Folk medicine  Health care providers  Traditional birth attendants  Traditional ecological knowledge 
@@463734 Public health is the science and art of preventing disease , prolonging life and promoting health through the organized efforts and informed choices of society , organizations , public and private , communities and individuals . It is concerned with threats to health based on population health analysis . The population in question can be as small as a handful of people , or as large as all the inhabitants of several continents ( for instance , in the case of a pandemic ) . The dimensions of health can encompass a state of complete physical , mental and social well-being and not merely the absence of disease or infirmity , as defined by the United Nations ' World Health Organization . Public health incorporates the interdisciplinary approaches of epidemiology , biostatistics and health services . environmental health , community health , behavioral health , health economics , public policy , insurance medicine and occupational safety and health are other important subfields . The focus of public health intervention is to improve health and quality of life through the prevention and treatment of disease and other physical and mental health conditions , through surveillance of cases and health indicators , and through the promotion of healthy behaviors . Promotion of hand washing and breastfeeding , delivery of vaccinations , and distribution of condoms to control the spread of sexually transmitted diseases are examples of common public health measures . Modern public health practice requires multidisciplinary teams of public health workers and professionals including physicians specializing in public health/community medicine/infectious disease , psychologists epidemiologists , biostatisticians , medical assistants or Assistant Medical Officers , public health nurses , medical microbiologists , environmental health officers / public health inspectors , pharmacists , dental hygienists , dietitians and nutritionists , veterinarians , public health engineers , public health lawyers , sociologists , community development workers , communications experts , bioethicists , and others . # Objectives # The focus of a public health intervention is to prevent and manage diseases , injuries and other health conditions through surveillance of cases and the promotion of healthy behaviors , communities and environments . Many diseases are preventable through simple , non-medical methods . For example , research has shown that the simple act of hand washing with soap can prevent many contagious diseases . In other cases , treating a disease or controlling a pathogen can be vital to preventing its spread to others , such as during an outbreak of infectious disease , or contamination of food or water supplies . Public health communications programs , vaccination programs , and distribution of condoms are examples of common public health measures . Measures such as these have contributed greatly to the health of populations and increases in life expectancy . Public health plays an important role in disease prevention efforts in both the developing world and in developed countries , through local health systems and non-governmental organizations . The World Health Organization ( WHO ) is the international agency that coordinates and acts on global public health issues . Most countries have their own government public health agencies , sometimes known as ministries of health , to respond to domestic health issues . For example in the United States , the front line of public health initiatives are state and local health departments . The United States Public Health Service ( PHS ) , led by the Surgeon General of the United States , and the Centers for Disease Control and Prevention , headquartered in Atlanta , are involved with several international health activities , in addition to their national duties . In Canada , the Public Health Agency of Canada is the national agency responsible for public health , emergency preparedness and response , and infectious and chronic disease control and prevention . The Public health system in India is managed by the Ministry of Health &amp; Family Welfare of the government of India with state owned health care facilities . There is a great disparity in access to health care and public health initiatives between developed nations and developing nations . In the developing world , public health infrastructures are still forming . There may not be enough trained health workers or monetary resources to provide even a basic level of medical care and disease prevention . As a result , a large majority of disease and mortality in the developing world results from and contributes to extreme poverty . For example , many African governments spend less than US$10 per person per year on health care , while , in the United States , the federal government spent approximately US$4,500 per capital in 2000 . However , expenditures on health care should not be confused with spending on public health . Public health measures may not generally be considered health care in the strictest sense . For example , mandating the use of seat belts in cars can save countless lives and contribute to the health of a population , but typically money spent enforcing this rule would not count as money spent on health care . # History # # Early history # Public health has early roots in antiquity . From the beginnings of human civilization , it was recognized that polluted water and lack of proper waste disposal spread communicable diseases ( theory of miasma ) . Early religions attempted to regulate behavior that specifically related to health , from types of food eaten , to regulating certain indulgent behaviors , such as drinking alcohol or sexual relations . Leaders were responsible for the health of their subjects to ensure social stability , prosperity , and maintain order . By Roman times , it was well understood that proper diversion of human waste was a necessary tenet of public health in urban areas . The ancient Chinese medical doctors developed the practice of variolation following a smallpox epidemic around 1000 BC . An individual without the disease could gain some measure of immunity against it by inhaling the dried crusts that formed around lesions of infected individuals . Also , children were protected by inoculating a scratch on their forearms with the pus from a lesion . During the 14th century Black Death in Europe , it was believed that removing bodies of the dead would further prevent the spread of the bacterial infection . This did little to stem the plague , however , which was most likely spread by rodent-borne fleas . Burning parts of cities resulted in much greater benefit , since it destroyed the rodent infestations . The development of quarantine in the medieval period helped mitigate the effects of other infectious diseases . However , according to Michel Foucault , the plague model of governmentality was later controverted by the cholera model . A Cholera pandemic devastated Europe between 1829 and 1851 , and was first fought by the use of what Foucault called social medicine , which focused on flux , circulation of air , location of cemeteries , etc . All those concerns , born of the miasma theory of disease , were mixed with urbanistic concerns for the management of populations , which Foucault designated as the concept of biopower . The German conceptualized this in the ' ' Polizeiwissenschaft ' ' ( Police science ) . # Modern public health # The 18th century witnessed rapid growth in voluntary hospitals in England . The latter part of the century saw the establishment of the basic pattern of improvements in public health over the next two centuries ; a social evil was identified , private philanthropists brought attention to it and changing public opinion led to government action . The practice of vaccination became prevalent in the 1800s , following the pioneering work of Edward Jenner in treating smallpox with vaccination . James Lind 's discovery of the causes of scurvy amongst sailors and its mitigation via the introduction of fruit on lengthy voyages was published in 1754 and led to the adoption of this idea by the Royal Navy . Efforts were also made to promulgate health matters to the broader public ; in 1752 the British physician Sir John Pringle published ' ' Observations on the Diseases of the Army in Camp and Garrison ' ' , in which he advocated for the importance of adequate ventilation in the military barracks and the provision of latrines for the soldiers . With the onset of the Industrial Revolution , living standards amongst the working population began to worsen , with cramped and unsanitary urban conditions . In the first four decades of the 19th century alone , London 's population doubled and even greater growth rates were recorded in the new industrial towns , such as Leeds and Manchester . This rapid urbanisation exacerbated the spread of disease in the large conurbations that built up around the workhouses and factories . These settlements were cramped and primitive with no organised sanitation . Disease was inevitable and its incubation in these areas was encouraged by the poor lifestyle of the inhabitants . Unavailable housing led to the rapid growth of slums and the per capita death rate began to rise alarmingly , almost doubling in Birmingham and Liverpool . Thomas Malthus warned of the dangers of overpopulation in 1798 . His ideas , as well as those of Jeremy Bentham , became very influential in government circles in the early years of the 19th century . # #Public health legislation# # The first attempts at sanitary reform and the establishment of public health institutions were made in the 1840s . Thomas Southwood Smith , physician at the London Fever Hospital , began to write papers on the importance of public health , and was one of the first physicians brought in to give evidence before the Poor Law Commission in the 1830s , along with Neil Arnott and James Phillips Kay . Smith advised the government on the importance of quarantine and sanitary improvement for limiting the spread of infectious diseases such as cholera and yellow fever . The Poor Law Commission reported in 1838 that the expenditures necessary to the adoption and maintenance of measures of prevention would ultimately amount to less than the cost of the disease now constantly engendered . It recommended the implementation of large scale government engineering projects to alleviate the conditions that allowed for the propagation of disease . The Health of Towns Association was formed in Exeter on 11 December 1844 , and vigorously campaigned for the development of public health in the United Kingdom . Its formation followed the 1843 establishment of the Health of Towns Commission , chaired by Sir Edwin Chadwick , which produced a series of reports on poor and insanitary conditions in British cities . These national and local movements led to the Public Health Act , finally passed in 1848 . It aimed to improve the sanitary condition of towns and populous places in England and Wales by placing the supply of water , sewerage , drainage , cleansing and paving under a single local body with the General Board of Health as a central authority . The Act was passed by the Liberal government of Lord John Russell , in response to the urging of Edwin Chadwick . Chadwick 's seminal report on ' ' The Sanitary Condition of the Labouring Population ' ' was published in 1842 and was followed up with a supplementary report a year later . Vaccination for various diseases was made compulsory in the United Kingdom in 1851 , and by 1871 legislation required a comprehensive system of registration run by appointed vaccination officers . Further interventions were made by a series of subsequent Public Health Acts , notably the 1875 Act . Reforms included latrinization , the building of sewers , the regular collection of garbage followed by incineration or disposal in a landfill , the provision of clean water and the draining of standing water to prevent the breeding of mosquitoes . So began the inception of the modern public health . In the U.S. , the first public health organization based on a state health department and local boards of health was founded in New York City in 1866. # #Epidemiology# # The science of epidemiology was founded by John Snow 's identification of a polluted public water well as the source of an 1854 cholera outbreak in London . Dr. Snow believed in the germ theory of disease as opposed to the prevailing miasma theory . He first publicized his theory in an essay , ' ' On the Mode of Communication of Cholera ' ' , in 1849 , followed by a more detailed treatise in 1855 incorporating the results of his investigation of the role of the water supply in the Soho epidemic of 1854 . By talking to local residents ( with the help of Reverend Henry Whitehead ) , he identified the source of the outbreak as the public water pump on Broad Street ( now Broadwick Street ) . Although Snow 's chemical and microscope examination of a water sample from the Broad Street pump did not conclusively prove its danger , his studies of the pattern of the disease were convincing enough to persuade the local council to disable the well pump by removing its handle . Snow later used a dot map to illustrate the cluster of cholera cases around the pump . He also used statistics to illustrate the connection between the quality of the water source and cholera cases . He showed that the Southwark and Vauxhall Waterworks Company was taking water from sewage-polluted sections of the Thames and delivering the water to homes , leading to an increased incidence of cholera . Snow 's study was a major event in the history of public health and geography . It is regarded as the founding event of the science of epidemiology. # #Disease control# # With the pioneering work in bacteriology of French chemist Louis Pasteur and German scientist Robert Koch , methods for isolating the bacteria responsible for a given disease and vaccines for remedy were developed at the turn of the 20th century . British physician Ronald Ross identified the mosquito as the carrier of malaria and laid the foundations for combating the disease . Joseph Lister revolutionized surgery by the introduction of antiseptic surgery to eliminate infection . French epidemiologist Paul-Louis Simond proved that plague was carried by fleas on the back of rats , and the Americans Walter Reed and James Carroll demonstrated that mosquitoes carry the virus responsible for yellow fever . With the onset of the epidemiological transition and as the prevalence of infectious diseases decreased through the 20th century , public health began to put more focus on chronic diseases such as cancer and heart disease . Previous efforts in many developed countries had already led to dramatic reductions in the infant mortality rate using preventative methods . In Britain , the infant mortality rate fell from over 15% in 1870 to 7% by 1930 . In the United States , public health worker Dr. Sara Josephine Baker established many programs to help the poor in New York City keep their infants healthy , leading teams of nurses into the crowded neighborhoods of Hell 's Kitchen and teaching mothers how to dress , feed , and bathe their babies . Dramatic increases in average life span in the late 19th century and 20th century , is widely credited to public health achievements , such as vaccination programs and control of many infectious diseases including polio , diphtheria , yellow fever and smallpox ; effective health and safety policies such as road traffic safety and occupational safety ; improved family planning ; tobacco control measures ; and programs designed to decrease non-communicable diseases by acting on known risk factors such as a person 's background , lifestyle and environment . Another major public health improvement was the decline in the urban penalty brought about by improvements in sanitation . These improvements included chlorination of drinking water , filtration and sewage treatment which led to the decline in deaths caused by infectious waterborne diseases such as cholera and intestinal diseases . # Recent # Large parts of the developing world remained plagued by largely preventable/treatable infectious diseases and poor maternal and child health outcomes , exacerbated by malnutrition and poverty . The WHO reports that a lack of exclusive breastfeeding during the first six months of life contributes to over a million avoidable child deaths each year . Intermittent preventive therapy aimed at treating and preventing malaria episodes among pregnant women and young children is one public health measure in endemic countries . Front-page headlines continue to present society with public health issues on a daily basis : emerging infectious diseases such as SARS , rapidly making its way from China ( see Public health in China ) to Canada , the United States and other geographically distant countries ; reducing inequities in health care access through publicly funded health insurance programs ; the HIV/AIDS pandemic and its spread from certain high-risk groups to the general population in many countries , such as in South Africa ; the increase of childhood obesity and the concomitant increase in type II diabetes among children ; the social , economic and health impacts of adolescent pregnancy ; and the ongoing public health challenges related to natural disasters such as the 2004 Indian Ocean tsunami , 2005 's Hurricane Katrina in the United States and the 2010 Haiti earthquake . Since the 1980s , the growing field of population health has broadened the focus of public health from individual behaviors and risk factors to population-level issues such as inequality , poverty , and education . Modern public health is often concerned with addressing determinants of health across a population . There is a recognition that our health is affected by many factors including where we live , genetics , our income , our educational status and our social relationships - these are known as social determinants of health . A social gradient in health runs through society , with those that are poorest generally suffering the worst health . However even those in the ' ' middle classes ' ' will generally have worse health outcomes than those of a higher social stratum . The ' ' new ' ' public health seeks to address these health inequalities by advocating for population-based policies that improve health in an equitable manner . # #Public Health 2.0# # ' ' Public Health 2.0 ' ' is the term given to a movement within public health that aims to make the field more accessible to the general public and more user-driven . There are three senses in which the term Public Health 2.0 is used . In the first sense , Public Health 2.0 is similar to the term Health 2.0 and is used to describe the ways in which traditional public health practitioners and institutions are reaching out ( or could reach out ) to the public through social media and health blogs . In the second sense , Public Health 2.0 is used to describe public health research that uses data gathered from social networking sites , search engine queries , cell phones , or other technologies . In the third sense , Public Health 2.0 is used to describe public health activities that are completely user-driven . An example this type of Public Health 2.0 is the collection and sharing of information about environmental radiation levels following the March 2011 tsunami in Japan . In all cases , Public Health 2.0 draws on ideas from Web 2.0 , such as crowdsourcing , information sharing , and user-centred design . # Education and training # Education and training of public health professionals is available throughout the world in Medical Schools , Veterinary Schools , Schools of Nursing , Schools of Public Health , and Schools of Public Affairs . The training typically requires a university degree with a focus on core disciplines of biostatistics , epidemiology , health services administration , health policy , health education , behavioral science and environmental health . The National Commission for Health Education Credentialing ( NCHEC ) offers a national certification , Certified Health Education Specialist , C.H.E.S. , for those who meet the eligibility requirements . # Schools of public health # In the United States , the Welch-Rose Report of 1915 has been viewed as the basis for the critical movement in the history of the institutional schism between public health and medicine because it led to the establishment of schools of public health supported by the Rockefeller Foundation . The report was authored by William Welch , founding dean of the Johns Hopkins Bloomberg School of Public Health , and Wycliffe Rose of the Rockefeller Foundation . The report focused more on research than practical education . Some have blamed the Rockefeller Foundation 's 1916 decision to support the establishment of schools of public health for creating the schism between public health and medicine and legitimizing the rift between medicine 's laboratory investigation of the mechanisms of disease and public health 's nonclinical concern with environmental and social influences on health and wellness . Even though schools of public health had already been established in Canada , Europe and North Africa , the United States had still maintained the traditional system of housing faculties of public health within their medical institutions . A $25,000 donation from businessman Samuel Zemurray instituted the School of Public Health and Tropical Medicine at Tulane University in 1912 conferring its first doctor of public health degree in 1914 . The Johns Hopkins School of Hygiene and Public Health became the an independent , degree-granting institution for research and training in public health , and the largest public health training facility in the United States , when it was founded in 1916 . By 1922 , schools of public health were established at Columbia , Harvard and Yale on the Hopkins model . By 1999 there were twenty nine schools of public health in the US , enrolling around fifteen thousand students . Over the years , the types of students and training provided have also changed . In the beginning , students who enrolled in public health schools typically had already obtained a medical degree ; public health school training was largely a second degree for medical professionals . However , in 1978 , 69% of American students enrolled in public health schools had only a bachelor 's degree . # Degrees in public health # Schools of public health offer a variety of degrees which generally fall into two categories : professional or academic . The two major postgraduate degrees are the Master of Public Health ( M.P.H. ) or the Master of Science in Public Health ( MSPH ) . Doctoral studies in this field include Doctor of Public Health ( DrPH ) and Doctor of Philosophy ( Ph.D. ) in a subspeciality of greater Public Health disciplines . DrPH is regarded as a professional leadership degree and Ph.D . as more of an academic degree . Professional degrees are oriented towards practice in public health settings . The Master of Public Health , Doctor of Public Health , Doctor of Health Science ( DHSc ) and the Master of Health Administration Academic degrees are more oriented towards those with interests in the scientific basis of public health and preventive medicine who wish to pursue careers in research , university teaching in graduate programs , policy analysis and development , and other high-level public health positions . Examples of academic degrees are the Master of Science , Doctor of Philosophy , Doctor of Science ( ScD ) , and Doctor of Health Science ( DHSc ) . The doctoral programs are distinct from the MPH and other professional programs by the addition of advanced coursework and the nature and scope of a dissertation research project . In the United States , the Association of Schools of Public Health represents Council on Education for Public Health ( CEPH ) accredited schools of public health . Delta Omega is the honor society for graduate studies in public health . The society was founded in 1924 at the Johns Hopkins School of Hygiene and Public Health . Currently , there are approximately 68 chapters throughout the United States and Puerto Rico . # Public health programs # Today , most governments recognize the importance of public health programs in reducing the incidence of disease , disability , and the effects of aging and other physical and mental health conditions , although public health generally receives significantly less government funding compared with medicine . In recent years , public health programs providing vaccinations have made strides in promoting health , including the eradication of smallpox , a disease that plagued humanity for thousands of years . The World Health Organization ( WHO ) identifies core functions of public health programs including :  providing leadership on matters critical to health and engaging in partnerships where joint action is needed ;  shaping a research agenda and stimulating the generation , translation and dissemination of valuable knowledge ;  setting norms and standards and promoting and monitoring their implementation ;  articulating ethical and evidence-based policy options ;  monitoring the health situation and assessing health trends . In particular , public health surveillance programs can :  serve as an early warning system for impending public health emergencies ;  document the impact of an intervention , or track progress towards specified goals ; and  monitor and clarify the epidemiology of health problems , allow priorities to be set , and inform health policy and strategies .  diagnose , investigate , and monitor health problems and health hazards of the community Public health surveillance has led to the identification and prioritization of many public health issues facing the world today , including HIV/AIDS , diabetes , waterborne diseases , zoonotic diseases , and antibiotic resistance leading to the reemergence of infectious diseases such as tuberculosis . Antibiotic resistance , also known as drug resistance , was the theme of World Health Day 2011 . Although the prioritization of pressing public health issues is important , Laurie Garrett argues that there are following consequences . When foreign aid is funneled into disease-specific programs , the importance of public health in general is disregarded . This public health problem of stovepiping is thought to create a lack of funds to combat other existing diseases in a given country . For example , the WHO reports that at least 220 million people worldwide suffer from diabetes . Its incidence is increasing rapidly , and it is projected that the number of diabetes deaths will double by the year 2030 . In a June 2010 editorial in the medical journal ' ' The Lancet ' ' , the authors opined that The fact that type 2 diabetes , a largely preventable disorder , has reached epidemic proportion is a public health humiliation . The risk of type 2 diabetes is closely linked with the growing problem of obesity . The WHOs latest estimates highlighted that globally approximately 1.5 billion adults were overweight in 2008 , and nearly 43 million children under the age of five were overweight in 2010 . The United States is the leading country with 30.6% of its population being obese . Mexico follows behind with 24.2% and the United Kingdom with 23% . Once considered a problem in high-income countries , it is now on the rise in low-income countries , especially in urban settings . Many public health programs are increasingly dedicating attention and resources to the issue of obesity , with objectives to address the underlying causes including healthy diet and physical exercise . Some programs and policies associated with public health promotion and prevention can be controversial . One such example is programs focusing on the prevention of HIV transmission through safe sex campaigns and needle-exchange programmes . Another is the control of tobacco smoking . Changing smoking behavior requires long-term strategies , unlike the fight against communicable diseases , which usually takes a shorter period for effects to be observed . Many nations have implemented major initiatives to cut smoking , such as increased taxation and bans on smoking in some or all public places . Proponents argue by presenting evidence that smoking is one of the major killers , and that therefore governments have a duty to reduce the death rate , both through limiting passive ( second-hand ) smoking and by providing fewer opportunities for people to smoke . Opponents say that this undermines individual freedom and personal responsibility , and worry that the state may be emboldened to remove more and more choice in the name of better population health overall . Simultaneously , while communicable diseases have historically ranged uppermost as a global health priority , non-communicable diseases and the underlying behavior-related risk factors have been at the bottom . This is changing however , as illustrated by the United Nations hosting its first General Assembly Special Summit on the issue of non-communicable diseases in September 2011 . Many health problems are due to maladaptive personal behaviors . From an evolutionary psychology perspective , over consumption of novel substances that are harmful is due to the activation of an evolved reward system for substances such as drugs , tobacco , alcohol , refined salt , fat , and carbohydrates . New technologies such as modern transportation also cause reduced physical activity . Research has found that behavior is more effectively changed by taking evolutionary motivations into consideration instead of only presenting information about health effects . Thus , the increased use of soap and hand-washing to prevent diarrhea is much more effectively promoted if its lack of use is associated with the emotion of disgust . Disgust is an evolved system for avoiding contact with substances that spread infectious diseases . Examples might include films that show how fecal matter contaminates food . The marketing industry has long known the importance of associating products with high status and attractiveness to others . Conversely , it has been argued that emphasizing the harmful and undesirable effects of tobacco smoking on other persons and imposing smoking bans in public places have been particularly effective in reducing tobacco smoking . # Applications in health care # As well as seeking to improve population health through the implementation of specific population-level interventions , public health contributes to medical care by identifying and assessing population needs for health care services , including :  Assessing current services and evaluating whether they are meeting the objectives of the health care system  Ascertaining requirements as expressed by health professionals , the public and other stakeholders  Identifying the most appropriate interventions  Considering the effect on resources for proposed interventions and assessing their cost-effectiveness  Supporting decision making in health care and planning health services including any necessary changes .  Informing , educating , and empowering people about health issues # Implementing effective improvement strategies # To improve public health , one important strategy is to promote modern medicine and scientific neutrality to drive the public health policy and campaign , which is recommended by Armanda Solorzana , through a case study of the Rockefeller Foundation 's hookworm campaign in Mexico in the 1920s . Soloranza argues that public health policy ca n't concern only politics or economics . Political concerns can lead government officials to hide the real numbers of people affected by disease in their regions , such as upcoming elections . Therefore , scientific neutrality in making public health policy is critical ; it can ensure treatment needs are met regardless of political and economic conditions . The history of public health care clearly shows the global effort to improve health care for all . However , in modern-day medicine , real , measurable change has not been clearly seen , and critics argue that this lack of improvement is due to ineffective methods that are being implemented . As argued by Paul E. Farmer , structural interventions could possibly have a large impact , and yet there are numerous problems as to why this strategy has yet to be incorporated into the health system . One of the main reasons that he suggests could be the fact that physicians are not properly trained to carry out structural interventions , meaning that the ground level health care professionals can not implement these improvements . While structural interventions can not be the only area for improvement , the lack of coordination between socioeconomic factors and health care for the poor could be counterproductive , and end up causing greater inequity between the health care services received by the rich and by the poor . Unless health care is no longer treated as a commodity , global public health can ultimately not be achieved . This being said , without changing the way in which health care is delivered to those who have less access to it , the universal goal of public health care can not be achieved 
@@490201 Health insurance is insurance against the risk of incurring medical expenses among individuals . By estimating the overall risk of health care and health system expenses , among a targeted group , an insurer can develop a routine finance structure , such as a monthly premium or payroll tax , to ensure that money is available to pay for the health care benefits specified in the insurance agreement . The benefit is administered by a central organization such as a government agency , private business , or not-for-profit entity . According to the Health Insurance Association of America , health insurance is defined as coverage that provides for the payments of benefits as a result of sickness or injury . Includes insurance for losses from accident , medical expense , disability , or accidental death and dismemberment ( pg . 225 ) . # Background # A health insurance policy is : # A contract between an insurance provider ( e.g. an insurance company or a government ) and an individual or his/her sponsor ( e.g. an employer or a community organization ) . The contract can be renewable ( e.g. annually , monthly ) or lifelong in the case of private insurance , or be mandatory for all citizens in the case of national plans . The type and amount of health care costs that will be covered by the health insurance provider are specified in writing , in a member contract or Evidence of Coverage booklet for private insurance , or in a national health policy for public insurance . # Provided by an employer-sponsored self-funded ERISA plan . The company generally advertises that they have one of the big insurance companies . However , in an ERISA case , that insurance company does n't engage in the act of insurance , they just administer it . Therefore ERISA plans are not subject to state laws . ERISA plans are governed by federal law under the jurisdiction of the US Department of Labor ( USDOL ) . The specific benefits or coverage details are found in the Summary Plan Description ( SPD ) . An appeal must go through the insurance company , then to the Employer 's Plan Fiduciary . If still required , the Fiduciarys decision can be brought to the USDOL to review for ERISA compliance , and then file a lawsuit in federal court . The individual insured person 's obligations may take several forms :  Premium : The amount the policy-holder or their sponsor ( e.g. an employer ) pays to the health plan to purchase health coverage .  Deductible : The amount that the insured must pay out-of-pocket before the health insurer pays its share . For example , policy-holders might have to pay a $500 deductible per year , before any of their health care is covered by the health insurer . It may take several doctor 's visits or prescription refills before the insured person reaches the deductible and the insurance company starts to pay for care . Furthermore , most policies do not apply co-pays for doctor 's visits or prescriptions against your deductible .  Co-payment : The amount that the insured person must pay out of pocket before the health insurer pays for a particular visit or service . For example , an insured person might pay a $45 co-payment for a doctor 's visit , or to obtain a prescription . A co-payment must be paid each time a particular service is obtained .  Coinsurance : Instead of , or in addition to , paying a fixed amount up front ( a co-payment ) , the co-insurance is a percentage of the total cost that insured person may also pay . For example , the member might have to pay 20% of the cost of a surgery over and above a co-payment , while the insurance company pays the other 80% . If there is an upper limit on coinsurance , the policy-holder could end up owing very little , or a great deal , depending on the actual costs of the services they obtain .  Exclusions : Not all services are covered . The insured are generally expected to pay the full cost of non-covered services out of their own pockets .  Coverage limits : Some health insurance policies only pay for health care up to a certain dollar amount . The insured person may be expected to pay any charges in excess of the health plan 's maximum payment for a specific service . In addition , some insurance company schemes have annual or lifetime coverage maxima . In these cases , the health plan will stop payment when they reach the benefit maximum , and the policy-holder must pay all remaining costs .  Out-of-pocket maxima : Similar to coverage limits , except that in this case , the insured person 's payment obligation ends when they reach the out-of-pocket maximum , and health insurance pays all further covered costs . Out-of-pocket maxima can be limited to a specific benefit category ( such as prescription drugs ) or can apply to all coverage provided during a specific benefit year .  Capitation : An amount paid by an insurer to a health care provider , for which the provider agrees to treat all members of the insurer .  In-Network Provider : ( U.S. term ) A health care provider on a list of providers preselected by the insurer . The insurer will offer discounted coinsurance or co-payments , or additional benefits , to a plan member to see an in-network provider . Generally , providers in network are providers who have a contract with the insurer to accept rates further discounted from the usual and customary charges the insurer pays to out-of-network providers .  Prior Authorization : A certification or authorization that an insurer provides prior to medical service occurring . Obtaining an authorization means that the insurer is obligated to pay for the service , assuming it matches what was authorized . Many smaller , routine services do not require authorization.  Explanation of Benefits : A document that may be sent by an insurer to a patient explaining what was covered for a medical service , and how payment amount and patient responsibility amount were determined . Prescription drug plans are a form of insurance offered through some health insurance plans . In the U.S. , the patient usually pays a copayment and the prescription drug insurance part or all of the balance for drugs covered in the formulary of the plan . Such plans are routinely part of national health insurance programs . For example in the province of Quebec , Canada , prescription drug insurance is universally required as part of the public health insurance plan , but may be purchased and administered either through private or group plans , or through the public plan . Some , if not most , health care providers in the United States will agree to bill the insurance company if patients are willing to sign an agreement that they will be responsible for the amount that the insurance company does n't pay . The insurance company pays out of network providers according to reasonable and customary charges , which may be less than the provider 's usual fee . The provider may also have a separate contract with the insurer to accept what amounts to a discounted rate or capitation to the provider 's standard charges . It generally costs the patient less to use an in-network provider . # Comparison # The Commonwealth Fund , in its annual survey , Mirror , Mirror on the Wall , compares the performance of the health care systems in Australia , New Zealand , the United Kingdom , Germany , Canada and the U.S. Its 2007 study found that , although the U.S. system is the most expensive , it consistently under-performs compared to the other countries . One difference between the U.S. and the other countries in the study is that the U.S. is the only country without universal health insurance coverage . The Commonwealth Fund completed its thirteenth annual health policy survey in 2010 . A study of the survey found significant differences in access , cost burdens , and problems with health insurance that are associated with insurance design . Of the countries surveyed , the results indicated that people in the United States had more out-of-pocket expenses , more disputes with insurance companies than other countries , and more insurance payments denied ; paperwork was also higher although Germany had similarly high levels of paperwork. # Australia # The public health system is called Medicare . It ensures free universal access to hospital treatment and subsidised out-of-hospital medical treatment . It is funded by a 1.5% tax levy on all taxpayers , an extra 1% levy on high income earners , as well as general revenue . The private health system is funded by a number of private health insurance organizations . The largest of these is Medibank Private , which is government-owned , but operates as a government business enterprise under the same regulatory regime as all other registered private health funds . The Coalition Howard government had announced that Medibank would be privatized if it won the 2007 election , however they were defeated by the Australian Labor Party under Kevin Rudd which had already pledged that it would remain in government ownership . Some private health insurers are ' for profit ' enterprises such as Australian Unity , and some are non-profit organizations such as HCF and the HBF Health Fund ( HBF ) . Some have membership restricted to particular groups , but the majority have open membership . Membership to most health funds is now also available through comparison websites like moneytime , Comparethemarket.com , iSelect , and YouCompare . These comparison sites operate on a commission-basis by agreement with their participating health funds . The Private Health Insurance Ombudsman also operates a free website which allows consumers to search for and compare private health insurers ' products , which includes information on price and level of cover . Most aspects of private health insurance in Australia are regulated by the ' ' Private Health Insurance Act 2007 ' ' . Complaints and reporting of the private health industry is carried out by an independent government agency , the Private Health Insurance Ombudsman . The ombudsman publishes an annual report that outlines the number and nature of complaints per health fund compared to their market share The private health system in Australia operates on a community rating basis , whereby premiums do not vary solely because of a person 's previous medical history , current state of health , or ( generally speaking ) their age ( but see Lifetime Health Cover below ) . Balancing this are waiting periods , in particular for pre-existing conditions ( usually referred to within the industry as PEA , which stands for pre-existing ailment ) . Funds are entitled to impose a waiting period of up to 12 months on benefits for any medical condition the signs and symptoms of which existed during the six months ending on the day the person first took out insurance . They are also entitled to impose a 12-month waiting period for benefits for treatment relating to an obstetric condition , and a 2-month waiting period for all other benefits when a person first takes out private insurance . Funds have the discretion to reduce or remove such waiting periods in individual cases . They are also free not to impose them to begin with , but this would place such a fund at risk of adverse selection , attracting a disproportionate number of members from other funds , or from the pool of intending members who might otherwise have joined other funds . It would also attract people with existing medical conditions , who might not otherwise have taken out insurance at all because of the denial of benefits for 12 months due to the PEA Rule . The benefits paid out for these conditions would create pressure on premiums for all the fund 's members , causing some to drop their membership , which would lead to further rises in premiums , and a vicious cycle of higher premiums-leaving members would ensue . The Australian government has introduced a number of incentives to encourage adults to take out private hospital insurance . These include :  Lifetime Health Cover : If a person has not taken out private hospital cover by 1 July after their 31st birthday , then when ( and if ) they do so after this time , their premiums must include a loading of 2% per annum for each year they were without hospital cover . Thus , a person taking out private cover for the first time at age 40 will pay a 20 percent loading . The loading is removed after 10 years of continuous hospital cover . The loading applies only to premiums for hospital cover , not to ancillary ( extras ) cover .  Medicare Levy Surcharge : People whose taxable income is greater than a specified amount ( in the 2011/12 financial year $80,000 for singles and $168,000 for couples ) and who do not have an adequate level of private hospital cover must pay a 1% surcharge on top of the standard 1.5% Medicare Levy . The rationale is that if the people in this income group are forced to pay more money one way or another , most would choose to purchase hospital insurance with it , with the possibility of a benefit in the event that they need private hospital treatment rather than pay it in the form of extra tax as well as having to meet their own private hospital costs . * The Australian government announced in May 2008 that it proposes to increase the thresholds , to $100,000 for singles and $150,000 for families . These changes require legislative approval . A bill to change the law has been introduced but was not passed by the Senate . An amended version was passed on 16 October 2008 . There have been criticisms that the changes will cause many people to drop their private health insurance , causing a further burden on the public hospital system , and a rise in premiums for those who stay with the private system . Other commentators believe the effect will be minimal .  Private Health Insurance Rebate : The government subsidises the premiums for all private health insurance cover , including hospital and ancillary ( extras ) , by 10% , 20% or 30% , depending on age . The Rudd Government announced in May 2009 that as of July 2010 , the Rebate would become means-tested , and offered on a sliding scale . While this move ( which would have required legislation ) was defeated in the Senate at the time , in early 2011 the Gillard Government announced plans to reintroduce the legislation after the Opposition loses the balance of power in the Senate . The ALP and Greens ( which currently combine in Australia to form a minority government ) have long been against the rebate , referring to it as middle-class welfare . # Canada # Health care is mainly a constitutional , provincial government responsibility in Canada ( the main exceptions being federal government responsibility for services provided to aboriginal peoples covered by treaties , the Royal Canadian Mounted Police , the armed forces , and members of parliament ) . Consequently each province administers its own health insurance program . The federal government influences health insurance by virtue of its fiscal powers it transfers cash and tax points to the provinces to help cover the costs of the universal health insurance programs . Under the Canada Health Act , the federal government mandates and enforces the requirement that all people have free access to what are termed medically necessary services , defined primarily as care delivered by physicians or in hospitals , and the nursing component of long term residential care . If provinces allow doctors or institutions to charge patients for medically necessary services , the federal government reduces its payments to the provinces by the amount of the prohibited charges . Collectively , the public provincial health insurance systems in Canada are frequently referred to as Medicare . This public insurance is tax-funded out of general government revenues , although British Columbia and Ontario levy a mandatory premium with flat rates for individuals and families to generate additional revenues in essence a surtax . Private health insurance is allowed , but in six provincial governments only for services that the public health plans do not cover , for example , semi-private or private rooms in hospitals and prescription drug plans . Four provinces allow insurance for services also mandated by the Canada Health Act , but in practice there is no market for it . All Canadians are free to use private insurance for elective medical services such as laser vision correction surgery , cosmetic surgery , and other non-basic medical procedures . Some 65% of Canadians have some form of supplementary private health insurance ; many of them receive it through their employers . Private-sector services not paid for by the government account for nearly 30 percent of total health care spending . In 2005 , the Supreme Court of Canada ruled , in Chaoulli v. Quebec , that the province 's prohibition on private insurance for health care already insured by the provincial plan violated the Quebec Charter of Rights and Freedoms , and in particular the sections dealing with the right to life and security , if there were unacceptably long wait times for treatment , as was alleged in this case . The ruling has not changed the overall pattern of health insurance across Canada but has spurred on attempts to tackle the core issues of supply and demand and the impact of wait times . # China # # France # The national system of health insurance was instituted in 1945 , just after the end of the Second World War . It was a compromise between Gaullist and Communist representatives in the French parliament . The Conservative Gaullists were opposed to a state-run healthcare system , while the Communists were supportive of a complete nationalisation of health care along a British Beveridge model . The resulting programme is profession-based : all people working are required to pay a portion of their income to a not-for-profit health insurance fund , which mutualises the risk of illness , and which reimburses medical expenses at varying rates . Children and spouses of insured people are eligible for benefits , as well . Each fund is free to manage its own budget , and used to reimburse medical expenses at the rate it saw fit , however following a number of reforms in recent years , the majority of funds provide the same level of reimbursement and benefits . The government has two responsibilities in this system .  The first government responsibility is the fixing of the rate at which medical expenses should be negotiated , and it does so in two ways : The Ministry of Health directly negotiates prices of medicine with the manufacturers , based on the average price of sale observed in neighboring countries . A board of doctors and experts decides if the medicine provides a valuable enough medical benefit to be reimbursed ( note that most medicine is reimbursed , including homeopathy ) . In parallel , the government fixes the reimbursement rate for medical services : this means that a doctor is free to charge the fee that he wishes for a consultation or an examination , but the social security system will only reimburse it at a pre-set rate . These tariffs are set annually through negotiation with doctors ' representative organisations .  The second government responsibility is oversight of the health-insurance funds , to ensure that they are correctly managing the sums they receive , and to ensure oversight of the public hospital network . Today , this system is more-or-less intact . All citizens and legal foreign residents of France are covered by one of these mandatory programs , which continue to be funded by worker participation . However , since 1945 , a number of major changes have been introduced . Firstly , the different health-care funds ( there are five : General , Independent , Agricultural , Student , Public Servants ) now all reimburse at the same rate . Secondly , since 2000 , the government now provides health care to those who are not covered by a mandatory regime ( those who have never worked and who are not students , meaning the very rich or the very poor ) . This regime , unlike the worker-financed ones , is financed via general taxation and reimburses at a higher rate than the profession-based system for those who can not afford to make up the difference . Finally , to counter the rise in health-care costs , the government has installed two plans , ( in 2004 and 2006 ) , which require insured people to declare a referring doctor in order to be fully reimbursed for specialist visits , and which installed a mandatory co-pay of 1 ( about $1.45 ) for a doctor visit , 0,50 ( about 80 ) for each box of medicine prescribed , and a fee of 1618 ( $2025 ) per day for hospital stays and for expensive procedures . An important element of the French insurance system is solidarity : the more ill a person becomes , the less the person pays . This means that for people with serious or chronic illnesses , the insurance system reimburses them 100% of expenses , and waives their co-pay charges . Finally , for fees that the mandatory system does not cover , there is a large range of private complementary insurance plans available . The market for these programs is very competitive , and often subsidised by the employer , which means that premiums are usually modest . 85% of French people benefit from complementary private health insurance . # Germany # Germany has the world 's oldest national social health insurance system , with origins dating back to Otto von Bismarck 's Sickness Insurance Law of 1883 . Currently 85% of the population is covered by a basic health insurance plan provided by statute , which provides a standard level of coverage . The remainder opt for private health insurance , which frequently offers additional benefits . According to the World Health Organization , Germany 's health care system was 77% government-funded and 23% privately funded as of 2004 . The government partially reimburses the costs for low-wage workers , whose premiums are capped at a predetermined value . Higher wage workers pay a premium based on their salary . They may also opt for private insurance , which is generally more expensive , but whose price may vary based on the individual 's health status . Reimbursement is on a fee-for-service basis , but the number of physicians allowed to accept Statutory Health Insurance in a given locale is regulated by the government and professional societies . Co payments were introduced in the 1980s in an attempt to prevent over utilization . The average length of hospital stay in Germany has decreased in recent years from 14 days to 9 days , still considerably longer than average stays in the United States ( 5 to 6 days ) . Part of the difference is that the chief consideration for hospital reimbursement is the number of hospital days as opposed to procedures or diagnosis . Drug costs have increased substantially , rising nearly 60% from 1991 through 2005 . Despite attempts to contain costs , overall health care expenditures rose to 10.7% of GDP in 2005 , comparable to other western European nations , but substantially less than that spent in the U.S. ( nearly 16% of GDP ) . # #Insurance systems# # Germans are offered three kinds of social security insurance dealing with the physical status of a person and which are co-financed by employer and employee : health insurance , accident insurance , and long-term care insurance . Germany has a universal multi-payer system with two main types of health insurance : law enforced health insurance ( or public health insurance ) ( ' ' Gesetzliche Krankenversicherung ( GKV ) ' ' ) and private insurance ( ' ' Private Krankenversicherung ( PKV ) ' ' ) . Both systems struggle with the increasing cost of medical treatment and the changing demography . About 87.5% of the persons with health insurance are members of the public system , while 12.5% are covered by private insurance ( as of 2006 ) . There are many differences between the public health insurance and private insurance . In general the benefits and costs in the private insurance are better for young people without family . There are hard salary requirements to join the private insurance because its getting more expensive advanced in years . # #Statutory health insurance/Gesetzliche Krankenversicherung ( GKV ) # # The statutory health insurance ( est. in 1883 ) is together with the statutory accident insurance ( est. 1883 ) , the statutory old age and disability insurance ( est. in 1889 ) , the unemployment insurance ( est. in 1927 ) and the long term care insurance ( est. in 1995 ) part of the German social insurance system . Since 2009 it is compulsory to anyone living in Germany to have a health insurance . The GKV is a compulsory insurance for employees with an yearly income under 50,850 ( in 2012 , adjusted yearly ) and a lot of further persons . # @2 History of the GKV @2 # With the Imperial Bill of 15 . June 1883 and its novel from 10 . April 1892 the health insurance bill was created , who introduced compulsory health insurance for workers . Austria followed Germany in 1888 , Hungary in 1891 and Switzerland in 1911 . As long ago as 29 . April 1869 the county health insurance ill in Bavaria created the world wide first law that introduced and regulated a health insurance for people with low income . It was limited to people to employees with less than 2000 Mark income per year and did guarantee minimum 60% of the income of the insured person during a period of sickness . # @2 Functions of the GKV @2 # Function of the statutory health insurance is according to 1 SGB V to preserver , recreate or improve the health status of the insured person . According to 27 SGB V this includes to subdue the afflictions of sickness . All insured persons have fundamentally the same entitlement for benefits . The scope of benefits is regulated in SGB V ( social insurance bill five ) and limited by 1 SGB V. Benefits have to be adequate , appropriate and economic and shall not overshoot what is necessary for the insured person . Considering this background additional benefits can only be given based on special regulations based on formal law . These are e.g. additional service for the prevention of sickness , care at home , household support , rehabilitation etc . Based on the solidarity principle and the compulsory membership , the calculation of fees is different from private health insurance not depending on the personal health status or criteria like age or sex , but connected to ones personal income by a fixed percent quota . Aim is to cover the live risk of high costs the individual could not bear resulting from sickness . # @2 Organisation @2 # The German law maker has reduced the number of public health insurance organisations from 1209 in 1991 down to 146 in 2012 . The most important are : Allgemeine Ortskrankenkassen ( AOK ) , Betriebskrankenkassen ( BKK ) , Innungskrankenkassen ( IKK ) , Ersatzkassen and Knappschaft . Additionally there are special public insurance systems for farmers . As far as an insured person has the right to choose his health insurance , he can join an insurance that is open to his type of person . # #Private health insurance/Private Krankenversicherung ( PKV ) # # # #Law enforced accident insurance/gesetzliche Unfallversicherung# # Accident insurance ( Unfallversicherung ) is covered by the employer and basically covers all risks for commuting to work and at the workplace . # #Law enforced long term care insurance/Gesetzliche Pflegeversicherung# # Long-term care ( Pflegeversicherung ) is covered half and half by employer and employee and covers cases in which a person is not able to manage his or her daily routine ( provision of food , cleaning of apartment , personal hygiene , etc . ) . It is about 2% of a yearly salaried income or pension , with employers matching the contribution of the employee . In 2013 a state funded private care insurance was introduced ( Private Pflegeversicherung ) . Insurance contracts that fit certain criteria are subsidised with 60 Euro per year . It is expected that the number of contracts will grow from 400,000 by end of 2013 to over a million within the next few years . These contracts have been criticized by consumer rights foundations . # Japan # There are two major types of insurance programs available in Japan Employees Health Insurance ( Kenk-Hoken ) , and National Health Insurance ( Kokumin-Kenk-Hoken ) . National Health insurance is designed for people who are not eligible to be members of any employment-based health insurance program . Although private health insurance is also available , all Japanese citizens , permanent residents , and non-Japanese with a visa lasting one year or longer are required to be enrolled in either National Health Insurance or Employees Health Insurance . # Netherlands # In 2006 , a new system of health insurance came into force in the Netherlands . This new system avoids the two pitfalls of adverse selection and moral hazard associated with traditional forms of health insurance by using a combination of regulation and an insurance equalization pool . Moral hazard is avoided by mandating that insurance companies provide at least one policy which meets a government set minimum standard level of coverage , and all adult residents are obliged by law to purchase this coverage from an insurance company of their choice . All insurance companies receive funds from the equalization pool to help cover the cost of this government-mandated coverage . This pool is run by a regulator which collects salary-based contributions from employers , which make up about 50% of all health care funding , and funding from the government to cover people who can not afford health care , which makes up an additional 5% . The remaining 45% of health care funding comes from insurance premiums paid by the public , for which companies compete on price , though the variation between the various competing insurers is only about 5% . However , insurance companies are free to sell additional policies to provide coverage beyond the national minimum . These policies do not receive funding from the equalization pool , but cover additional treatments , such as dental procedures and physiotherapy , which are not paid for by the mandatory policy . Funding from the equalization pool is distributed to insurance companies for each person they insure under the required policy . However , high-risk individuals get more from the pool , and low-income persons and children under 18 have their insurance paid for entirely . Because of this , insurance companies no longer find insuring high risk individuals an unappealing proposition , avoiding the potential problem of adverse selection . Insurance companies are not allowed to have co-payments , caps , or deductibles , or to deny coverage to any person applying for a policy , or to charge anything other than their nationally set and published standard premiums . Therefore , every person buying insurance will pay the same price as everyone else buying the same policy , and every person will get at least the minimum level of coverage . # New Zealand # Since 1974 , New Zealand has had a system of universal no-fault health insurance for personal injuries through the Accident Compensation Corporation ( ACC ) . The ACC scheme covers most of the costs of related to treatment of injuries acquired in New Zealand ( including overseas visitors ) regardless of how the injury occurred , and also covers lost income ( at 80 percent of the employee 's pre-injury income ) and costs related to long-term rehabilitation , such as home and vehicle modifications for those seriously injured . Funding from the scheme comes from a combination of levies on employers ' payroll ( for work injuries ) , levies on an employee 's taxable income ( for non-work injuries to salary earners ) , levies on vehicle licensing fees and petrol ( for motor vehicle accidents ) , and funds from the general taxation pool ( for non-work injuries to children , senior citizens , unemployed people , overseas visitors , etc. ) # Rwanda # Rwanda is one of a handful of low income countries that has implemented community-based health insurance schemes in order to reduce the financial barriers that prevent poor people from seeking and receiving needed health services . This scheme has helped reach 90% of the country 's population with health-care coverage . # Switzerland # ' ' Healthcare in Switzerland ' ' is universal and is regulated by the ' ' Swiss Federal Law on Health Insurance ' ' . ' ' Health insurance ' ' is compulsory for all persons residing in Switzerland ( within three months of taking up residence or being born in the country ) . It is therefore the same throughout the country and avoids double standards in healthcare . Insurers are required to offer this basic insurance to everyone , regardless of age or medical condition . They are not allowed to make a profit off this basic insurance , but can on supplemental plans . The universal compulsory coverage provides for treatment in case of illness or accident and pregnancy . Health insurance covers the costs of medical treatment , medication and hospitalization of the insured . However , the insured person pays part of the costs up to a maximum , which can vary based on the individually chosen plan , premiums are then adjusted accordingly . The whole healthcare system is geared towards to the general goals of enhancing general public health and reducing costs while encouraging individual responsibility . The Swiss healthcare system is a combination of public , subsidised private and totally private systems . Insurance premiums vary from insurance company to company , the excess level individually chosen ( ' ' franchise ' ' ) , the place of residence of the insured person and the degree of supplementary benefit coverage chosen ( complementary medicine , routine dental care , semi-private or private ward hospitalisation , etc . ) . The insured person has full freedom of choice among the approximately 60 recognised healthcare providers competent to treat their condition ( in his region ) on the understanding that the costs are covered by the insurance up to the level of the official tariff . There is freedom of choice when selecting an insurance company to which one pays a premium , usually on a monthly basis . The insured person pays the insurance premium for the basic plan up to 8% of their personal income . If a premium is higher than this , the government gives the insured person a cash subsidy to pay for any additional premium . The compulsory insurance can be supplemented by private complementary insurance policies that allow for coverage of some of the treatment categories not covered by the basic insurance or to improve the standard of room and service in case of hospitalisation . This can include complementary medicine , routine dental treatment and private ward hospitalisation , which are not covered by the compulsory insurance . As far as the compulsory health insurance is concerned , the insurance companies can not set any conditions relating to age , sex or state of health for coverage . Although the level of premium can vary from one company to another , they must be identical within the same company for all insured persons of the same age group and region , regardless of sex or state of health . This does not apply to complementary insurance , where premiums are risk-based . Switzerland has an infant mortality rate of about 3.6 out of 1,000 . The general life expectancy in 2012 was for men 80.5 years compared to 84.7 years for women . These are the world 's best figures ! # United Kingdom # The UK 's National Health Service ( NHS ) is a publicly funded healthcare system that provides coverage to everyone normally resident in the UK . It is not strictly an insurance system because ( a ) there are no premiums collected , ( b ) costs are not charged at the patient level and ( c ) costs are not pre-paid from a pool . However , it does achieve the main aim of insurance which is to spread financial risk arising from ill-health . The costs of running the NHS ( est. 104 billion in 2007-8 ) are met directly from general taxation . The NHS provides the majority of health care in the UK , including primary care , in-patient care , long-term health care , ophthalmology , and dentistry . Private health care has continued parallel to the NHS , paid for largely by private insurance , but it is used by less than 8% of the population , and generally as a top-up to NHS services . There are many treatments that the private sector does not provide . For example , health insurance on pregnancy is generally not covered or covered with restricting clauses . Typical exclusions for Bupa schemes ( and many other insurers ) include : # ageing , menopause and puberty ; AIDS/HIV ; allergies or allergic disorders ; birth control , conception , sexual problems and sex changes ; chronic conditions ; complications from excluded or restricted conditions/ treatment ; convalescence , rehabilitation and general nursing care ; cosmetic , reconstructive or weight loss treatment ; deafness ; dental/oral treatment ( such as fillings , gum disease , jaw shrinkage , etc ) ; dialysis ; drugs and dressings for out-patient or take-home use ; experimental drugs and treatment ; eyesight ; HRT and bone densitometry ; learning difficulties , behavioural and developmental problems ; overseas treatment and repatriation ; physical aids and devices ; pre-existing or special conditions ; pregnancy and childbirth ; screening and preventive treatment ; sleep problems and disorders ; speech disorders ; temporary relief of symptoms . ( = except in exceptional circumstances ) # There are a number of other companies in the United Kingdom which include , among others , ACE Limited , AXA , Aviva , Bupa , Groupama Healthcare , WPA and PruHealth . Similar exclusions apply , depending on the policy which is purchased . Recently ( 2009 ) the main representative body of British Medical physicians , the British Medical Association , adopted a policy statement expressing concerns about developments in the health insurance market in the UK . In its Annual Representative Meeting which had been agreed earlier by the Consultants Policy Group ( i.e. Senior physicians ) stating that the BMA was extremely concerned that the policies of some private healthcare insurance companies are preventing or restricting patients exercising choice about ( i ) the consultants who treat them ; ( ii ) the hospital at which they are treated ; ( iii ) making top up payments to cover any gap between the funding provided by their insurance company and the cost of their chosen private treatment . It went in to call on the BMA to publicise these concerns so that patients are fully informed when making choices about private healthcare insurance . The practice of insurance companies deciding which consultant a patient may see as opposed to GPs or patients is referred to as Open Referral . The NHS offers patients a choice of hospitals and consultants and does not charge for its services . The private sector has been used to increase NHS capacity despite a large proportion of the British public opposing such involvement . According to the World Health Organization , government funding covered 86% of overall health care expenditures in the UK as of 2004 , with private expenditures covering the remaining 14% . Nearly one in three patients receiving NHS hospital treatment is privately insured and could have the cost paid for by their insurer . Some private schemes provide cash payments to patients who opt for NHS treatment , to deter use of private facilities . A report , by private health analysts Laing and Buisson , in November 2012 , estimated that more than 250,000 operations were performed on patients with private medical insurance each year at a cost of 359 million . In addition , 609 million was spent on emergency medical or surgical treatment . Private medical insurance does not normally cover emergency treatment but subsequent recovery could be paid for if the patient were moved into a private patient unit . # United States # In 2004 , U.S. health insurers directly employed almost 470,000 people at an average salary of $61,409 . ( As of the fourth quarter of 2007 , the total U.S. labor force stood at 153.6 million , of whom 146.3 million were employed . Employment related to all forms of insurance totaled 2.3 million . Mean annual earnings for full-time civilian workers as of June 2006 were $41,231 ; median earnings were $33,634. ) -- The United States health care system relies heavily on private health insurance , which is the primary source of coverage for most Americans . According to the CDC , approximately 58% of Americans have private health insurance . The Agency for Healthcare Research and Quality ( AHRQ ) found that in 2011 , private insurance was billed for 12.2 million U.S. inpatient hospital stays and incurred approximately $112.5 billion in aggregate inpatient hospital costs ( 29% of the total national aggregate costs ) . Public programs provide the primary source of coverage for most senior citizens and for low-income children and families who meet certain eligibility requirements . The primary public programs are Medicare , a federal social insurance program for seniors and certain disabled individuals ; and Medicaid , funded jointly by the federal government and states but administered at the state level , which covers certain very low income children and their families . Together , Medicare and Medicaid accounted for approximately 63 percent of the national inpatient hospital costs in 2011 . SCHIP is a federal-state partnership that serves certain children and families who do not qualify for Medicaid but who can not afford private coverage . Other public programs include military health benefits provided through TRICARE and the Veterans Health Administration and benefits provided through the Indian Health Service . Some states have additional programs for low-income individuals . In the late 1990s and early 2000s , health advocacy companies began to appear to help patients deal with the complexities of the healthcare system . The complexity of the healthcare system has resulted in a variety of problems for the American public . A study found that 62 percent of persons declaring bankruptcy in 2007 had unpaid medical expenses of $1000 or more , and in 92% of these cases the medical debts exceeded $5000 . Nearly 80 percent who filed for bankruptcy had health insurance . The Medicare and Medicaid programs were estimated to soon account for 50 percent of all national health spending . These factors and many others fueled interest in an overhaul of the health care system in the United States . In 2010 President Obama signed into law the Patient Protection and Affordable Care Act . This Act includes an ' individual mandate ' that every American must have medical insurance ( or pay a fine ) . Health policy experts such as David Cutler and Jonathan Gruber , as well as the American medical insurance lobby group America 's Health Insurance Plans , argued this provision was required in order to provide guaranteed issue and a community rating , which address unpopular features of America 's health insurance system such as premium weightings , exclusions for pre-existing conditions , and the pre-screening of insurance applicants . During March 2628 , the Supreme Court heard arguments regarding the validity of the Act . The Patient Protection and Affordable Care Act was determined to be constitutional on June 28 , 2012 . SCOTUS determined that Congress had the authority to apply the individual mandate within its taxing powers . # # History and evolution # # In the late 19th century , accident insurance began to be available , which operated much like modern ' ' disability ' ' insurance . This payment model continued until the start of the 20th century in some jurisdictions ( like California ) , where all laws regulating health insurance actually referred to disability insurance . Accident insurance was first offered in the United States by the Franklin Health Assurance Company of Massachusetts . This firm , founded in 1850 , offered insurance against injuries arising from railroad and steamboat accidents . Sixty organizations were offering accident insurance in the U.S. by 1866 , but the industry consolidated rapidly soon thereafter . While there were earlier experiments , the origins of sickness coverage in the U.S. effectively date from 1890 . The first employer-sponsored group disability policy was issued in 1911 . Before the development of medical expense insurance , patients were expected to pay health care costs out of their own pockets , under what is known as the fee-for-service business model . During the middle-to-late 20th century , traditional disability insurance evolved into modern health insurance programs . One major obstacle to this development was that early forms of comprehensive health insurance were enjoined by courts for violating the traditional ban on corporate practice of the professions by for-profit corporations . State legislatures had to intervene and expressly legalize health insurance as an exception to that traditional rule . Today , most comprehensive private health insurance programs cover the cost of routine , preventive , and emergency health care procedures , and most prescription drugs ( but this is not always the case ) . Hospital and medical expense policies were introduced during the first half of the 20th century . During the 1920s , individual hospitals began offering services to individuals on a pre-paid basis , eventually leading to the development of Blue Cross organizations . The predecessors of today 's Health Maintenance Organizations ( HMOs ) originated beginning in 1929 , through the 1930s and on during World War II . # #Health plan vs. health insurance# # Historically , Health maintenance organizations ( HMO ) tended to use the term health plan , while commercial insurance companies used the term health insurance . A health plan can also refer to a subscription-based medical care arrangement offered through HMOs , preferred provider organizations , or point of service plans . These plans are similar to pre-paid dental , pre-paid legal , and pre-paid vision plans . Pre-paid health plans typically pay for a fixed number of services ( for instance , $300 in preventive care , a certain number of days of hospice care or care in a skilled nursing facility , a fixed number of home health visits , a fixed number of spinal manipulation charges , etc . ) . The services offered are usually at the discretion of a utilization review nurse who is often contracted through the managed care entity providing the subscription health plan . This determination may be made either prior to or after hospital admission ( concurrent utilization review ) . # #Comprehensive vs. scheduled# # Comprehensive health insurance pays a percentage of the cost of hospital and physician charges after a deductible ( usually applies to hospital charges ) or a co-pay ( usually applies to physician charges , but may apply to some hospital services ) is met by the insured . These plans are generally expensive because of the high potential benefit payout $1,000,000 to $5,000,000 is common and because of the vast array of covered benefits . Scheduled health insurance plans are not meant to replace a traditional comprehensive health insurance plans and are more of a basic policy providing access to day-to-day health care such as going to the doctor or getting a prescription drug . In recent years in the USA , these plans have taken the name mini-med plans or association plans . The term association is often used to describe them because they require membership in an association that must exist for some other purpose than to sell insurance . Examples include the Health Care Credit Union Association . These plans may provide benefits for hospitalization and surgical , but these benefits will be limited . Scheduled plans are not meant to be effective for catastrophic events . These plans cost much less than comprehensive health insurance . They generally pay limited benefits amounts directly to the service provider , and payments are based upon the plan 's schedule of benefits . Annual benefits maxima for a typical scheduled health insurance plan may range from $1,000 to $25,000. # #Factors affecting insurance prices# # A recent study by PricewaterhouseCoopers examining the drivers of rising health care costs in the U.S. pointed to increased utilization created by increased consumer demand , new treatments , and more intensive diagnostic testing , as the most significant . However , Wendell Potter , a long-time PR representative for the health insurance industry , has noted that the group which sponsored this study , AHIP , is a front-group funded by various insurance companies . People in developed countries are living longer . The population of those countries is aging , and a larger group of senior citizens requires more intensive medical care than a young , healthier population . Advances in medicine and medical technology can also increase the cost of medical treatment . Lifestyle-related factors can increase utilization and therefore insurance prices , such as : increases in obesity caused by insufficient exercise and unhealthy food choices ; excessive alcohol use , smoking , and use of street drugs . Other factors noted by the PWC study included the movement to broader-access plans , higher-priced technologies , and cost-shifting from Medicaid and the uninsured to private payers . Other researchers note that doctors and other healthcare providers are rewarded for merely treating patients rather than curing them and that patients insured through employer group policies have incentives to go to the absolute best HCPs rather than the most cost-effective ones . # #Military# # The price of health insurance for retired and active duty military personnel has gone up from $19 billion just a decade ago to $49 billion in the last year . Now , TRICARE , the government health insurance program , makes up nine percent of the total budget for the Pentagon . # #California# # In 2007 , 87% of Californians had some form of health insurance . Services in California range from private offerings : HMOs , PPOs to public programs : Medi-Cal , Medicare , and Healthy Families ( SCHIP ) . California developed a solution to assist people across the state and is one of the few states to have an Office devoted to giving people tips and resources to get the best care possible . California 's Office of the Patient Advocate was established July 2000 to publish a yearly Health Care Quality Report Card on the Top HMOs , PPOs , and Medical Groups and to create and distribute helpful tips and resources to give Californians the tools needed to get the best care . Additionally , California has a Help Center that assists Californians when they have problems with their health insurance . The Help Center is run by the Department of Managed Health Care , the government department that oversees and regulates HMOs and some PPOs. # Standards of hospitals and clinics used by insurance companies # A key factor in patient safety is that the health care providers should be safe and fit for purpose . In the USA , insurers will often only make use of health care providers that are independently surveyed by a recognized quality assurance program , such as being accredited by accreditation schemes such as the Joint Commission and the American Accreditation Healthcare Commission 
@@499685 Sulfonamide or sulphonamide is the basis of several groups of drugs . The original antibacterial sulfonamides ( sometimes called sulfa drugs or sulpha drugs ) are synthetic antimicrobial agents that contain the sulfonamide group . Some sulfonamides are also devoid of antibacterial activity , e.g. , the anticonvulsant sultiame . The sulfonylureas and thiazide diuretics are newer drug groups based on the antibacterial sulfonamides . Allergies to sulfonamide are common , hence medications containing sulfonamides are prescribed carefully . It is important to make a distinction between sulfa drugs and other sulfur-containing drugs and additives , such as sulfates and sulfites , which are chemically unrelated to the sulfonamide group , and do not cause the same hypersensitivity reactions seen in the sulfonamides . Because sulfonamides displace bilirubin from albumin , kernicterus ( brain damage due to excess bilirubin ) is an important potential side effect of sulfonamide use . # Function # # Antimicrobial # In bacteria , antibacterial sulfonamides act as competitive inhibitors of the enzyme dihydropteroate synthetase ( DHPS ) , an enzyme involved in folate synthesis . Sulfonamides are therefore bacteriostatic and inhibit growth and multiplication of bacteria , but do not kill them . Humans , in contrast to bacteria , acquire folate ( vitamin B <sub> 9 </sub> ) through the diet . # Other uses # The sulfonamide chemical moiety is also present in other medications that are not antimicrobials , including thiazide diuretics ( including hydrochlorothiazide , metolazone , and indapamide , among others ) , loop diuretics ( including furosemide , bumetanide , and torsemide ) , acetazolamide , sulfonylureas ( including glipizide , glyburide , among others ) , and some COX-2 inhibitors ( e.g. , celecoxib ) . Sulfasalazine , in addition to its use as an antibiotic , is also used in the treatment of inflammatory bowel disease . # History # Sulfonamide drugs were the first antimicrobial drugs , and paved the way for the antibiotic revolution in medicine . The first sulfonamide , trade-named Prontosil , was a prodrug . Experiments with Prontosil began in 1932 in the laboratories of Bayer AG , at that time a component of the huge German chemical trust IG Farben . The Bayer team believed that coal-tar dyes which are able to bind preferentially to bacteria and parasites might be used to attack harmful organisms in the body . After years of fruitless trial-and-error work on hundreds of dyes , a team led by physician/researcher Gerhard Domagk ( working under the general direction of Farben executive Heinrich Hrlein ) finally found one that worked : a red dye synthesized by Bayer chemist Josef Klarer that had remarkable effects on stopping some bacterial infections in mice . The first official communication about the breakthrough discovery was not published until 1935 , more than two years after the drug was patented by Klarer and his research partner Fritz Mietzsch . Prontosil , as Bayer named the new drug , was the first medicine ever discovered that could effectively treat a range of bacterial infections inside the body . It had a strong protective action against infections caused by streptococci , including blood infections , childbed fever , and erysipelas , and a lesser effect on infections caused by other cocci . However , it had no effect at all in the test tube , exerting its antibacterial action only in live animals . Later , it was discovered by Bovet , Federico Nitti and J. and Th . Jacques Trfoul , a French research team led by Ernest Fourneau at the Pasteur Institute , that the drug was metabolized into two pieces inside the body , releasing from the inactive dye portion a smaller , colorless , active compound called sulfanilamide . The discovery helped establish the concept of bioactivation and dashed the German corporation 's dreams of enormous profit ; the active molecule sulfanilamide ( or sulfa ) had first been synthesized in 1906 and was widely used in the dye-making industry ; its patent had since expired and the drug was available to anyone . The result was a sulfa craze . For several years in the late 1930s , hundreds of manufacturers produced tens of thousands of tons of myriad forms of sulfa . This and nonexistent testing requirements led to the elixir sulfanilamide disaster in the fall of 1937 , during which at least 100 people were poisoned with diethylene glycol . This led to the passage of the Federal Food , Drug , and Cosmetic Act in 1938 in the United States . As the first and only effective antibiotic available in the years before penicillin , sulfa drugs continued to thrive through the early years of World War II . They are credited with saving the lives of tens of thousands of patients , including Franklin Delano Roosevelt , Jr . ( son of US President Franklin Delano Roosevelt ) ( in 1936 ) and Winston Churchill . Sulfa had a central role in preventing wound infections during the war . American soldiers were issued a first-aid kit containing sulfa pills and powder , and were told to sprinkle it on any open wound . The sulfanilamide compound is more active in the protonated form . The drug has very low solubility and sometimes can crystallize in the kidneys , due to its first pK <sub> a </sub> of around 10 . This is a very painful experience , so patients are told to take the medication with copious amounts of water . Newer analogous compounds prevent this complication because they have a lower pK <sub> a </sub> , around 56 , making them more likely to remain in a soluble form . Many thousands of molecules containing the sulfanilamide structure have been created since its discovery ( by one account , over 5,400 permutations by 1945 ) , yielding improved formulations with greater effectiveness and less toxicity . Sulfa drugs are still widely used for conditions such as acne and urinary tract infections , and are receiving renewed interest for the treatment of infections caused by bacteria resistant to other antibiotics . # Preparation # Sulfonamides are prepared by the reaction of a sulfonyl chloride with ammonia or an amine . Certain sulfonamides ( sulfadiazine or sulfamethoxazole ) are sometimes mixed with the drug trimethoprim , which acts against dihydrofolate reductase . As of 2013 , Republic of Ireland is the largest exporter worldwide of Sulfonamides , accounting for approximately 32% of total exports . # List of sulfonamides # # Child antibacterial drugs # Pediazole # Antimicrobials # ; Short-acting Sulfacetamide Sulfadiazine Sulfadimidine Sulfafurazole Sulfisomidine ( also known as sulfaisodimidine ) ; Intermediate-acting Sulfadoxine Sulfamethoxazole Sulfamoxole ; Long-acting Sulfadimethoxine Sulfamethoxypyridazine Sulfametoxydiazine ; Ultra long-acting Sulfadoxine Sulfametopyrazine # Sulfonylureas ( anti-diabetic agents ) # Acetohexamide Carbutamide Chlorpropamide Glibenclamide ( also known as glyburide ) Glibornuride Gliclazide Glyclopyramide Glimepiride Glipizide Gliquidone Glisoxepide Tolazamide Tolbutamide # Diuretics # Acetazolamide Bumetanide Chlorthalidone Clopamide Dorzolamide Furosemide Hydrochlorothiazide ( HCT , HCTZ , HZT ) Indapamide Mefruside Metolazone Xipamide # Anticonvulsants # Ethoxzolamide Sultiame Topiramate Zonisamide # Dermatologicals # Mafenide # Antiretrovirals #  Amprenavir ( protease inhibitor )  Darunavir ( protease inhibitor )  Delavirdine ( non-nucleoside reverse transcriptase inhibitor )  Fosamprenavir ( protease inhibitor )  Tipranavir ( protease inhibitor ) # Other # Apricoxib ( COX-2 inhibitor ) Bosentan ( endothelin receptor antagonist ) Celecoxib ( COX-2 inhibitor ) Dofetilide ( class III antiarrhythmic ) Dronedarone ( class III antiarrhythmic ) Ibutilide ( class III antiarrhythmic ) Parecoxib ( COX-2 inhibitor ) Probenecid ( PBN ) Sotalol ( beta blocker ) Sulfasalazine ( SSZ ) Sumatriptan ( SMT ) Tamsulosin ( alpha blocker ) Udenafil ( PDE5 inhibitor ) # Stimulant # Azabon # Side effects # Sulfonamides have the potential to cause a variety of untoward reactions , including urinary tract disorders , haemopoietic disorders , porphyria , and hypersensitivity reactions . When used in large doses , they may cause a strong allergic reaction . Two of the most serious are StevensJohnson syndrome and toxic epidermal necrolysis ( also known as Lyell syndrome ) . Approximately 3% of the general population have adverse reactions when treated with sulfonamide antimicrobials . Of note is the observation that patients with HIV have a much higher prevalence , at about 60% . Hypersensitivity reactions are less common in nonantibiotic sulfonamides , and , though controversial , the available evidence suggests those with hypersensitivity to sulfonamide antibiotics do not have an increased risk of hypersensitivity reaction to the nonantibiotic agents . A key component to the allergic response to sulfonamide antibiotics is the arylamine group at N4 , found in sulfamethoxazole , sulfasalazine , sulfadiazine , and the anti-retrovirals amprenavir and fosamprenavir . Other sulfonamide drugs do not contain this arylamine group ; available evidence suggests that patients who are allergic to arylamine sulfonamides do not cross-react to sulfonamides that lack the arylamine group , and may therefore safely take non-arylamine sulfonamides . It has therefore been argued that the terms ' sulfonamide allergy ' or ' sulfa allergy ' are misleading , and should be replaced by a reference to a specific drug ( e.g. ' cotrimoxazole allergy ' ) . Two regions of the sulfonamide antibiotic chemical structure are implicated in the hypersensitivity reactions associated with the class . The first is the N1 heterocyclic ring , which causes a type I hypersensitivity reaction . The second is the N4 amino nitrogen that , in a stereospecific process , forms reactive metabolites that cause either direct cytotoxicity or immunologic response . The nonantibiotic sulfonamides lack both of these structures . The most common manifestations of a hypersensitivity reaction to sulfa drugs are rash and hives . However , there are several life-threatening manifestations of hypersensitivity to sulfa drugs , including StevensJohnson syndrome , toxic epidermal necrolysis , agranulocytosis , hemolytic anemia , thrombocytopenia , fulminant hepatic necrosis , and acute pancreatitis , among others . 
@@512662 ICDO = Cardiovascular disease ( also called heart disease ) is a class of diseases that involve the heart , the blood vessels ( arteries , capillaries , and veins ) or both . The causes of cardiovascular disease are diverse but atherosclerosis and/or hypertension are the most common . In addition , with aging come a number of physiological and morphological changes that alter cardiovascular function and lead to increased risk of cardiovascular disease , even in healthy asymptomatic individuals . Cardiovascular disease is the leading cause of deaths worldwide , though , since the 1970s , cardiovascular mortality rates have declined in many high-income countries . At the same time , cardiovascular deaths and disease have increased at a fast rate in low- and middle-income countries . Although cardiovascular disease usually affects older adults , the antecedents of cardiovascular disease , notably atherosclerosis , begin in early life , making primary prevention efforts necessary from childhood . There is therefore increased emphasis on preventing atherosclerosis by modifying risk factors , for example by healthy eating , exercise , and avoidance of smoking tobacco . # Types #  Coronary artery disease ( also known as coronary heart disease and ischemic heart disease )  Cardiomyopathy - diseases of cardiac muscle Hypertensive heart disease - diseases of the heart secondary to high blood pressure  Heart failure  Cor pulmonale - a failure at the right side of the heart with respiratory system involvement  Cardiac dysrhythmias - abnormalities of heart rhythm Inflammatory heart disease * Endocarditis inflammation of the inner layer of the heart , the endocardium . The structures most commonly involved are the heart valves . * Inflammatory cardiomegaly * Myocarditis inflammation of the myocardium , the muscular part of the heart . Valvular heart disease Cerebrovascular disease - disease of blood vessels that supply blood to the brain such as stroke Peripheral arterial disease - disease of blood vessels that supply blood to the arms and legs Congenital heart disease - heart structure malformations existing at birth Rheumatic heart disease - heart muscles and valves damage due to rheumatic fever caused by streptococcal bacteria infections # Risk factors # Evidence suggests a number of risk factors for heart diseases : age , gender , high blood pressure , hyperlipidemia , diabetes mellitus , tobacco smoking , processed meat consumption , excessive alcohol consumption , sugar consumption , family history , obesity , lack of physical activity , psychosocial factors , and air pollution . While the individual contribution of each risk factor varies between different communities or ethnic groups the consistency of the overall contribution of these risk factors to epidemiological studies is remarkably strong . Some of these risk factors , such as age , gender or family history , are immutable ; however , many important cardiovascular risk factors are modifiable by lifestyle change , social change , drug treatment and prevention of Serrano 's Cardiac Triad : hypertension , hyperlipidemia , and diabetes . # Age # Age is by far the most important risk factor in developing cardiovascular or heart diseases , with approximately a tripling of risk with each decade of life . It is estimated that 82 percent of people who die of coronary heart disease are 65 and older . At the same time , the risk of stroke doubles every decade after age 55 . Multiple explanations have been proposed to explain why age increases the risk of cardiovascular/heart diseases . One of them is related to serum cholesterol level . In most populations , the serum total cholesterol level increases as age increases . In men , this increase levels off around age 45 to 50 years . In women , the increase continues sharply until age 60 to 65 years . Aging is also associated with changes in the mechanical and structural properties of the vascular wall , which leads to the loss of arterial elasticity and reduced arterial compliance and may subsequently lead to coronary artery disease . # Sex # Men are at greater risk of heart disease than pre-menopausal women . Once past menopause , it has been argued that a woman 's risk is similar to a man 's although more recent data from the WHO and UN disputes this . If a female has diabetes , she is more likely to develop heart disease than a male with diabetes . Among middle-aged people , coronary heart disease is 2 to 5 times more common in men than in women . In a study done by the World Health Organization , sex contributes to approximately 40% of the variation in the sex ratios of coronary heart disease mortality . Another study reports similar results that gender difference explains nearly half of the risk associated with cardiovascular diseases One of the proposed explanations for the gender difference in cardiovascular disease is hormonal difference . Among women , estrogen is the predominant sex hormone . Estrogen may have protective effects through glucose metabolism and hemostatic system , and it may have a direct effect on improving endothelial cell function . The production of estrogen decreases after menopause , and may change the female lipid metabolism toward a more atherogenic form by decreasing the High-density lipoprotein Among men and women , there are notable differences in body weight , height , body fat distribution , heart rate , stroke volume , and arterial compliance . In the very elderly , age-related large artery pulsatility and stiffness is more pronounced in women . This may be caused by the smaller body size and arterial dimensions independent of menopause . # Air pollution # Particulate matter has been studied for its short- and long-term exposure effects on cardiovascular disease . Currently , PM <sub> 2.5 </sub> is the major focus , in which gradients are used to determine CVD risk . For every 10 g/m <sup> 3 </sup> of PM <sub> 2.5 </sub> long-term exposure , there was an estimated 8-18% CVD mortality risk . Women had a higher relative risk ( RR ) ( 1.42 ) for PM <sub> 2.5 </sub> induced coronary artery disease than men ( 0.90 ) did . Overall , long-term PM exposure increased rate of atherosclerosis and inflammation . In regards to short-term exposure ( 2 hours ) , every 25 g/m <sup> 3 </sup> of PM <sub> 2.5 </sub> resulted in a 48% increase of CVD mortality risk . In addition , after only 5 days of exposure , a rise in systolic ( 2.8 mmHg ) and diastolic ( 2.7 mmHg ) blood pressure occurred for every 10.5 g/m <sup> 3 </sup> of PM <sub> 2.5 </sub> . Other research has implicated PM <sub> 2.5 </sub> in irregular heart rhythm , reduced heart rate variability ( decreased vagal tone ) , and most notably heart failure . PM <sub> 2.5 </sub> is also linked to carotid artery thickening and increased risk of acute myocardial infarction. # Pathophysiology # Population-based studies show that atherosclerosis , the major precursor of cardiovascular disease , begins in childhood . The Pathobiological Determinants of Atherosclerosis in Youth Study demonstrated that intimal lesions appear in all the aortas and more than half of the right coronary arteries of youths aged 79 years . This is extremely important considering that 1 in 3 people will die from complications attributable to atherosclerosis . In order to stem the tide , education and awareness that cardiovascular disease poses the greatest threat , and measures to prevent or reverse this disease must be taken . Obesity and diabetes mellitus are often linked to cardiovascular disease , as are a history of chronic kidney disease and hypercholesterolaemia . In fact , cardiovascular disease is the most life-threatening of the diabetic complications and diabetics are two- to four-fold more likely to die of cardiovascular-related causes than nondiabetics. # Screening # Screening ECGs ( either at rest or with exercise ) are not recommended in those without symptoms who are at low risk . In those at higher risk the evidence for screening with ECGs is inconclusive . Some biomarkers may add to conventional cardiovascular risk factors in predicting the risk of future cardiovascular disease ; however , the clinical value of some biomarkers is still questionable . Currently , biomarkers that may reflect a higher risk of cardiovascular disease include the following :  Coronary artery calcification  Carotid intima-media thickness  Carotid total plaque area  Higher fibrinogen and PAI-1 blood concentrations  Elevated homocysteine  Elevated blood levels of asymmetric dimethylarginine  Inflammation as measured by C-reactive protein  Elevated Low-density lipoprotein-p  Elevated blood levels of brain natriuretic peptide ( also known as B-type ) ( BNP ) # Prevention # Currently practiced measures to prevent cardiovascular disease include :  A low-fat , high-fiber diet including whole grains and plenty of fresh fruit and vegetables ( at least five portions a day )  Tobacco cessation and avoidance of second-hand smoke  Limit alcohol consumption to the recommended daily limits consumption of 1-2 standard alcoholic drinks per day may reduce risk by 30% However excessive alcohol intake increases the risk of cardiovascular disease .  Lower blood pressures , if elevated  Decrease body fat ( BMI ) if overweight or obese  Increase daily activity to 30 minutes of vigorous exercise per day at least five times per week ( multiply by three if horizontal ) ;  Reduce sugar consumptions  Decrease psychosocial stress . Stress however plays a relatively minor role in hypertension ( if it even plays any role in the development of hypertension at all is often disputed ) . Specific relaxation therapies are not supported by the evidence . For adults without a known diagnosis of hypertension , diabetes , hyperlipidemia , or cardiovascular disease , routine counseling to advise them to improve their diet and increase their physical activity has not been found to significantly alter behavior , and thus is not recommended . # Diet # A diet high in fruits and vegetables decreases the risk of cardiovascular disease and death . Evidence suggests that the Mediterranean diet may improve cardiovascular outcomes . This may be by about 30% in those at high risk . There is also evidence that a Mediterranean diet may be more effective than a low-fat diet in bringing about long-term changes to cardiovascular risk factors ( e.g. , lower cholesterol level and blood pressure ) . The DASH diet ( high in nuts , fish , fruits and vegetables , and low in sweets , red meat and fat ) has been shown to reduce blood pressure , lower total and low density lipoprotein cholesterol and improve metabolic syndrome ; but the long term benefits outside the context of a clinical trial have been questioned . A high fiber diet appears to lower the risk . Total fat intake does not appear to be an important risk factor . A diet high in trans fatty acids ; however , does appear to increase rates of cardiovascular disease . Worldwide , dietary guidelines recommend a reduction in saturated fat . However , there are some questions around the effect of saturated fat on cardiovascular disease in the medical literature . A 2014 review did not find evidence of harm from saturated fats . A 2012 Cochrane review found suggestive evidence of a small benefit from replacing dietary saturated fat by unsaturated fat . A 2013 meta analysis concludes that substitution with omega 6 linoleic acid ( a type of unsaturated fat ) may increase cardiovascular risk . Replacement of saturated fats with carbohydrates does not change or may increase risk . Benefits from replacement with polyunsaturated fat appears greatest however supplementation with omega-3 fatty acids ( a type of polysaturated fat ) does not appear have an effect . The effect of a low-salt diet is unclear . A Cochrane review concluded that any benefit in either hypertensive or normal-tensive people is small if present . In addition , the review suggested that a low-salt diet may be harmful in those with congestive heart failure . However , the review was criticized in particular for not excluding a trial in heart failure where people had low-salt and -water levels due to diuretics . When this study is left out , the rest of the trials show a trend to benefit . Another review of dietary salt concluded that there is strong evidence that high dietary salt intake increases blood pressure and worsens hypertension , and that it increases the number of cardiovascular disease events ; the latter happen both through the increased blood pressure ' ' and ' ' , quite likely , through other mechanisms . Moderate evidence was found that high salt intake increases cardiovascular mortality ; and some evidence was found for an increase in overall mortality , strokes , and left-ventricular hypertrophy. # Supplements # While a healthy diet is beneficial , in general the effect of antioxidant supplementation ( vitamin E , vitamin C , etc. ) or vitamins has not been shown to protection against cardiovascular disease and in some cases may possibly result in harm . Mineral supplements have also not been found to be useful . Niacin , a type of vitamin B3 , may be an exception with a modest decrease in the risk of cardiovascular events in those at high risk . Magnesium supplementation lowers high blood pressure in a dose dependent manner . Magnesium therapy is recommended for patients with ventricular arrhythmia associated with torsade de pointes who present with long QT syndrome as well as for the treatment of patients with digoxin intoxication-induced arrhythmias . Evidence to support omega-3 fatty acid supplementation is lacking . # Medication # Aspirin has been found to be of benefit overall in those at low risk of heart disease as the risk of serious bleeding is equal to the benefit with respect to cardiovascular problems . Statins are effective in preventing further cardiovascular disease in people with a history of cardiovascular disease . As the event rate is higher in men than in women , the decrease in events is more easily seen in men than women . In those without cardiovascular disease but risk factors statins appear to also be beneficial with a decrease in mortality and further heart disease . The time course over which statins provide preventation against death appears to be long , of the order of one year , which is much longer than the duration of their effect on lipids. # Management # Cardiovascular disease is treatable with initial treatment primarily focused on diet and lifestyle interventions . # Epidemiology # Cardiovascular diseases are the leading cause of death . In 2008 , 30% of all global death is attributed to cardiovascular diseases . Death caused by cardiovascular diseases are also higher in low- and middle-income countries as over 80% of all global death caused by cardiovascular diseases occurred in those countries . It is also estimated that by 2030 , over 23 million people will die from cardiovascular diseases each year . # Research # The first studies on cardiovascular health were performed in year 1949 by Jerry Morris using occupational health data and were published in year 1958 . The causes , prevention , and/or treatment of all forms of cardiovascular disease remain active fields of biomedical research , with hundreds of scientific studies being published on a weekly basis . A fairly recent emphasis is on the link between low-grade inflammation that hallmarks atherosclerosis and its possible interventions . C-reactive protein ( CRP ) is a common inflammatory marker that has been found to be present in increased levels in patients who are at risk for cardiovascular disease . Also osteoprotegerin , which is involved with regulation of a key inflammatory transcription factor called NF-B , has been found to be a risk factor of cardiovascular disease and mortality . Some areas currently being researched include the possible links between infection with ' ' Chlamydophila pneumoniae ' ' ( a major cause of pneumonia ) and coronary artery disease . The ' ' Chlamydia ' ' link has become less plausible with the absence of improvement after antibiotic use . Several research also investigated the benefits of melatonin on cardiovascular diseases prevention and cure . Melatonin is a pineal gland secretion and it is shown to be able to lower total cholesterol , very-low-density and low-density lipoprotein cholesterol levels in the blood plasma of rats . Reduction of blood pressure is also observed when pharmacological doses are applied . Thus , it is deemed to be a plausible treatment for hypertension . However , further research needs to be conducted to investigate the side-effects , optimal dosage , etc. before it can be licensed for use . 
@@520540 The National Institute for Occupational Safety and Health ( NIOSH ) is the U.S. federal agency responsible for conducting research and making recommendations for the prevention of work-related injury and illness . NIOSH is part of the Centers for Disease Control and Prevention ( CDC ) within the U.S. Department of Health and Human Services . NIOSH is headquartered in Washington , D.C. , with research laboratories and offices in Cincinnati , Ohio ; Morgantown , West Virginia ; Pittsburgh , Pennsylvania ; Denver , Colorado ; Anchorage , Alaska ; Spokane , Washington ; and Atlanta , Georgia . NIOSH is a professionally diverse organization with a staff of 1,400 people representing a wide range of disciplines including epidemiology , medicine , industrial hygiene , safety , psychology , engineering , chemistry , and statistics . The director of NIOSH is John Howard . The Occupational Safety and Health Act , signed by President Richard M. Nixon , on December 29 , 1970 , created both NIOSH and the Occupational Safety and Health Administration ( OSHA ) . NIOSH was established to help ensure safe and healthful working conditions by providing research , information , education , and training in the field of occupational safety and health . NIOSH provides national and world leadership to prevent work-related illness , injury , disability , and death by gathering information , conducting scientific research , and translating the knowledge gained into products and services . # Strategic goals # NIOSH abides by a strategic plan for meeting institutional goals and allocating resources . The Institute has three overarching goals :  Conduct research to reduce work-related illnesses and injuries  Promote safe and healthy workplaces through interventions , recommendations and capacity building  Enhance global workplace safety and health through international collaborations The goals are supported by NIOSH 's program portfolio . The portfolio categorizes Institute efforts into 8 groups representing industrial sectors . The program portfolio further subdivides efforts into 24 cross sectors . # NIOSH authority # Unlike its counterpart , the Occupational Safety and Health Administration , NIOSH is not a regulatory agency . It does not issue safety and health standards that are enforceable under U.S. law . Rather , NIOSH 's authority under the Occupational Safety and Health Act 29 CFR 671 is to develop recommendations for health and safety standards , to develop information on safe levels of exposure to toxic materials and harmful physical agents and substances , and to conduct research on new safety and health problems . NIOSH may also conduct on-site investigations ( Health Hazard Evaluations ) to determine the toxicity of materials used in workplaces and fund research by other agencies or private organizations through grants , contracts , and other arrangements . NIOSH was intended to function as an agency at the same level as , and independent from , the Centers for Disease Control . NIOSH was initially placed within the Centers for Disease Control in order to obtain administrative support from the Centers until NIOSH was ready to assume those responsibilities for itself ; the Centers , however , never relinquished control and the original intent of the Act never came to pass . Also , pursuant to its authority granted to it by the Mine Safety and Health Act of 1977 , NIOSH may develop recommendations for mine health standards for the Mine Safety and Health Administration , administer a medical surveillance program for miners , including chest X&amp;#8209 ; rays to detect pneumoconiosis ( black lung disease ) in coal miners , conduct on-site investigations in mines similar to those authorized for general industry under the Occupational Safety and Health Act ; and test and certify personal protective equipment and hazard-measurement instruments . # NIOSH publications # Alerts are put out by the agency to request assistance in preventing , solving , and controlling newly identified occupational hazards . They briefly present what is known about the risk for occupational injury , illness , and death . Criteria Documents contain NIOSH 's recommendations for the prevention of occupational diseases and injuries . These documents are submitted to the Occupational Safety and Health Administration or the Mine Safety and Health Administration for consideration in their formulation of legally-binding safety and health standards . Current Intelligence Bulletins analyze new information about occupational health and safety hazards . The National Agricultural Safety Database is published by NIOSH and contains citations and summaries of scholarly journal articles and reports about agricultural health and safety . The Fatality Assessment and Control Evaluation ( FACE ) program publishes occupational fatality data . Data is used to publish fatality reports by specific sectors of industry and types of fatal incidents . The NIOSH Power Tools Database contains sound power levels , sound pressure levels , and vibrations data for a variety of common power tools that have been tested by NIOSH researchers . # NIOSH education and research centers # NIOSH Education and Research Centers are multidisciplinary centers supported by the National Institute for Occupational Safety and Health for education and research in the field of occupational health . Through the centers , NIOSH supports academic degree programs and research opportunities . The ERCs , distributed in regions across the United States , establish academic , labor , and industry research partnerships . The research conducted at the centers is related to the National Occupational Research Agenda ( NORA ) established by NIOSH . Founded in 1977 , NIOSH ERCs are responsible for nearly half of post-baccalaureate graduates entering occupational health and safety fields . The ERCs focus on industrial hygiene , occupational health nursing , occupational medicine , occupational safety , and other areas of specialization . At many ERCs , students in specific disciplines have their tuition paid in full and receive additional stipend money . ERCs provide a benefit to local businesses by offering reduced price assessments to local businesses . # Current education and research centers # University of Alabama at Birmingham &amp; Auburn University University of California , Berkeley University of California , Los Angeles University of Cincinnati Mountain &amp; Plains ERC in Colorado Harvard School of Public Health University of Illinois at Chicago University of Iowa Johns Hopkins University University of Michigan University of Minnesota Icahn School of Medicine at Mount Sinai University of North Carolina University of South Florida University of Texas University of Utah - University of Washington 
@@570661 Universal health care , sometimes referred to as universal health coverage , universal coverage , or universal care , usually refers to a health care system which provides health care and financial protection to all its citizens . It is organized around providing a specified package of benefits to all members of a society with the end goal of providing financial risk protection , improved access to health services , and improved health outcomes . Universal health care is not a one-size-fits-all concept and does not imply coverage for all people for everything . Universal health care can be determined by three critical dimensions : who is covered , what services are covered , and how much of the cost is covered . # History # The Soviet Union implemented universal health care in 1937 and extended equal access to its rural residents in 1969 . New Zealand created a universal health care system in a series of steps from 1939 to 1941 . On July 5 , 1948 , the United Kingdom implemented its universal National Health Service . Universal health care was next introduced in the Nordic countries of Sweden ( 1955 ) , Iceland ( 1956 ) , Norway ( 1956 ) , Denmark ( 1961 ) , and Finland ( 1964 ) . Universal health insurance was then implemented in Japan ( 1961 ) , Saskatchewan ( 1962 ) followed by the rest of Canada ( 19681972 ) , and twice in Australia ( 1974 and 1984 ) . Universal national health services were then introduced in the Southern European countries of Italy ( 1978 ) , Portugal ( 1979 ) , Greece ( 1983 ) , and Spain ( 1986 ) , followed by the Asian countries of South Korea ( 1989 ) , Taiwan ( 1995 ) , and Israel ( 1995 ) . From the 1970s to 1990s , the Western European countries of Austria , Belgium , France , Germany , and Luxembourg expanded their social health insurance systems to provide universal or nearly universal coverage , as did the Netherlands ( 1986 and 2006 ) and Switzerland ( 1996 ) . # Funding models # Universal health care in most countries has been achieved by a mixed model of funding . General taxation revenue is the primary source of funding , but in many countries it is supplemented by specific levies ( which may be charged to the individual and/or an employer ) or with the option of private payments ( either direct or via optional insurance ) for services beyond those covered by the public system . Almost all European systems are financed through a mix of public and private contributions . The majority of universal health care systems are funded primarily by tax revenue ( e.g. Portugal Spain , Denmark , and Sweden ) . Some nations , such as Germany , France and Japan employ a multi-payer system in which health care is funded by private and public contributions . However , much of the non-government funding is by contributions by employers and employees to regulated non-profit sickness funds . These contributions are compulsory and defined according to law . A distinction is also made between municipal and national healthcare funding . For example , one model is that the bulk of the healthcare is funded by the municipality , speciality healthcare is provided and possibly funded by a larger entity , such as a municipal co-operation board or the state , and the medications are paid by a state agency . Universal health care systems are modestly redistributive . Progressivity of health care financing has limited implications for overall income inequality . In some European countries where there is private insurance and universal health care , such as Germany , Belgium , and the Netherlands , the problem of adverse selection ( see Private insurance below ) is overcome using a risk compensation pool to equalize , as far as possible , the risks between funds . Thus a fund with a predominantly healthy , younger population has to pay into a compensation pool and a fund with an older and predominantly less healthy population would receive funds from the pool . In this way , sickness funds compete on price , and there is no advantage to eliminate people with higher risks because they are compensated for by means of risk-adjusted capitation payments . Funds are not allowed to pick and choose their policyholders or deny coverage but then mainly compete on price and service . In some countries , the basic coverage level is set by the government and can not be modified . Ireland at one time had a community rating system through VHI , effectively a single-payer or common risk pool . The government later opened VHI to competition but without a compensation pool . This resulted in foreign insurance companies entering the Irish market and offering cheap health insurance to relatively healthy segments of the market , which then made higher profits at VHI 's expense . The government later reintroduced community rating through a pooling arrangement and at least one main major insurance company , BUPA , then withdrew from the Irish market . Among the potential solutions posited by economists are single payer systems as well as other methods of ensuring that health insurance is universal , such as by requiring all citizens to purchase insurance and limiting the ability of insurance companies to deny insurance to individuals or vary price between individuals . # Single payer # Single-payer health care is a system in which the government , rather than private insurers , pays for all health care costs . Single-payer systems may contract for healthcare services from private organizations ( as is the case in Canada ) or may own and employ healthcare resources and personnel ( as is the case in the United Kingdom ) . The term single-payer thus describes only the funding mechanism and refers to health care financed by a single public body from a single fund and does not specify the type of delivery , or for whom doctors work . Although the fund holder is usually the state , some forms of single-payer use a mixed public-private system . # Tax-based financing # In tax-based financing , individuals contribute to the provision of health services through various taxes . These are typically pooled across the whole population , unless local governments raise and retain tax revenues . Some countries ( notably the United Kingdom , Canada , Ireland , Australia , Italy , Spain , Portugal , Greece and the Nordic countries ) choose to fund health care directly from taxation alone . Other countries with insurance-based systems effectively meet the cost of insuring those unable to insure themselves via social security arrangements funded from taxation , either by directly paying their medical bills or by paying for insurance premiums for those affected . # Social health insurance # In social health insurance , contributions from workers , the self-employed , enterprises and government are pooled into a single or multiple funds on a compulsory basis . These funds typically contract with a mix of public and private providers for the provision of a specified benefit package . Preventive and public health care may be provided by these funds or responsibility kept solely by the Ministry of Health . Within social health insurance , a number of functions may be executed by parastatal or non-governmental sickness funds or in a few cases by private health insurance companies . # Private insurance # In private health insurance , premiums are paid directly from employers , associations , individuals and families to insurance companies , which pool risks across their membership base . Private insurance includes policies sold by commercial for profit firms , non-profit companies , and community health insurers . Generally , private insurance is voluntary , in contrast to social insurance programs , which tend to be compulsory . In some countries with universal coverage , private insurance often excludes many health conditions which are expensive and which the state health care system can provide . For example , in the United Kingdom , one of the largest private health care providers is BUPA , which has a long list of general exclusions even in its highest coverage policy , most of which are routinely provided by the National Health Service . In the United States , dialysis treatment for end stage renal failure is generally paid for by government and not by the insurance industry . Persons with privatized Medicare ( Medicare Advantage ) are the exception and must get their dialysis paid through their insurance company , but persons with end stage renal failure generally can not buy Medicare Advantage plans . The Planning Commission of India has also suggested that the country should embrace insurance to achieve universal health coverage . General tax is currently used to meet the essential health requirements of all people . # Community-based health insurance # A particular form of private health insurance that has often emerged in environments where financial risk protection mechanisms only have a limited impact is community-based health insurance . Contributions are not risk-related , and there is generally a high level of community involvement in the running of such schemes . # Implementation and comparisons # Universal health care systems vary according to the degree of government involvement in providing care and/or health insurance . In some countries , such as the UK , Spain , Italy , Australia and the Nordic countries , the government has a high degree of involvement in the commissioning or delivery of health care services and access is based on residence rights , not on the purchase of insurance . Others have a much more pluralistic delivery system , based on obligatory health with contributory insurance rates related to salaries or income and usually funded by employers and beneficiaries jointly . Sometimes , the health funds are derived from a mixture of insurance premiums , salary related mandatory contributions by employees and/or employers to regulated sickness funds , and by government taxes . These insurance based systems tend to reimburse private or public medical providers , often at heavily regulated rates , through mutual or publicly owned medical insurers . A few countries , such as the Netherlands and Switzerland , operate via privately owned but heavily regulated private insurers , which are not allowed to make a profit from the mandatory element of insurance but can profit by selling supplemental insurance . Universal health care is a broad concept that has been implemented in several ways . The common denominator for all such programs is some form of government action aimed at extending access to health care as widely as possible and setting minimum standards . Most implement universal health care through legislation , regulation and taxation . Legislation and regulation direct what care must be provided , to whom , and on what basis . Usually , some costs are borne by the patient at the time of consumption , but the bulk of costs come from a combination of compulsory insurance and tax revenues . Some programs are paid for entirely out of tax revenues . In others , tax revenues are used either to fund insurance for the very poor or for those needing long-term chronic care . The United Kingdom government 's National Audit Office in 2003 published an international comparison of ten different health care systems in ten developed countries , nine universal systems against one non-universal system ( the United States ) , and their relative costs and key health outcomes . A wider international comparison of 16 countries , each with universal health care , was published by the World Health Organization in 2004 . In some cases , government involvement also includes directly managing the health care system , but many countries use mixed public-private systems to deliver universal health care . 
@@616967 MeshID = D015212 In medicine , inflammatory bowel disease ( IBD ) is a group of inflammatory conditions of the colon and small intestine . Crohn 's disease and ulcerative colitis are the principal types of IBD . It is important to note that not only does Crohn 's disease affect the small intestine and large intestine , it can also affect the mouth , oesophagus , stomach and the anus. # Classification # The chief types of IBD are Crohn 's disease and ulcerative colitis ( UC ) . Inflammatory bowel diseases fall into the class of autoimmune diseases , in which the body 's own immune system attacks elements of the digestive system . Accounting for far fewer cases are other forms of IBD , which are not always classified as typical IBD :  Collagenous colitis  Lymphocytic colitis  Diversion colitis  Behet 's disease  Indeterminate colitis The way doctors can tell the difference between Crohn 's disease and UC is the ' ' location ' ' and ' ' nature ' ' of the inflammatory changes . Crohn 's can affect any part of the gastrointestinal tract , from mouth to anus ( ' ' skip lesions ' ' ) , although a majority of the cases start in the terminal ileum . Ulcerative colitis , in contrast , is restricted to the colon and the rectum . Microscopically , ulcerative colitis is restricted to the mucosa ( epithelial lining of the gut ) , while Crohn 's disease affects the full thickness of the bowel wall ( transmural lesions ) . Lastly , Crohn 's disease and ulcerative colitis present with extra-intestinal manifestations ( such as liver problems , arthritis , skin manifestations and eye problems ) in different proportions . Rarely , a definitive diagnosis neither of Crohn 's disease nor of ulcerative colitis can be made because of idiosyncrasies in the presentation . In this case , a diagnosis of indeterminate colitis may be made . Although a recognised definition , not all centres refer to this . # Signs and symptoms # In spite of Crohn 's and UC being very different diseases , both may present with any of the following symptoms : abdominal pain , vomiting , diarrhea , rectal bleeding , severe internal cramps/muscle spasms in the region of the pelvis and weight loss . Anemia is the most prevalent extraintestinal complication of inflammatory bowel disease . Associated complaints or diseases include arthritis , pyoderma gangrenosum , primary sclerosing cholangitis , and non-thyroidal illness syndrome ( NTIS ) . Diagnosis is generally by assessment of inflammatory markers in stool followed by colonoscopy with biopsy of pathological lesions. # Causes # IBD is a complex disease which arises as a result of the interaction of environmental and genetic factors . It is increasingly thought that alterations to enteral bacteria can contribute to inflammatory gut diseases The enteral bacteria can be altered by environmental factors , such as Concentrated milk fats ( a common ingredient of processed foods and confectionery ) or oral medications such as antibiotics and oral iron preparations . # Genetics # The genetic contribution is poorly understood and seems to arise from the small contribution of dozens of genes . In 2012 163 IBD susceptibility loci were confirmed which means that 163 alleles that can increase the susceptibility to the disease . These 163 loci explain from an 8.2% to a 13.6% of variance in Crohns disease and 4.1% to 7.5% in ulcerative colitis . The 163 loci were related with 300 known genes . The functional enrichment analysis of this group of genes using Gene Ontology showed that there are many genes related with cytokine production , lymphocyte activation and the response to bacterial infection . In an effort to identify likely causal genes a probabilistic causal gene network was constructed . Here a sub-network including NOD2 , Il10 and CARD9 seems to indicate a close relationship between IBD and genes related with host interaction with bacteria . Of particular relevance is the presence of the gene HCK which seems to play an important role anti-inflammation . In the figure beside there is a NOD2-focused cluster in the causal gene sub-network. # Treatment # CD and UC are autoimmune diseases , and are not medically curable . Surgery can essentially cure ulcerative colitis if the large intestine is removed ( though medical treatment and endoscopic surveillance may be necessary if a stump of rectum is left behind ) , but surgery can not cure Crohn 's disease . Medical treatment of IBD is individualized to each patient . The choice of which drugs to use and by which route to administer them ( oral , rectal , injection , infusion ) depends on factors including the type , distribution , and severity of the patient 's disease , as well as other historical and biochemical prognostic factors , and patient preferences . For example , mesalazine is more useful in ulcerative colitis than in Crohn 's disease . Generally , depending on the level of severity , IBD may require immunosuppression to control the symptom , such as prednisone , TNF inhibition , azathioprine ( Imuran ) , methotrexate , or 6-mercaptopurine . Often , anti-inflammatory steroids are used to control disease flares and were once acceptable as a maintenance drug . In use for several years in Crohn 's disease patients and recently in patients with ulcerative colitis , biologicals have been used such as TNF inhibitors . Severe cases may require surgery , such as bowel resection , strictureplasty or a temporary or permanent colostomy or ileostomy . Ulcerative colitis can be cured by removing the entire large intestine and the rectum , and while this can not get rid of extra-intestinal symptoms , the disease can not recur without a large intestine . In Crohn 's disease , surgery involves removing the worst inflamed segments of the intestine and connecting the healthy regions , but unfortunately , it does not cure Crohn 's or eliminate the disease , as at some point after the first surgery , Crohn 's disease recurs in the healthy parts of the intestine , usually at the resection site . ( For example , if a patient with Crohn 's disease has an ileocecal anastomosis , in which the caecum and terminal ileum are removed and the ileum is joined to the ascending colon , their Crohn 's will nearly always flare-up near the anastomosis or in the rest of the ascending colon ) . Usually the treatment is started by administering drugs with high anti-inflammatory effects , such as prednisone . Once the inflammation is successfully controlled , the patient is usually switched to a lighter drug to keep the disease in remission , such as Asacol , a mesalazine . If unsuccessful , a combination of the aforementioned immunosuppression drugs with a mesalazine ( which may also have an anti-inflammatory effect ) may or may not be administered , depending on the patient . Budesomide is the easiest medication for the elderly and children . A relatively new treatment option is fecal bacteriotherapy ( FBT ) , which has been used to successfully treat IBD in several small studies . There is evidence of an infections contribution to inflammatory bowel disease in some patients and this subgroup of patients may benefit from antibiotic therapy . Anaemia is a common finding in both ulcerative colitis and Crohn 's disease . Due to raised levels of inflammatory cytokines which lead to the increased expression of hepcidin , parenteral iron is the preferred treatment option as it bypasses the gastrointestinal system , has lower incidence of adverse events and enables quicker treatment . Hepcidin itself is also an anti-inflammatory agent . In the murine model very low levels of iron restrict hepcidin synthesis , worsening the inflammation that is present . Enteral nutrition has been found to be efficient to improve hemoglobin level in patients with inflammatory bowel disease , especially combined with erythropoietin . Due to the fact that the disease might be triggered by the blooms of a rare type of gut bacteria some anti-bacterial drugs like chloroxine might be able to dispense the problem . A wider study is needed to confirm this . In February 2013 researchers identified adult stem cells in the bone marrow that could one day be used to treat inflammatory bowel disease ( IBD ) . # Prognosis # While IBD can limit quality of life because of pain , vomiting , diarrhea , and other socially unacceptable symptoms , it is rarely fatal on its own . Fatalities due to complications such as toxic megacolon , bowel perforation and surgical complications are also rare . While patients of IBD do have an increased risk of colorectal cancer , this is usually caught much earlier than the general population in routine surveillance of the colon by colonoscopy , and therefore patients are much more likely to survive . New evidence suggests that patients with IBD may have an elevated risk of endothelial dysfunction and coronary artery disease . A recent literature review by Gandhi et al . described that IBD patients over the age of 65 and females are at increased risk of coronary artery disease despite the lack of traditional risk factors . The goal of treatment is toward achieving remission , after which the patient is usually switched to a lighter drug with fewer potential side effects . Every so often , an acute resurgence of the original symptoms may appear ; this is known as a flare-up . Depending on the circumstances , it may go away on its own or require medication . The time between flare-ups may be anywhere from weeks to years , and varies wildly between patients - a few have never experienced a flare-up . # Epidemiology # Globally , as of 2010 , IBD resulted in 34,000 deaths . # Research # The following treatment strategies are not used routinely , but appear promising in most forms of inflammatory bowel disease . Initial reports suggest that helminthic therapy may not only prevent but even control IBD : a drink with roughly 2,500 ova of the ' ' Trichuris suis ' ' helminth taken twice monthly decreased symptoms markedly in many patients . It is even speculated that an effective immunization procedure could be developedby ingesting the cocktail at an early age . Prebiotics and probiotics are showing increasing promise as treatments for IBD and in some studies have proven to be as effective as prescription drugs . In 2005 New Scientist published a joint study by Bristol University and the University of Bath on the apparent healing power of cannabis on IBD . Reports that cannabis eased IBD symptoms indicated the possible existence of cannabinoid receptors in the intestinal lining , which respond to molecules in the plant-derived chemicals . CB1 cannabinoid receptors which are known to be present in the brain exist in the endothelial cells which line the gut , it is thought that they are involved in repairing the lining of the gut when damaged . The team deliberately damaged the cells to cause inflammation of the gut lining and then added synthetically produced cannabinoids ; the result was that gut started to heal : the broken cells were repaired and brought back closer together to mend the tears . It is believed that in a healthy gut , natural endogenous cannabinoids are released from endothelial cells when they are injured , which then bind to the CB1 receptors . The process appears to set off a wound-healing reaction , and when people use cannabis , the cannabinoids bind to these receptors in the same way . Previous studies have shown that CB1 receptors located on the nerve cells in the gut respond to cannabinoids by slowing gut motility , therefore reducing the painful muscle contractions associated with diarrhea . The team also discovered another cannabinoid receptor , CB2 , in the guts of IBD sufferers , which was not present in healthy guts . These receptors , which also respond to chemicals in cannabis , appear to be associated with apoptosis programmed cell death and may have a role in suppressing the overactive immune system and reducing inflammation by mopping up excess cells . Alicaforsen is a first generation antisense oligodeoxynucleotide designed to bind specifically to the human ICAM-1 messenger RNA through Watson-Crick base pair interactions in order to subdue expression of ICAM-1 . ICAM-1 propagates an inflammatory response promoting the extravasation and activation of leukocytes ( white blood cells ) into inflamed tissue . Increased expression of ICAM-1 has been observed within the inflamed intestinal mucosa of ulcerative colitis , pouchitis and Crohn 's sufferers where ICAM-1 over production correlated with disease activity . This suggests that ICAM-1 is a potential therapeutic target in the treatment of these diseases . In 2014 , an alliance among the Broad Institute , Amgen and Massachusetts General Hospital formed with the intention to collect and analyze patient DNA samples to identify and further validate genetic targets . 
@@665909 An injection ( often referred to as a shot in US English , or a jab in UK English ) is an infusion method of putting fluid into the body , usually with a syringe and a hollow needle which is pierced through the skin to a sufficient depth for the material to be administered into the body . An injection follows a parenteral route of administration ; that is , administration via a route other than through the digestive tract . Since the process inherently involves a small puncture wound to the body ( with varying degrees of pain depending on injection type and location , medication type , needle gauge and the skill of the individual administering the injection ) , fear of needles is a common phobia . There are several methods of injection or infusion used in humans , including intradermal , subcutaneous , intramuscular , intravenous , intraosseous , intraperitoneal , intrathecal , epidural , intracardiac , intraarticular , intracavernous , and intravitreal . Rodents used for research are often administered intracerebral and intracerebroventricular injections as well . Long-acting forms of *26;201934;TOOLONG injections are available for various drugs , and are called depot injections . Injections are among the most common health care procedures , with at least 16 billion administered in developing and transitional countries each year . 95% of injections are administered in curative care , 3% are for immunization , and the rest for other purposes , such as blood transfusions . In some instances the term ' ' injection ' ' is used synonymously with inoculation even by different workers in the same hospital . This should not cause confusion ; the focus is on what is being injected/inoculated , not the terminology of the procedure . # Intramuscular injection # In an intramuscular injection , the medication is delivered directly into a muscle . Many vaccines are administered intramuscularly , as are codeine , metoclopramide , and many other medications . Many drugs injected intramuscularly are absorbed into the muscle fairly quickly , while others are more gradual . Injections to the buttocks are known to reach the bloodstream quickly due to the large amount of muscular tissue and corresponding blood supply . Generally , intramuscular injections are administered by a trained medical professional ; however , prescribed self-administered intramuscular injections are becoming more common for patients who require these injections routinely . # Depot injection # A depot injection is an injection , usually subcutaneous or intramuscular , of a pharmacological agent which releases its active compound in a consistent way over a long period of time . Depot injections are usually either solid or oil-based . Depot injections may be available as certain forms of a drug , such as decanoate salts or esters . Examples of depot injections include Depo Provera and haloperidol decanoate . Prostate cancer patients receiving hormone therapy usually get depot injections as a treatment or therapy . Zoladex is an example of a medication delivered by depot for prostate cancer treatment or therapy . The advantages of using a long-acting depot injection include increased medication compliance due to reduction in the frequency of dosing , as well as more consistent serum concentrations . A significant disadvantage is that the drug is not immediately reversible , since it is slowly released . In psychiatric nursing , a short acting depot , zuclopenthixol acetate ( Clopixol Acuphase ) , which lasts in the system from 24 72 hours , is now more regularly used for rapid tranquillisation. # Hypodermic injections in nature # Various animals , and some plants , have been injecting for various reasons long before humans began doing so in a process commonly called stinging . Some examples include : Snakes , wasps , scorpions : poison , to kill prey and self-defense. Some bees : poison , to defend themselves and their nests . Cnidaria ( jellyfish , etc. ) : poison , to kill prey . Stinging nettles : poison , to try to avoid being eaten .  Stingrays : poison , defense mechanism when provoked . # Injection pain # The pain of an injection may be lessened by prior application of ice or topical anesthetic , or simultaneous pinching of the skin . Recent studies suggest that forced coughing during an injection stimulates a transient rise in blood pressure which inhibits the perception of pain . Sometimes , as with an amniocentesis , a local anesthetic is given . The most common technique to reduce the pain of an injection is simply to distract the patient . Babies can be distracted by giving them a small amount of sweet liquid , such as sugar solution , during the injection , which reduces crying . # Injection safety # 40% of injections worldwide are administered with unsterilized , reused syringes and needles , and in some countries this proportion is 70% , exposing millions of people to infections . Another risk is poor collection and disposal of dirty injection equipment , which exposes healthcare workers and the community to the risk of needle stick injuries . In some countries , unsafe disposal can lead to re-sale of used equipment on the black market . Many countries have legislation or policies that mandate that healthcare professionals use a safety syringe ( safety engineered needle ) or alternative methods of administering medicines whenever possible . Open burning of syringes , which is considered unsafe by the World Health Organization , is reported by half of the non-industrialized countries . According to one study , unsafe injections cause an estimated 1.3 million early deaths each year . To improve injection safety , the WHO recommends : # Changing the behavior of health care workers and patients # Ensuring the availability of equipment and supplies # Managing waste safely and appropriately A ' ' needle tract infection ' ' is an infection that occurs when pathogenic micro-organisms are seeded into the tissues of the body during an injection . Such infections are also referred to as ' ' needlestick infections ' ' . ; Glossary # See also #  Dart injection  Jet injector  Injection port  Needlestick injury  Needle remover  Safety Syringe 
@@748409 ' ' Dr. Quinn , Medicine Woman ' ' is an American Western drama series created by Beth Sullivan and starring Jane Seymour who plays Dr. Michaela Mike Quinn , a physician who leaves Boston in search of adventure in the American West and who settles in Colorado Springs , Colorado . The television series ran on CBS for six seasons , from January 1 , 1993 to May 16 , 1998 . In total , 150 episodes were produced , plus two television movies which were made after the series was cancelled . It aired in over 100 countries , including Denmark ( where it was aired on TV2 ) , the United Kingdom , France , and Canada ( where it was aired on CTV throughout its run ) . Since 1997 , reruns have been shown in syndication and on ABC Family ( formerly The Family Channel ) , Ion Television ( formerly PAX-TV ) , the Hallmark Channel , gmc , Eleven , CBS Drama , and INSP. # Plot # # Regular series # The series begins in the year 1867 and centers on a proper and wealthy female physician from Boston , Massachusetts , Michaela Quinn ( Jane Seymour ) , familiarly known as Dr. Mike . After her father 's death , she sets out west to the small wild west town of Colorado Springs , to set up her own practice . She makes the difficult adjustment to life in Colorado with the aid of rugged outdoorsman and friend to the Cheyenne , Byron Sully ( Joe Lando ) and a midwife named Charlotte Cooper ( played by Diane Ladd ) . After Charlotte is bitten by a rattlesnake , she asks Michaela on her deathbed to look after her three children : Matthew ( Chad Allen ) , Colleen ( played by Erika Flores and later , Jessica Bowman ) and Brian ( Shawn Toovey ) . Dr. Mike settles in Colorado Springs and adapts to her new life as a mother , with the children , while finding true love with Sully . Furthermore , she acts as a one-woman mission to convince the townspeople that a female doctor can successfully practice medicine . # ' ' Dr. Quinn : Revolutions ' ' # The cancellation of ' ' Dr. Quinn ' ' caused a massive fan uproar , the likes of which had not been seen since the campaign to save ' ' Star Trek ' ' in the mid-1960s . CBS decided that instead of producing another season , as the cost involved was deemed too high , it would instead produce a TV movie . In May 1999 , one year after its cancellation , CBS aired ' ' Dr. Quinn : Revolutions ' ' , a television movie special , set in 1877 . However , the actual date should have been 1875 , two years following the final episode , which would have been in 1873 . In this TV movie , Katie Sully , now age 4 , is kidnapped , and Dr. Mike and Sully , with help from some townsfolk , embark on a desperate search for their missing daughter in Mexico . Fans were delighted that a special movie was being produced , but they were not altogether impressed with its overall concept . The movie was very different in tone than the rest of the series , incorporating more guns and violence in an effort to please the twenty-something male audience demographics . Furthermore , both Jessica Bowman and Chad Allen declined appearances in that episode , due to its content , and William Olvis ' entire score was scrapped in favor of more cost-effective music that was completely unlike that of the original series . Fans were shocked to find a ' ' Dr. Quinn ' ' episode that did not include the main title sequence or theme . Moreover , the script , acting , and interpretations of the original characters came across as unfamiliar and very unlike their portrayals in the series . Beth Sullivan was so furious with CBS 's control over the whole project that she declined any involvement . It was critically panned and failed in the ratings . # ' ' Dr. Quinn : The Heart Within ' ' # A second movie entitled ' ' Dr Quinn : The Heart Within ' ' , aired in May 2001 . The movie was set a year after ' ' Revolutions ' ' , making it 9 years since the first episode of ' ' Dr. Quinn ' ' in the year 1876 . This time around , CBS gave Beth Sullivan total creative control ; however , there were some strong ground rules . To save money , the movie had to be filmed in Canada , and only the principal cast could be involved . Jane Seymour also served as an executive producer . The plot revolved around Michaela and the Sully family returning to Boston to attend Colleen 's graduation from Harvard Medical School . Having transferred from The Women 's Medical College to the male dominated university since the series finale , Colleen has met harsh criticism from the board as well as from Andrew 's father , who resents the fact that she continues to pursue medicine , despite his misgivings . Unfortunately , Michaela 's mother , Elizabeth , has fallen ill due to a heart condition , and eventually passes , leaving her entire estate to Michaela to establish a hospital back in Colorado Springs . Colleen soon finds herself in a similar situation as her mother , Michaela did just nine years earlier - in the same Bostonian sectorin that she is not respected or taken seriously as a woman doctor . The movie is a proper finale to the series , depicting the now-adult Cooper children 's farewell to Colorado Springs , and finding their new futures in Boston , while Michaela and Sully inevitably return to Colorado Springs to begin a new chapter in their own , now older , adult lives . While this movie was far better received by fans , they did complain that more of the townspeople and original supporting cast were not involved , due to CBS 's demands , as well as the last-minute absence of Chad Allen 's Matthew ( Allen had declined after learning that none of his original supporting costars were offered any appearances ) . Despite these criticisms , the movie was a success . # Cast and characters # # Starring # Main cast  Jane Seymour Dr. Michaela Quinn  Joe Lando Byron Sully  Chad Allen Matthew Cooper  Erika Flores Colleen Cooper ( up to mid-season 3 )  Jessica Bowman Colleen Cooper Cook ( from season 3 on )  Shawn Toovey Brian Cooper Supporting cast  Orson Bean Loren Bray  Jim Knobeloch Jake Slicker  Frank Collison Horace Bing  William Shockley Hank Lawson  Geoffrey Lower Rev. Timothy Johnson  Henry G. Sanders Robert E.  Nick Ramus - Chief Black Kettle  Larry Sellers Cloud Dancing  Jonelle Allen Grace  Heidi Kozak Emily Donovan ( season 1 )  Gail Strickland Ms. Olive Davis , Loren 's sister ( season 1 )  Jennifer Youngs Ingrid ( seasons 14 )  Helene Udy Myra Bing ( seasons 14 )  Haylie Johnson Becky Bonner ( seasons 16 )  Barbara Babcock Dorothy Jennings ( seasons 26 )  Georgann Johnson Elizabeth Quinn ( seasons 26 )  Alley Mills Marjorie Quinn ( seasons 26 )  Elinor Donahue Rebecka Quinn Dickinson ( season 26 )  Charlotte Chatton Emma ( seasons 4 &amp; 5 )  Michelle Bonilla Teresa Morales ( season 5 )  Brandon Douglas Dr. Andrew Cook ( seasons 46 )  Jason Leland Adams Preston A. Lodge III ( seasons 46 ) , George Armstrong Custer ( Season 3 )  Alex Meneses Teresa Morales Slicker ( season 6 )  John Schneider Daniel Simon ( season 6 )  Brenden Jefferson Anthony ( season 4 )  McKenzie Calabrese , Megan Calabrese , Alexandria Calabrese - Katherine Elizabeth Katie Sully Guest Stars  Edward Albert - Dr. William Burke ( ep . 2x06 )  David Beecroft - Sergeant Terence McKay ( ep . 5x25 , 5x26 , 6x01 , 6x02 , 6x03 , 6x11 )  Verna Bloom - Maude Bray ( ep . 1x01 )  Guy Boyd - Loren Bray ( ep . 1x01 ) later recast  David Carradine - Houston Currier ( ep . 5x20 )  June Carter Cash - Sister Ruth ( ep . 2x05 , 3x10 , 5x16 )  Johnny Cash - Kid Cole ( ep . 1x05 , 2x05 , 3x10 , 5x16 )  Maxwell Caulfield - Andrew Strauss/David Lewis ( ep . 2x24 )  Denise Crosby - Isabelle Maynard ( ep . 4x25 )  Robert Culp - Dr. Elias Jackson ( ep . 1x07 )  Steven Culp - Peter Doyle ( ep . 5x21 )  Jon Cypher - Preston A. Lodge II ( ep . 5x10 )  Kristin Davis - Carey McGee ( ep . 3x09 )  Zach Galligan - Chester Barnes ( ep . 6x12 )  Joseph Gordon-Levitt - Zach Lawson , Hank 's son ( ep . 1x15 )  Jerry Haynes - Mr. Royce ( ep . 6x08 , 6x09 )  Richard Herd - Dr. John Hansen ( ep . 2x06 , 2x07 )  James Keach - Brent Currier ( ep . 5x20 )  Stacy Keach , Sr. - Judge Webster ( ep . 5x03 , 5x07 , 5x14 )  Diane Ladd - Charlotte Cooper ( pilot , ep 2x11 )  Matt Letscher - Tom Jennings , Dorothy 's son ( ep . 2x19 )  Anne Lockhart - Maureen ( ep . 2x06 , 2x07 )  Barbara Mandrell - Gilda St. Clair ( ep . 5x04 )  Colm Meaney - Jake Slicker ( ep . 1x01 ) later recast  Richard Moll - John ( ep . 3x06 , 3x28 , 3x29 )  Willie Nelson - Marshall Elias Burch ( ep . 5x09 , 6x19 )  David Ogden Stiers - Theodore Quinn ( ep . 5x15 )  Tom Poston - Mysterious ' Dead Man ' ( ep . 2x03 )  Andrew Prine - Thaddeus Birch ( ep . 1x09 )  Fred Rogers - Reverend Thomas ( ep . 4x19 )  Kenny Rogers - Daniel Watkins ( ep . 1x16 )  Richard Roundtree - ' Barracuda ' Jim Barnes ( ep . 6x21 )  Nick Tate - Martin ' Avishominis ' Chesterfield ( ep . 6x18 )  Travis Tritt - Zachary Brett ( ep . 4x14 )  Casper Van Dien - Jesse ( ep . 3x03 , 3x04 )  Ray Walston - Lucius Slicker ( ep . 5x08 )  Jane Wyman - Elizabeth Quinn ( ep . 1x03 ) later recast  Trisha Yearwood - Choir Director ( ep . 3x10 ) # Replacement of Erika Flores with Jessica Bowman # There were various cast changes of minor characters during the series . The most controversial change took place during the show 's third season when the character of Colleen Cooper was recast halfway through the year . Unlike the other actors , who signed 5-year contracts with the show , Erika Flores was hesitant . She held out for an increase in her salary and refused to sign a contract unless offered a contract of less than 5 years , or an increase in salary . Rumors circulated that Flores 's father gave her an ultimatum to end the contract unless they offered her more money , or he would cut her off financially . Flores has denied such rumors , saying that she left the series for personal reasons and to pursue other opportunities . Whatever the reasons , the actress was abruptly dismissed with little warning by CBS after the show declined to meet her requests . Beth Sullivan decided that she wanted the character to continue instead of being killed off or sent away . As a result , Jessica Bowman was cast as the new Colleen in Flores 's place . Some of Erika Flores 's fans were quite vocal in their anger over the change and wrote CBS demanding to know why the actress had been replaced . CBS issued the following statement to the press : Official Dr. Quinn , Medicine Woman Web Site February 7 , 1996 # Dear Viewers : Over the past several months we have received numerous letters regarding the re-casting of Colleen on our show . When this change occurred , we released a statement to the effect of , Unwilling to commit to 5 years , Erika Flores is leaving the series to pursue other interests . Well , it 's now over one year and , the fact remains that Erika Flores left the show to pursue other interests . Now , what are those other interests ? I can tell you its primarily school . She 's auditioned for movies , but her primary focus , to our knowledge , is school . After all , she 's only 16 years old . The events leading up to her decision to leave the show did include CBS 's request that she sign a 5-year contract . Erika did not want to commit to that extended period of time , and CBS would not allow it ( all the series regulars , including Jane Seymour , are required to sign a 5-year contract . ) We , as producers of the show , were able to convince CBS to double Erika 's salary in an attempt to keep her on the show , but she still was unwilling to commit to 5 years . This being the case , we had no other choice but to replace her . I hope that this will help clarify your questions about Erika Flores . She remains a very close friend of the show , often visiting the set for lunch and we wish her all the best in her future pursuits . Tim Johnson Producer , Dr. Quinn , Medicine Woman ( c ) 1996 CBS # The producers of the show felt that Jessica Bowman had the ability to successfully recreate the character on her own . # Other cast changes # Numerous cast changes occurred throughout the series , although none was as significant . Most notable was the replacement of Jane Wyman as Michaela 's mother , Elizabeth Quinn . Wyman signed on to play the role for the third episode of ' ' Dr. Quinn ' ' in season one . Sources say that Seymour and Wyman did not get along during the shooting of the episode . Later Wyman refused to return for another guest appearance in season two . Georgann Johnson was hired to replace Wyman in the role and continued throughout the remainder of the series , making one guest appearance each season and appearing in the final ' ' Dr. Quinn ' ' television movie . Michelle Bonilla originated the role of Theresa Morales in season five and was replaced by Alex Meneses in season six . She was abruptly let go for reasons that were never publicly stated . Meneses 's portrayal was well received and she was featured throughout the sixth season , when her character fell in love with Jake Slicker . The role of Anthony ( Grace and Robert E. 's adopted son ) was played by Brenden Jefferson for four episodes in season four . He was replaced by Brandon Hammond , who continued in the role throughout season five and six . Jennifer Youngs did not begin playing Ingrid until the character 's second appearance ; the first time the character appeared , she was played by Ashley Jones . # Broadcast and release # # Broadcast history # During its entire original run on CBS , the show aired from 89 pm Eastern time on Saturday nights . It was the last successful TV Western drama to date until the premiere of ' ' Deadwood ( TV series ) # About the show # ' ' Dr. Quinn ' ' was best known for its large , supporting cast , and its high-concept storytelling . The series often used its semi-historical setting as a vehicle to address issues of gender and race within the community . For example , one episode took on homophobia when the famous poet Walt Whitman came to town . Religion played a somewhat minor role in the series , but was also used to address certain issues and new ideas . Veteran actress Jane Seymour , labeled a mini-series queen , was a last-minute casting choice for Michaela Quinn after reading the script only a day before production was set to begin on the pilot . She was instructed beforehand to review the script and make a decision of whether or not she felt the role was right for her , and , if so , that she truly wanted to commit to the strict contract Sullivan had demanded for the title character . Seymour is quoted as saying she was moved to tears by the script and that she was literally born to portray Michaela Quinn , the second most perfect character role she 'd ever portray in her career . The next day she began the wardrobe fittings for the series . The pilot episode was shot in early 1992 and aired in a 2-hour television special on New Year 's Day 1993 . CBS aired a second , hour-long episode the next night in order to attract and maintain the audience 's attention . Expectations for the show were low due to its airtime alongside the Orange Bowl that year . Initially , critics panned the series and predicted that it would be quickly cancelled . Therefore , the pilot served more as a made-for-television movie - or mini-series suggestion which could either be developed later into a full series or remain as a stand alone 2-hour movie . To the network 's surprise however , the ratings for the pilot and the first episode were remarkably high . CBS ordered the show picked up immediately for the full season . The show made some imperative casting changes , however . Several pilot leads and a few of the supporting cast were replaced . Henry Sanders was recast as Robert E. ; Orson Bean replaced Guy Boyd as a more fatherly , cynically-comical Loren Bray ; and Colm Meaney was replaced by Jim Knobeloch , a much younger , attractive Jake Slicker . The series ' central , inevitably-blossoming romance between Michaela and Sully grew popular with audiences . The popularity was related to the obvious on-screen chemistry between Seymour and Joe Lando . In the season 3 finale , titled , For Better or Worse , they were married during a special two-hour episode , which gained huge notoriety alongside its ratings , and very highly dramatized publicity in popular magazines and on television commercial break specials . During season 4 , Seymour 's real-life pregnancy was written into the show . Soon , another very highly rated episode centered on the long-awaited birth of Michaela and Sully 's daughter , Katie . Members of the large supporting cast were each given the opportunity , over time , to fully develop their own characters . The producers soon began leaving the doors open for the supporting cast to make suggestions and contribute ideas to the writers . ' ' Dr. Quinn ' ' was one of the few dramatic shows that allowed fans full access to their filming sets at the Paramount Ranch in Agoura Hills , California . Fans were permitted , often invited , to watch episodes being shot each week . Cast members were known to speak with their fans and sign autographs during shooting breaks . During the show 's final season run , an official web site was established , which remains active . Two fans went on to create the ' ' Dr. Quinn Times ' ' , a newsletter in which interviews with the cast , producers , directors , and technical specialists were conducted and distributed to fans , twice each year . Seymour and Barbara Babcock were the only cast members to receive Emmy nominations for their work on the series . Seymour was nominated several times during the series ' run , while Babcock received a single nomination in 1995 for the episode entitled Ladies ' Night . Her character , Dorothy Jennings , underwent a mastectomy . The show did win many technical awards , as well as hair and make-up honors . Seymour also won a Golden Globe in 1996 for her portrayal of Michaela Quinn . # Tensions # The cast was reported to get along well despite some tensions , which led to minor cast changes and some disagreements between the show 's writers and cast . The most documented tension came during the show 's fifth season , as Joe Lando was unhappy with both the show 's and his character 's direction . He seriously considered leaving . Lando , who felt the show needed a real shake up , openly stated , after a heated argument with Sullivan , that ' ' Dr. Quinn ' ' could continue just fine with Sully being killed off . Since it was not known if Lando would return , the fifth season finale showed Sully being thrown over a cliff into a river . Viewers were left to wonder , along with Michaela Quinn , if Sully had died or survived . During the early months of 1997 , it appeared Lando was not returning . John Schneider was asked to return to the show playing Sully 's best friend Daniel Simon . The intent was for Schneider to take Lando 's place as the show 's leading man and Michaela Quinn 's new love interest . But , upon learning this , ' ' Dr. Quinn ' ' fans created a campaign , known as Save Our Sully . By the time shooting had started for season 6 and its premiere in early 1997 , Lando , now free from his involvement with other projects , had agreed to return . He was allotted part-time status , meaning he would have full involvement in certain episodes but only occasional screen appearances in others . Though his episodes were spread out during the final season , they were shot over a period of several weeks . Lando then returned only in the final episode to appropriately finalize the series . # Ratings # class= wikitable style= text-align:center ! colspan= 2 Season ! ! U.S. ratings ! ! Network ! ! Rank # Demographics change and cancellation # The show was a major hit in the United States for CBS and drew large ratings even though it aired on Saturday nights . Despite the high ratings , CBS claimed that the demographics changed during the show 's run . During its final season , the majority of ' ' Dr. Quinn s viewers were women 40 years of age and older , and not the male and female 18-to-49 demographic that networks try to reach . In response , CBS ordered the writers to give the show a slightly darker feel than in previous seasons . As a result , season six was darker than any other season before it , with the death of several characters as well as some highly sensitive subject matter : the painful miscarriage of Michaela 's second child , as well as an episode entitled ' ' Point Blank ' ' where Michaela was shot by a man and then later developed post-traumatic stress disorder . Many fans did not like the changes while others felt that the tensions and high drama benefited the show after the overall pleasant past seasons . Despite these opposing opinions , the ratings still proved to be steady and consistent ( finishing at #51 for the year ) . The series was suddenly canceled in 1998 after its sixth season . # Reruns and future # The show has enjoyed strong ratings in reruns . ' ' Dr. Quinn ' ' was one of the rare instances of a show entering rerun syndication in the middle of a TV season . It debuted reruns in most American markets on Monday , December 30 , 1996 , just two days shy of the show 's 4th anniversary . With 4 seasons being the minimum requirement for syndication pickup , ' ' Dr. Quinn ' ' reruns could have started at the more traditional launch date of September 1996 , but the show 's distributor , like many , had an additional minimum episode limit in order for the show to be eligible for syndication . This episode count was not reached until several episodes into ' ' Dr. Quinn s fifth season ( 19961997 ) , and since stations had already purchased the show at the beginning of that season , the distributor decided not to hold off until the next fall and let the stations start airing reruns right away . When PAX TV launched in August 1998 , it acquired reruns of current family-friendly series from CBS , including ' ' Dr. Quinn ' ' . Because dedicated ' ' Dr. Quinn ' ' fans were angered by the show 's cancellation by CBS that year , these national reruns via PAX helped relieve the blow , especially in markets where local stations were not airing reruns in syndication . Until late 2005 , the Hallmark Channel aired it daily , but in late 2005 Hallmark removed ' ' Dr. Quinn ' ' from its lineup , citing a drop in viewership . It is also believed that the high cost in ' ' Dr. Quinn ' ' distribution rights played a role in its removal . ' ' Dr. Quinn ' ' continues to be seen throughout the world and has been translated to several languages . Starting in June 2009 , the Gospel Music Channel began airing ' ' Dr. Quinn ' ' weekdays at 5:00 and 6:00 . More recently Vision TV Canada began airing Dr Quinn week nights at 6PM AT . It also airs on CHNU10 in the Lower Mainland of BC , Canada at 3 PM PST Weekdays . It has also been shown continuously in Denmark since 2001 , with plans on to keep it at its daily broadcast time of 1:00 , Monday to Friday , on Danish TV station , tv2 . Since the last movie in 2001 , many of the show 's cast members have expressed interest in reprising their roles and would like to do another reunion movie , or even a new season . Jane Seymour , Joe Lando , Chad Allen , and other cast members have stated they would all like to work together again and would reprise their ' ' Dr. Quinn ' ' roles if the opportunity arises . In 2003 , A&amp;E Network managed to buy the distribution rights for ' ' Dr. Quinn , Medicine Woman ' ' from CBS . All six seasons plus the two made-for-TV movies have been released on DVD . The series appears on the GMC Network . GMC aired all the series episodes , including the season six episodes not shown in a decade , during the summer of 2010 . Joe Lando did several teasers and promotions for the weekend marathons , and says he finds GMC 's ad campaign funny , saying : Truthfully , I have n't had that many opportunities to make fun of Sully . No one 's really found me that funny . But it 's fun to do it now . GMC came up with a great ad campaign . My kids were entertained by it and my wife got a kick out of it . # Historical facts and filming information #  While much of ' ' Dr. Quinn ' ' was fictional , some of the events and people were based on historical fact : *Women 's Medical College of Pennsylvania actually existed and is today part of Drexel University College of Medicine . *The Sand Creek Massacre in 1864 was referred to in the pilot episode ( though it was historically inaccurate as the pilot took place in 1867 ) . *Lieutenant Colonel George Armstrong Custer , and Chief Black Kettle , are true historical figures . *The Battle of Washita River , seen in the third season episode ' ' Washita ' ' , was an actual historical event . In the show , the battle took place in 1869 in Colorado , while in fact it took place in the fall of 1868 in Oklahoma . In what most consider the final episode of the series , the town 's often-antagonist banker , Preston A. Lodge III , went bankrupt as a result of the great stock market crash , caused by the Panic of 1873 , a historically-accurate event . Lodge lost much of the townspeople 's money along with his own , in the Panic .  The episode ' ' The Body Electric ' ' features Walt Whitman , who was a poet and a true historical figure One of the major historical oversights of the show is that Colorado Springs was not technically founded until 1871 , by General William Palmer , and was mainly a resort town . There were no saloons , as Palmer declared Colorado Springs to be alcohol-free . Colorado Springs stayed dry until the end of Prohibition in 1933 . However , nearby towns , including Old Colorado City and Manitou Springs did permit saloons.  ' ' Dr. Quinn ' ' was largely filmed at the western set on Paramount Ranch in Agoura Hills . Fans of the show were able to visit the sets , talk to the actors , and watch episodes being shot during its 6-year run . Since ' ' Dr. Quinn ' ' ended , the ranch has been used numerous times for other filming projects . Numerous buildings , including the church , Sully 's homestead , the school house , and the Chateau Springs Hotel , were leveled soon after the series was canceled . However , the entire town still remains . Despite minor changes over the years , it is still recognizable as the ' ' Dr. Quinn ' ' set , and is a popular tourist attraction for many fans today . Other areas used throughout the series were the back lot at Universal Studios in Hollywood , including the New England street as the location of Quinn family home ; and the New York streets , doubling as the streets of Boston and Washington . The setting of Boston in the final movie was filmed in Canada , using various locations in Old Montreal . William Olvis wrote the underscoring music for the series , except for a few episodes in season one ( where he either alternated with Star Trek spin-off series composer David Bell , or co-scored with Bell ) and the ' ' Revolutions ' ' movie . Jane Seymour 's husband , James Keach , directed and produced numerous episodes of the show , and guest starred in the season 5 episode entitled , The Hostage . Due to child labor laws , the role of Katie , Dr. Mike and Sully 's young daughter , was portrayed by identical triplets : Alexandria , McKenzie , and Megan Calabrese. Jane Seymour is the only cast member who appeared in every episode of the series . Shawn Toovey missed only one episode as did Chad Allen , who also did not appear in episode titled Reunion ( Season 4 ) , as well as the two made-for-TV movies . Joe Lando came in third , missing only a few episodes in the sixth and final season . # Merchandise # # DVD releases # A&amp;E Home Video has released all six seasons of ' ' Dr. Quinn , Medicine Woman ' ' on DVD in Region 1 . They have also released the two television movies that were made after the series ended . In Region 2 , Revelation Films has released all 6 seasons on DVD in the UK . The 2 TV-movies were released separately , the first was entitled ' ' Dr. Quinn , Medicine Woman - The Movie ' ' and the second was entitled ' ' Dr. Quinn , Medicine Woman - The Heart Within ' ' . # Novels # There were several books based on the series written by as follows . Some of them were released also abroad , including in France , Germany , the Netherlands , Hungary , and Poland . The books by Dorothy Laudan were originally released in Germany and have never appeared in English version . However , it was these books which were most commonly translated into other languages . The series of nine covers most of the series , although the episodes on which they are based were shortened and some scenes were left out or were mentioned only briefly . # Spin-off # In the year of 1997 there were plans of making a spin-off series centered around the Hank Lawson character . Some of the other regular ' ' Dr. Quinn ' ' characters , including the ones of Jane Seymour , Joe Lando , Jim Knobeloch , Frank Collison and Orson Bean , were in as well . It was directed by Jerry London , with Robert Brooks Mendel as the first assistant director , Timothy O. Johnson as the executive producer , and Beth Sullivan as the producer . The rest of the cast members were Laura Harring ( ' ' Christina Guevara ' ' ) , Edward Albert ( ' ' Ted McKay ' ' ) , James Brolin ( ' ' Sheriff ' ' ) , Eddie Albert ( ' ' Ben McKay ' ' ) , Carlos Gmez ( ' ' Father Thomas Guevara ' ' ) and John Saxon ( ' ' Rafael Guevara ' ' ) . The show was entitled ' ' California ' ' and it is likely that only the pilot episode was filmed . It remains unclear whether it has ever aired on television , but it is still available on the YouTube service . 
@@832283 The Veterans Health Administration ( VHA ) is the component of the United States Department of Veterans Affairs ( VA ) led by the Under Secretary of Veterans Affairs for Health that implements the medical assistance program of the VA through the administration and operation of numerous VA Medical Centers ( VAMC ) , Outpatient Clinics ( OPC ) , Community Based Outpatient Clinics ( CBOC ) , and VA Community Living Centers ( VA Nursing Home ) Programs . The VHA is distinct from the U.S. Department of Defense Military Health System of which it is not a part . The VHA division has more employees than all other elements of the VA combined . # History # The first Federal agency to provide medical care to veterans was the Naval Home in Philadelphia , PA . The home was created in 1812 and was followed by the creation of Soldiers Home in 1853 and St. Elizabeth 's Hospital in 1855 . Congress created the National Home for Disabled Volunteer Soldiers in 1865 in response to the high number of Civil War casualties . These homes were initially intended to be room and board for disabled veterans . However , by the late 1920s , the homes were providing a level of care comparable to hospital care . President Hoover created the Veterans Administration ( VA ) in 1930 to consolidate all veteran services . General Omar N. Bradley was appointed to VA administrator and Bradley appointed Major General Paul Hawley as director of VA medicine , both in 1945 . Hawley successfully established a policy that affiliated new VA hospitals with medical schools . Hawley also promoted resident and teaching fellowships at VA hospitals . Ultimately , Hawley was responsible for starting the hospital-based research program at the VA . Bradley resigned in 1947 . However , upon resignation , 97 hospitals were in operation and 29 new hospitals had been built . As a result , the VA health system was able to serve a much larger population of veterans than it had served in previous years . In 1988 , President Reagan signed the Department of Veterans Affairs Act , which elevated the VA to Cabinet-level , then becoming known as the Department of Veterans Affairs . The Department of Veterans Affairs oversees the Veterans Health Administration . In the mid-1980s the VHA was criticized for their high operative mortality . To that end , Congress passed Public Law 99-166 in December 1985 which mandated the VHA to report their outcomes in comparison to national averages and the information must be risk-adjusted to account for the severity of illness of the VHA surgical patient population . In 1991 the National VA Surgical Risk Study ( NVASRS ) began in 44 Veterans Administration Medical Centers . By 31 December 1993 there was information for 500,000 non-cardiac surgical procedures . In 1994 NVASRS was expanded to all 128 VHA hospitals that performed surgery . The name was then changed to the National Surgical Quality Improvement Program . Beginning in the mid-1990s VHA underwent what the agency characterizes as a major transformation aimed at improving the quality and efficiency of care it provides to its patients . That transformation included eliminating underutilized inpatient beds and facilities , expanding outpatient clinics , and restructuring eligibility rules . A major focus of the transformation was the tracking of a number of performance indicatorsincluding quality-of-care measuresand holding senior managers accountable for improvements in those measures . # Veterans Health Administration scandal of 2014 # In May 2014 , major problems with scheduling timely access to medical care became public . As of May 2014 , at least 40 United States Armed Forces veterans died waiting for care at the Phoenix , Arizona Veterans Health Administration facilities , and an investigation of delays in treatment throughout the Veterans Health Administration system is being conducted by the Veterans Affairs Inspector General . On May 30 , 2014 , Secretary of Veterans Affairs Eric Shinseki resigned from office due to the fallout from the scandal . # VA Health Reform # # 1993 Clinton Healthcare Reform # The Clinton Healthcare Plan was a health care reform proposed by the Clinton Administration . Even though the reform was not successful , a task force was created in response to the Clinton Healthcare Reform proposal to determine if the VA was ready for managed care . The negative results of market research forced the VA system to re-evaluate its current operations . Research revealed that 3 out of 4 veterans would leave the VA network if a national healthcare system were adopted . They also found that there was a high demand for primary care throughout the VA system . Research showed that many VA facilities believed that 55 percent of patients would choose to receive primary care at the VA facility if a primary care system was fully implemented in 1993 . The study also showed that the VA facilities believed that 83 percent of veterans would choose to receive primary care at the VA if fully implemented by 1998 . These results made it clear to the administration that it was time for a reform . # 1994 VA Primary Care Directive # This directive required all VA facilities to have primary care teams by year 1996 . As a result , percentage of patients receiving primary care at the VA increased from 38 percent to 45 percent to 95 percent , during 1993 , 1996 , and 1999 . This mandate served as the foundation for the VA reorganization under Dr. Kenneth W. Kizer. # Dr. Kenneth W. Kizer and the VA Reform # Dr. Kizer , a physician trained in emergency medicine and Public Health , was appointed by President Bill Clinton as Director of U.S. Veterans Health Administration in 1994 . He was hired to update and modernize the VA health system in order to eliminate negative perception and to align the system with current market trends . Core issues included : : Advancements in technology and biomedical knowledge : Aging and socioeconomically disadvantaged Medicare patients : Coordinating care : Rising healthcare costs There was much opposition to a major reform . Many legislators preferred an incremental change over a wide-scale reform . However , Kizer was known as being very innovative . In order to publicize his vision he expressed his mission and vision of the new VHA and outlined seven key principles to guide change . His ultimate goal was to provide coordinated , high quality care at a low cost . He launched his reorganization plan in 1995 by decentralizing the VA system . He organized all VA operating units into 22 geographic based networks known as Veterans Integrated Service Networks ( VISNs ) . This allowed networks to manage themselves and adapt to the demographics of their location . Patients were then assigned to a group of doctors who would provide coordinated care . One director was hired for each VISN network . Instead of hiring all directors internally , a third of the newly hired VISN directors were hired outside of the VA system . The directors were responsible for meeting performance goals and improving upon measurable key efficiency and quality indicators . Directors monitored performances and reports were generated to show each network 's performance . Some of these indicators included : : : chronic disease quality : : prevention performance : : patient satisfaction ratings : : utilization management The reform also changed the procedure for allocating funds to the various VISNs . Historically , funds were distributed between hospitals based on historical costs . However , it was found that this method affected efficiency and quality of services . Therefore , funding for each VISN was distributed based on the number of veterans seen in each network , rather than on historical values . The New England Journal of Medicine conducted a study from 19942000 to evaluate the efficacy of the healthcare reform . They gathered the results of the evaluated key indicators from each of the networks and interpreted the results . There were noticeable improvements , compared with the same key indicators used for the Medicare fee for service system , as soon as two years after the reorganization . These improvements continued through year 2000 . These results indicate that the changes made throughout the VA healthcare system , under the leadership of Kizer , did improve the efficiency and quality of care in VA healthcare system . # Use of electronic records # VHA is especially praised for its efforts in developing a low cost open source electronic medical records system VistA which can be accessed remotely ( with secure passwords ) by health care providers . With this system , patients and nurses are given bar-coded wristbands , and all medications are bar-coded as well . Nurses are given wands , which they use to scan themselves , the patient , and the medication bottle before dispensing drugs . This helps prevent four of the most common dispensing errors : wrong med , wrong dose , wrong time , and wrong patient . The system , which has been adopted by all veterans hospitals and clinics and continuously improved by users , has cut the number of dispensing errors in half at some facilities and saved thousands of lives . At some VHA medical facilities , doctors use wireless laptops , putting in information and getting electronic signatures for procedures . Doctors can call up patient records , order prescriptions , view X-rays or graph a chart of risk factors and medications to decide treatments . Patients have a home page that have boxes for allergies and medications , records every visit , call and note , and issues prompts reminding doctors to make routine checks . This technology has helped the VHA achieve cost controls and care quality that the majority of private providers can not achieve . The Veterans Health Administration Office of Research and Development 's research into developing better-functioning prosthetic limbs , and treatment of PTSD are also heralded . The VHA has devoted many years of research into the health effects of the herbicide Agent Orange used by military forces in Vietnam . In October 2012 , the VHA announced a new goal to care for and heal our wounded Veterans . In addition to repairing their damaged bodies and minds , VA has embarked on a unique campaign to repair their crumbling intimate relationships . # Initiatives # The VHA has expanded its outreach efforts to include men and women veterans and homeless veterans . The VHA , through its academic affiliations , has helped train thousands of physicians , dentists , and other health professionals . Several newer VA medical centers have been purposely located adjacent to medical schools . The VHA support for research and residency/fellowship training programs has made the VA system a leader in the fields of geriatrics , spinal cord injuries , Parkinson 's disease , and palliative care . The VHA has initiatives in place to provide a seamless transition to newly discharged veterans transitioning from Department of Defense health care to VA care for conditions incurred in Iraq or Afghanistan . The Veterans Health Administration Office of Research and Development 's research into developing better-functioning prosthetic limbs , and treatment of PTSD are also heralded . The VHA has devoted many years of research into the health effects of the herbicide Agent Orange used by military forces in Vietnam . In October 2012 , the VHA announced a new goal to care for and heal our wounded Veterans . In addition to repairing their damaged bodies and minds , VA has embarked on a unique campaign to repair their crumbling intimate relationships . # Services # # Mental health # The percentage of patients with a mental illness was 15 percent in 2007 . The percentage of veterans with mental illnesses has trended up . The VHA allocated an extra 1.4 billion dollars per year to mental health program between 2005 and 2008 . Mental health services in 2006 were evaluated as a part of the Mental Health Strategic Plan . The report concluded : In 2009 , the VA implemented an initiative called Suicide Assessment and Follow-Up Engagement : Veteran Emergency Treatment ( SAFE VET ) to identify and treat veterans at risk of suicide by providing care coordination for outpatient mental health services and community-based support . # Women # With the population of Women veterans projected to rise from 1.6 million in 2000 to 1.9 million in 2020 , the VA has worked to integrate quality women 's medical services into the VA system . However , studies show that 66.9 percent of women who do not use the VA for women 's services consider private practice physicians more convenient . Also , 48.5 percent of women do not use women 's services at the VA due to a lack of knowledge of VA eligibility and services . # # Primary care # # General Care includes health evaluation and counseling , disease prevention , nutrition counseling , weight control , smoking cessation , and substance abuse counseling and treatment as well as gender-specific primary care , e.g. , cervical cancer screens ( Pap smears ) , breast cancer screens ( mammograms ) , birth control , preconception counseling , Human Papillomavirus ( HPV ) vaccine and menopausal support ( hormone replacement therapy ) . Mental Health includes evaluation and assistance for issues such as depression , mood and anxiety disorders ; intimate partner and domestic violence ; elder abuse or neglect ; parenting and anger management ; marital , caregiver , or family-related stress ; and post-deployment adjustment or post-traumatic stress disorder ( PTSD ) . Veterans may have experienced sexual harassment or sexual assault , known as military sexual trauma ( MST ) during their service . Health services are available to victims . VHA provides free , confidential counseling and treatment for MST-related mental and physical health conditions . # # Specialty care # # Management and screening of chronic conditions includes heart disease , diabetes , cancer , glandular disorders , osteoporosis and fibromyalgia as well as sexually transmitted diseases such as HIV/AIDS and hepatitis . Reproductive Health Care includes maternity care , infertility evaluation and limited treatment ; sexual problems , tubal ligation , urinary incontinence , and others . VHA is prohibited from providing either in-vitro fertilization or abortion services . Rehabilitation , home care , and long-term care referrals are given to those in need of rehabilitation therapies such as physical therapy , occupational therapy , speech-language therapy , exercise therapy , recreational therapy , and vocational therapy . # Evaluations # Patients routinely rank the veterans system above the alternatives , according to the American Customer Satisfaction Index . In 2008 , the VHA got a satisfaction rating of 85 for inpatient treatment , compared with 77 for private hospitals . In the same report VHA outpatient care scored 3 points higher than for private hospitals . As compared with the Medicare fee-for-service program , the VA performed significantly better on all 11 similar quality indicators for the period from 1997 through 1999 . In 2000 , the VA outperformed Medicare on 12 of 13 indicators . A study that compared VHA with commercial managed care systems in their treatment of diabetes patients found that in all seven measures of quality , the VHA provided better care . A RAND Corporation study in 2004 concluded that the VHA outperforms all other sectors of American health care in 294 measures of quality . Patients from the VHA scored significantly higher for adjusted overall quality , chronic disease care , and preventive care , but not for acute care . A 2009 Congressional Budget Office report on the VHA found that the care provided to VHA patients compares favorably with that provided to non-VHA patients in terms of compliance with widely recognized clinical guidelines particularly those that VHA has emphasized in its internal performance measurement system . Such research is complicated by the fact that most users of VHA 's services receive at least part of their care from outside providers . A Harvard Medical School-led study shows that cancer care provided by the Veterans Health Administration for men 65 years and older is at least as good as , and by some measures better than , Medicare-funded fee-for-service care obtained through the private sector . # Physicians # Doctors who work in the VHA system are typically paid less in core compensation than their counterparts in private practice . However , VHA compensation includes benefits not generally available to doctors in private practice , such as lesser threat of malpractice lawsuits , freedom from billing and insurance company payment administration , and the availability of the government 's open source electronic records system VistA . # Eligibility for VA Health Care Benefits # To be eligible for VA health care benefit programs you must have served in the active military , naval or air service and separated under any condition other than dishonorable , may qualify for VA health care . The Minimum Duty Requirements , Veterans who enlisted after Sept. 7 , 1980 , or who entered active duty after Oct. 16 , 1981 , must have served 24 continuous months or the full period for which they were called to active duty in order to be eligible . The minimum duty requirement may not apply to Veterans who were discharged for a disability incurred in the line of duty , for a hardship or early out . The VA determines the minimum requirements when the Veteran enrolls for VA health care benefits . To apply for entry into the VA health care system the Veteran must complete VA Form 10-10EZ , Application for health care benefits . Eligible Veterans will receive a VA Veteran identification card ( VIC ) for use at VA Medical Facilities . By Federal law , eligibility for benefits is determined by a system of eight Priority Groups . Retirees from military service , veterans with service-connected injuries or conditions rated by VA , and Purple Heart recipients are within the higher priority groups . Current and former members of the Reserves and the National Guard who were called to active duty ( other than of monthly drills and annual traning ) by a Federal Executive Order may be eligible for VA health care benefits . Veterans without rated service-connected conditions may become eligible based on financial need , adjusted for local cost of living . Veterans who do not have service-connected disabilities totaling 50% or more may be subject to copayments for any care they received for nonservice-connected conditions . # Eligibility priority groups # # Covered services/acute care benefits # # Standard benefits # Preventive Care Services  Counseling on inheritance of genetically determined disease  Immunization  Nutrition Education  Physical Examinations ( Including eye and hearing examinations )  Health Care Assessments  Screening Test  Health Education Programs Ambulatory ( Outpatient ) and Hospital ( Inpatient ) , Diagnostic and Treatment Services  Medical  Surgical ( Including reconstructive/plastic surgery as a result of disease or trauma )  Mental Health  Dialysis  Substance Abuse  Prescription Drugs ( when prescribed by a VA Physician ) # Limited benefits # The following care services have limitations and may have special eligibility criteria :  Ambulance Services  Chiropractic Care cite web  Dental Care ( see VA Dental Care )  Durable Medical Equipment ( walkers , crutches , canes , bathtub seats )  Eyeglasses  Hearing Aids  Home Health Care  Maternity and Parturition ( Childbirth ) Services Usually provided in non-VA contracted hospitals at VA expense ; care is usually limited to a mother . ( VA may furnish health care services to a newborn child of a woman Veteran who is receiving maternity care furnished by VA for not more than seven days after the birth if the Veteran delivered the child in ( 1 ) a VA facility , or ( 2 ) another facility pursuant to a VA contract for services relating to such delivery )  Non-VA Health Care Services # Long term benefits # # Standard benefits #  Geriatric Evaluation . Geriatric evaluation is the comprehensive assessment of a Veteran 's ability to care for him/herself physical health and social environment , which leads to a plan of care . The plan could include treatment , rehabilitation , health promotion and social services . These evaluations are performed by inpatient Geriatic Evaluation Management ( GEM ) Units , GEM clinics , geriatic primary care clinics and other outpatient settings .  Adult Day Health Care . The adult day health care ( ADHC ) program is a therapeutic day care program , providing medical and rehabilitation services to disabled Veterans in a combined setting .  Respite Care . Respite care provides supportive care to Veterans on a short-term basis to give the caregiver planned relief from the physical and emotional demands associated with providing care . Respite care can be provided in the home or other institutional settings .  Home Care . Skilled home care is provided by VA and contract agencies to Veterans that are home bound with chronic diseases and includes nursing , physical/occupational therapy and social services .  Hospice/Palliative Care . Hospice/Palliative care programs offers pain management , symptom control and other medical services to terminally ill Veterans or Veterans in the late stages of the choronic disease process . Services also include respite care as well as bereaverement counseling to family members . # Limited benefits #  Nursing Home Care . VA provides nursing home services to Veterans through three national programs : VA owned and operated Community Living Centers ( CLC ) , State Veterans ' Homes owned and operated by the states , and the community nursing home program . Each program has admission and eligibility criteria specific to the program . Nursing home care is available for enrolled Veterans who need nursing home care for a service-connected disability , or Veterans or who have a 70 percent or greater service-connected disability and Veterans with a rating of total disability based on individual unemployability . VA provided nursing home care for all other Veterans is based on available resources .  Domiciliary Care . Domiciliary care provides rehabilitative and long-term , health maintenance care for Veterans who require some care , but who do not require all services provided in nursing homes . Domiciliary care emphasizes rehabilitation and return to the community . VA may provide domiciliary care to Veterans whose annual income does not exceed the maximum annual rate of VA pension or to Veterans who have no adequate means of support . # Financial Assessment for Long-Term Care Services # For Veterans who are not automatically exempt from making co-pays for long-term care services separates financial assessment ( VA Form 10-10EC , APPLICATION FOR EXTENDED CARE SERVICES ) Must be completed to determine whether a Veteran qualifies for cost-free services or to what extent they are required to make long-care co-pays . Unlike co-pyas for other VA health care services , which are based on fixed changes for all long-term care co-pay changes are individually adjusted based on each Veteran 's financial status . # Home Health Care # Home Health Care includes VA 's Skilled Home Health Care Services ( SHHC ) and Homemakers and Home Health Aide Services ( H/HHA ) . # Skilled Home Health Care Services ( SHHC ) #  SHHC services are in-home services provided by specially trained personnel , including nurses , physical therapists , occupational therapists and social workers . Care includes clinical assessment , treatment planning and treatment provision , health status monitoring , patient and family education , reassessment , referral and follow-up . # Homemakers/Home Health Aide Services ( H/HHA ) #  H/HHA services are personal care and related support services that enable frail or disabled Veterans to live at home . # Family Caregivers Program #  VA 's Family Caregivers Program provides support and assistance to caregivers of post 9/11 Veterans and Servicemembers being medically discharged . Eligible primary Family Caregivers can receive a stipend , training , mental health services , travel and lodging reimbursement , and access to health insurance if they are not already under a health plan care . # Patient Aligned Care Team ( PACT ) # The Department of Veterans Affairs Office of Patient Care Services , Primary Care Program Office , implement a new patient-centered medical home ( PCMH ) model at all VHA Primary Care sites which is referred to as Patient Aligned Care Teams ( PACT ) . PACT provides accessible , patient-centered care , and is managed by primary care providers with the active involvement of other clinical and non-clinical staff . Veterans patients will be at the center of a teamlet , which will include a Primary Care Provider , RN Care Manager , LPN/Health-tech and a Medical Support Assistant ( MSA ) . This teamlet is supported by a broader Team which includes social workers , dieticians , pharmacists and mental health . Patient Aligned Care Teams ( PACT ) are being implemented at all VA Primary Care Sites , including VA Community Based Outpatient Clinics ( CBOC ) . # VA dental care # For VA dental care a Veteran must have a service-connected compensable dental disability or condition , have a service-connected disabilities rated 70 percent disabling or are unemployable and paid at 100 percent rate due to service-connected conditions , former prisoners of war , have a service-connected non-compensable dental condition or disability from combat wounds or service trauma , Veterans actively engaged in a 38 USC Chapter 31 vocational rehabilitation program and Veterans enrolled who may be homeless and receiving care under VHA Directive 2007-039. # Transplant service # If the need arises , veterans are eligible for transplant service . The request will be coordinated by the Primary Care Team . # Readjustment Counseling Services # Veterans Administration provides readjustment counseling and outreach services to all Veterans who served on active duty in any combat zone , through community based counseling centers called Vet Centers . Services are also available for their family members for military related issues . Vet Centers are staffed with small multidisciplinary teams some of whom are Combat Veterans themselves . # OEF/OIF/OND veterans # # OEF/OIF/OND Care Management Team # The Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn ( OEF/OIF/OND ) Care Management Team helps returning service members achieve a smooth transition of health care services . A specialized OEF/OIF/OND care management team provides case management and care coordination for all severely ill , injured and impaired combat veterans , including those suffering from :  Mental illness  Traumatic Brain Injury ( TBI )  Spinal Cord Injury  Blindness  Burns  Amputation  Terminal Illness/Injury  Polytrauma  Other conditions not mentioned above that cause significant impairment to daily living # Mental Health Residential Rehabilitation # Mental Health Residential Rehabilitation Treatment Programs ( MH RRTP ) ( including domiciliaries ) provide residential rehabilitative and clinical care to Veterans who have a wide range of problems , illnesses , or rehabilitative care needs which can be medical , psychiatric , substance use , homelessness , vocational , educational , or social . The MH RRTP provides a 24-hour therapeutic setting utilizing a peer and professional support environment . The programs provide a strong emphasis on psychosocial rehabilitation and recovery services that instill personal responsibility to achieve optimal levels of independence upon discharge to independent or supportive community living . MH RRTP also provides rehabilitative care for homeless Veterans .  Eligibility : VA may provide domiciliary care to Veterans whose annual gross household income does not exceed the maximum annual rate of VA pension or to Veterans the Secretary of Veterans Affairs determines have no adequate means of support . The copays for extended care services apply to domiciliary care . Call the nearest benefits or health care facility to obtain the latest information . # VA Travel Reimbursement # Veterans may be eligible for mileage reimbursement or special mode transport in association with obtaining VA health care services if the veteran have a service-connected rating of 30 percent or more , or you are traveling for treatment of a service connected condition , receive a VA pension , the veterans ' income does not exceed the maximum annual VA pension rate , traveling for a scheduled compensation or pension examination , veterans in certain emergency situations . veterans whose medical condition requires a special mode of transportation and travel is pre-authorized , certain non-Veterans when related to care of a Veteran ( Caregivers , attendants &amp; donors ) . # Federal Benefits for Veterans , Dependents and Survivors # # Medical Programs #  The Civilian Health and Medical Program of the Department of Veterans Affairs ( CHAMPVA ) . Is a health benefit program in which the Department of Veterans Affairs ( VA ) shares the cost of certain health care services and supplies with eligible beneficiaries . The program is available to spouses and children of Veterans with permanent and total service-connected disability ineligible for the DoD TRICARE . Surviving spouse or child of a Veteran who died from a VA service-connected disability , or who at the time of death was rated permanently and total disabled . Similarly to TRICARE , CHAMPVA beneficiaries are also accepted by TRICARE providers .  The Spina Bifida Program ( SB ) . Is a comprehensive health care benefits program administered by the Department of Veterans Affairs for birth children of certain Vietnam and Korea War Veterans who have been diagnosed with spina bifida ( except spina bifida occulta ) . The SB program provides reimbursement for inpatient and outpatient medical services , pharmacy , durable medical equipment , and supplies .  The Children of Women Vietnam Veterans ( CWVV ) Health Care Program . Is a federal health benefits program administered by the Department of Veterans Affairs for children of women Vietnam War Veterans born with certain birth defects . The CWVV Program provides reimbursement for medical care related to covered birth defects and conditions associated with the covered birth defect except for spina bifida 
@@865271 Liver disease ( also called hepatic disease ) is a type of damage to or disease of the liver . # Signs and symptoms # The symptoms related to liver dysfunction include both physical signs and a variety of symptoms related to digestive problems , coagulopathy The malabsorption of fats may lead to symptoms that include indigestion , reflux , deficit of fat soluble vitamins , hemorrhoids , gallstones , intolerance to fatty foods , intolerance to alcohol , nausea and vomiting attacks , abdominal bloating , and constipation . Nervous system disorders include depression , mood changes , especially anger and irritability , poor concentration and foggy brain , overheating of the body , especially the face and torso , and recurrent headaches ( including migraine ) associated with nausea . The blood sugar problems include hypoglycaemia . Hypercholesterolemia : elevated LDL cholesterol , reduced HDL cholesterol , elevated triglycerides , clogged arteries leading to high blood pressure , heart attacks and strokes , buildup of fat in other body organs ( fatty degeneration of organs ) , lumps of fat in the skin ( lipomas and other fatty tumors ) , excessive weight gain ( which may lead to obesity ) , inability to lose weight even while dieting , sluggish metabolism , protuberant abdomen ( pot belly ) , cellulite , fatty liver , and a roll of fat around the upper abdomen ( liver roll ) etc . Or too low levels of lipids : hypocholesterolemia : low total cholesterol , low LDL and VLDL cholesterol , low triglycerides. # Types # There are more than a hundred kinds of liver disease . The most widely spread are as follows :  Hepatitis , inflammation of the liver , is caused mainly by various viruses ( viral hepatitis ) but also by some liver toxins ( e.g. alcoholic hepatitis ) , autoimmunity ( autoimmune hepatitis ) or hereditary conditions .  Alcoholic liver disease is any hepatic manifestation of alcohol overconsumption , including fatty liver disease , alcoholic hepatitis , and cirrhosis . Analogous terms such as drug-induced or toxic liver disease are also used to refer to the range of disorders caused by various drugs and environmental chemicals .  Fatty liver disease ( hepatic steatosis ) is a reversible condition where large vacuoles of triglyceride fat accumulate in liver cells . Non-alcoholic fatty liver disease is a spectrum of disease associated with obesity and metabolic syndrome , among other causes . Fatty liver may lead to inflammatory disease ( i.e. steatohepatitis ) and , eventually , cirrhosis.  Cirrhosis is the formation of fibrous tissue ( fibrosis ) in the place of liver cells that have died due to a variety of causes , including viral hepatitis , alcohol overconsumption , and other forms of liver toxicity . Cirrhosis causes chronic liver failure .  Primary liver cancer most commonly manifests as hepatocellular carcinoma and/or cholangiocarcinoma ; rarer forms include angiosarcoma and hemangiosarcoma of the liver . ( Many liver malignancies are secondary lesions that have metastasized from primary cancers in the gastrointestinal tract and other organs , such as the kidneys , lungs , breast , or prostate. )  Primary biliary cirrhosis is a serious autoimmune disease of the bile capillaries.  Primary sclerosing cholangitis is a serious chronic inflammatory disease of the bile duct , which is believed to be autoimmune in origin .  Centrilobular necrosis of liver can be caused by leakage of enteric toxins into cirulation . Salmonella toxins in ileum have been shown to cause severe damage to liver hepatic cells  BuddChiari syndrome is the clinical picture caused by occlusion of the hepatic vein , which in some cases may lead to cirrhosis.  Hereditary diseases that cause damage to the liver include hemochromatosis , involving accumulation of iron in the body , and Wilson 's disease , which causes the body to retain copper . Liver damage is also a clinical feature of alpha 1-antitrypsin deficiency and glycogen storage disease type II .  In transthyretin-related hereditary amyloidosis , the liver produces a mutated transthyretin protein which has severe neurodegenerative and/or cardiopathic effects . Liver transplantation can provide a curative treatment option .  Gilbert 's syndrome , a genetic disorder of bilirubin metabolism found in about 5% of the population , can cause mild jaundice . There are also many pediatric liver diseases including : biliary atresia , alpha-1 antitrypsin deficiency , Alagille syndrome , and progressive familial intrahepatic cholestasis. # Diagnostics # A number of liver function tests ( LFTs ) are available to test the proper function of the liver . These test for the presence of enzymes in blood that are normally most abundant in liver tissue , metabolites or products . serum proteins , serum albumin , serum globulin , A/G Ratio , alanine transaminase , aspartate transaminase , prothrombin time , partial thromboplastin time , platelet count . # Treatment # The most effective way to treat alcoholic liver disease and non-alcoholic fatty liver disease is to make lifestyle changes , such as :  Cutting out alcohol  Improving the diet  Engaging in regular exercise Anti-viral medications are available to treat infections such as Hepatitis B and Hepatitis C. This is an area of active research and drug development and today many treatments offer improved outcomes , by clearing or controlling the virus to slow any decline in the condition of your liver . Other conditions may be managed by slowing down disease progression , for example :  By using steroid-based drugs in autoimmune hepatitis.  Regularly removing a quantity of blood from a vein ( venesection ) in the iron overload condition , hemochromatosis.  Wilsons disease , a condition where copper builds up in the body , can be managed with drugs which bind copper allowing it to be passed from your body in urine .  In cholestatic liver disease ( where the flow of bile is affected ) a medication called ursodeoxycholic acid ( URSO , also referred to as UDCA ) may be given . Made from naturally occurring bile acid , it may offer some protection for the liver from the harmful chemicals in the bile , slowing damage . 
@@874207 The Yale School of Medicine at Yale University is a located in New Haven , Connecticut , U.S. It was founded in 1810 as The Medical Institution of Yale College , and formally opened its doors in 1813 . The primary teaching hospital for the school is Yale-New Haven Hospital . The school is home to the Harvey Cushing/John Hay Whitney Medical Library , one of the largest modern medical libraries , also known for its historical collections . The faculty includes 62 National Academy of Sciences members , 40 Institute of Medicine investigators , and 16 Howard Hughes Medical Institute investigators . U.S. News and World Report currently ranks the Yale School of Medicine 7th in the country for research , and 72nd in primary care . Entrance is highly selective ; for the class of 2016 , the school received 4,103 applications to fill its class of 100 students . The average GPA for admitted students was a 3.8 , with an average MCAT of 36.0. # Education # The School of Medicine offers the Doctor of Medicine ( M.D. ) degree and a Master of Medical Science ( M.M.Sc. ) degree through the Yale Physician Associate Program for prospective physician assistants . Public health degrees are administered through the Yale School of Public Health . There are also joint degree programs with other disciplines at Yale , including the M.D/Juris Doctor ( J.D. ) in conjunction with Yale Law School ; the M.D./Master of Business Administration ( M.B.A. ) in conjunction with the Yale School of Management ; the M.D./Master of Public Health ( M.P.H. ) in conjunction with the Yale School of Public Health ; science or engineering in conjunction with the Yale Graduate School of Arts and Sciences ( M.D./Ph.D. ) ; and the M.D./Master of Divinity ( M.Div ) in conjunction with Yale Divinity School . Students pursuing a tuition-free fifth year of research are eligible for the Master of Health Science degree . The M.D. program is notable for its assessment of student achievement . In particular , the school employs the so-called Yale System established by Dean Winternitz in the 1920s , wherein first- and second-year students are not graded or ranked among their classmates . In addition , course examinations are anonymous , and are intended only for students ' self-evaluation . Student performance is thus based on seminar participation , qualifying examinations ( if a student fails , it is his or her responsibility to meet with a professor and arrange for an alternative assessment - passing grades are not released ) , clinical clerkship evaluations , and the United States Medical Licensing Examination ( USMLE ) . Prior to graduation , students are required to submit a thesis based on original research . A hallmark of the Yale System is the unusual flexibility that it provides ; with this flexibility comes great responsibility for the student to take an active role in directing his or her education according to individual interests . Other key features of the Yale System include : commentary-based feedback from small group leaders an integrated Molecules to Systems course that includes Biochemistry , Physiology , and Cell Biology and the corresponding small group conferences ( Biochemistry Conference , Physiology Case Conference , Histology Lab ) early clinical exposure through the two-year Pre-Clinical Clerkship ( PCC ) course , in which students ( in groups of 4 ) are assigned a physician mentor with whom they will learn the History and Physical Examination a surgery-based Human Anatomy course that focuses on teaching the principles of anatomy through case-based dissections involving surgical procedures rather than rote memorization a comprehensive student teaching program ( Students Helping Students ) in which second-year students review key concepts during optional evening sessions several times each week the opportunity to take electives that include advanced cell biology and neuroscience , global health , translational research , or any topic being taught through graduate or undergraduate programs at the University More graduates of the Yale School of Medicine enter medical scholarship ( including Ph.D . degrees in Medicine ) as professors of medicine than those graduates of other medical schools . # History # In 18th century United States , credentials were not needed to practice medicine . Prior to the founding of the medical school , Yale graduates would train through an apprenticeship in order to become physicians . Yale president Ezra Stiles conceived the idea of training physicians at Yale and ultimately , his successor Timothy Dwight IV helped to found the medical school . The school was chartered in 1810 and opened in New Haven in 1813 . Nathan Smith ( medicine and surgery ) and Benjamin Silliman ( pharmacology ) were the first faculty members . Silliman was a professor of chemistry and taught at both Yale College and the Medical School . The other two founding faculty were Jonathan Knight , anatomy , physiology and surgery and Eli Ives , pediatrics . One of Yale 's earliest medical graduates was Dr. Asaph Leavitt Bissell of Hanover , New Hampshire , who graduated in 1815 , a member of the school 's second graduating class . Following his graduation , Dr. Bissell moved to Suffield , Connecticut , a tobacco-farming community where his parents came from , and where he practiced as a country physician for the rest of his life . The saddlebags that Dr. Bissell carried in his practice , packed with paper packets and glass bottles , are today in the school 's Medical Historical Library . The original building ( at Grove and Prospect ) later became Sheffield Hall , part of the Sheffield Scientific School ( razed in 1931 ) . In 1860 , the school moved to Medical Hall on York Street , near Chapel ( this building was razed in 1957 ) . In 1925 , the school moved to its current campus , neighboring the hospital . This campus includes the Sterling Hall of Medicine , Boyer Center for Molecular Medicine ( 1991 , designed by Cesar Pelli ) , Anlyan Center ( 2003 , designed by Payette and Venturi Scott Brown ) and the Amistad Building ( 2007 , designed by Herbert Newman ) . # Deans # Before 1845 , there was no dean . Nathan Smith , followed by Jonathan Knight , provided leadership in the early years .  Charles Hooker ( 18451863 ) , Professor of Anatomy and Physiology . His practice included surgery , obstetrics , and practical medicine .  Charles Augustus Lindsley ( 18631885 ) , Professor of Materia Medica and Therapeutics ; later of the Theory and Practice of Medicine .  Herbert Eugene Smith ( 18851910 ) , physician and chemist  George Blumer ( 19101920 )  Milton Winternitz ( 19201935 ) , pathologist  Stanhope Bayne-Jones ( 19351940 ) , physician and bacteriologist  Francis Gilman Blake ( 19401947 )  Cyril Norman Hugh Long ( 19471952 ) , physician and biochemist  Vernon W. Lippard ( 19521967 )  Frederick Carl Redlich ( 19671972 ) , psychiatrist  Lewis Thomas ( 19721973 ) , physician and author  Robert Berliner ( 19731984 )  Leon Rosenberg ( 19841991 )  Robert M. Donaldson ( acting ) ( 19911992 )  Gerard N. Burrow ( 19921997 )  David Aaron Kessler ( 19972003 ) , pediatrician , lawyer and former commissioner of the U.S. Food and Drug Administration  Dennis Spencer ( acting ) ( 20032004 ) , neurosurgeon  Robert Alpern ( 2004 ) , nephrologist. # Notable faculty #  Gretchen Berland , Physician and filmmaker  Harvey Cushing , Neurosurgeon , pioneer of brain surgery , identified Cushing 's syndrome  Russell Henry Chittenden , Physiological Chemist , pioneer of digestion and nutrition  Stephen Fleck , Psychiatrist , co-author of Schizophrenia and the Family  Patricia Goldman-Rakic , Neurobiologist , pioneer of studies on the frontal lobe and the cellular basis of working memory  Arnold Gesell , Psychologist and Pediatrician , developed the Yale Child Study Center  Harry S.N. Greene , Professor of pathology  Joy Hirsch Professor of Psychiatry and Neurobiology , Brain Function Laboratory  Dorothy Horstmann , Epidemiologist , virologist , pioneer in the study of polio and the first woman appointed as a professor at the school .  Orvan Hess , developed the fetal heart monitor and early use of penicillin  James D. Jamieson , Cell biologist , established the function of the Golgi apparatus alongside George Palade  Theodore Lidz , Psychiatrist , researcher of schizophrenia  Lafayette Mendel , Biochemist , discoverer of Vitamin A  Sherwin B. Nuland , winner of the National Book Award for ' ' How We Die : Reflections on Life 's Final Chapter ' '  William Prusoff , discovered idoxuridine , the first antiviral agent approved by the U.S. Food and Drug Administration , and discovered the anti-HIV effect of stavudine ( D4T ) . Citation Juan Rosai , Professor of pathology and Director of the Department of Anatomic Pathology at Yale School of Medicine between 1985 and 1991 . Author and editor of a main textbook in surgical pathology and discoverer of several entities such as Rosai-Dorfman disease and Desmoplastic small round cell tumor  James Rothman , Fergus F. Wallace Professor of Biomedical Sciences , Chairman of the Department of Cell Biology , Winner of Nobel Prize in Physiology or Medicine 2013  Lisa Sanders , The New York Times ' ' Diagnosis ' ' columnist , technical advisor for T.V. show House , M.D.  Richard Selzer , Surgeon and author  Nathan Smith , Founder of Dartmouth Medical School ( now the Geisel School of Medicine at Dartmouth ) and the University of Vermont College of Medicine  Joan Steitz Sterling Professor of Biophysics and Biochemistry  Thomas A. Steitz Sterling Professor of Biophysics and Biochemistry , Winner of Nobel Prize in Chemistry 2009  Frans J. Th . Wackers , Nuclear cardiologist 
@@885047 Health sciences encompasses a variety of sub-disciplines , all of which relate to the application of science to health . # Classification # A list of health sciences :  Clinical laboratory sciences/Clinical pathology/Laboratory medicine * Clinical biochemistry * Cytogenetics * Cytohematology * Cytology * Haemostasiology * Histology * Clinical immunology * Clinical microbiology * Molecular genetics * Parasitology  Clinical Physiology  Dentistry ( outline ) * Dental hygiene and epidemiology * Dental surgery * Endodontics * Orthodontics * Oral and maxillofacial surgery * Periodontics * Prosthodontics * Implantology  Health informatics/Clinical informatics  Nursing * Nursing theory  Obstetrics  Nutrition ( outline ) and dietetics  Optometry  Orthoptics  Audiology  Physiotherapy  Occupational therapy  Speech and language pathology  Internal medicine * Preventive medicine * Cardiology * Dermatology * Pulmonology ** Medical toxicology * Endocrinology * Gastroenterology **Hepatology * Oncology * Geriatrics * Gynaecology * Hematology * Infectious disease * Nephrology * Neurology * Neurosurgery * Nutrition * Obstetrics and gynaecology * Ophthalmology * Orthopedic surgery ** Hand surgery ** Foot and ankle surgery ** Sports medicine ** Joint replacement ** Shoulder surgery * Otolaryngology * Pathology * Pediatrics  Pharmacy  Pharmaceutical sciences  Physical fitness * Group Fitness / aerobics * Personal fitness training * Kinesiology / Exercise science / Human performance  Podiatry  Primary care * General practice  Psychiatry ( outline ) * Addiction medicine  Psychology ( outline ) * Behavioral medicine * Clinical psychology * Health psychology * Medical psychology * Counseling psychology  Public health  Radiology  Recreation therapy  Rehabilitation medicine  Respiratory medicine * Pulmonology * Sleep medicine  Respiratory therapy  Rheumatology  Sports medicine  Surgery * Bariatric surgery * Cardiothoracic surgery * Neurosurgery * Plastic surgery * Traumatology  Urology * Andrology Social Worker  Veterinary medicine # See also # # References # 
@@910147 Bachelor of medicine , bachelor of surgery , or in ( abbreviated in various ways , viz. ' ' MBBS ' ' or ' ' MBChB ' ' , ' ' MB BS ' ' , ' ' MB BChir ' ' , ' ' BM BCh ' ' , ' ' MB BCh ' ' , ' ' MB ChB ' ' , ' ' BM BS ' ' , ' ' BM ' ' , ' ' BMed ' ' etc. ) , are the two first professional undergraduate degrees awarded upon graduation from medical school in medicine and surgery by universities in various countries that follow the tradition of the United Kingdom . The naming suggests that they are two separate degrees ; however , in practice , they are usually treated as one and awarded together . In countries that follow the tradition of the United States , the degree is awarded as M.D. or D.O. , which is a professional doctorate degree . # History and nature # The degree is currently awarded in various forms in institutions in Australia , Botswana , Bahrain , Bangladesh , Barbados , China , Egypt , Fiji , Ghana , Guyana , Hong Kong , India , Indonesia , Iran , Iraq , Ireland , Jamaica , Jordan , Kenya , Kuwait , Libya , Malawi , Malaysia , Mauritius , Mexico , Myanmar , Nepal , New Zealand , Nigeria , Pakistan , Papua New Guinea , Samoa , Saudi Arabia , Sierra Leone , Singapore , South Africa , Sri Lanka , Sudan , Tanzania , Trinidad and Tobago , Uganda , the United Arab Emirates , the United Kingdom , Zambia and Zimbabwe . Historically , Bachelor of Medicine was also the primary medical degree conferred by institutions in the United States and Canada , such as University of Pennsylvania , Harvard , University of Toronto , University of Maryland , and Columbia . Several early North American medical schools were ( for the most part ) founded by physicians and surgeons who had trained in England and Scotland . University medical education in England culminated with the Bachelor of Medicine qualification , and in Scotland the Doctor of Medicine , until the mid-19th century when the public bodies that regulated medical practice at the time required practitioners in Scotland as well as England to hold the dual Bachelor of Medicine and Bachelor of Surgery degrees . Throughout the 19th century , North American medical schools switched to the tradition of the Ancient universities of Scotland and began conferring Doctor of Medicine rather than Bachelor of Medicine , the first institution to make such a switch being King 's College ( now Columbia University ) in New York . In the countries that award bachelors ' degrees in medicine , however , Doctor of Medicine denotes a holder of a higher doctorate and is reserved for medical practitioners who undertake research and submit a thesis in the field of medicine . Nevertheless , those holding Bachelor of Medicine , Bachelor of Surgery are usually referred to by the courtesy title of Doctor and use the prefix Dr , whether or not they also hold a Ph.D . or DSc . In theory the right to the use of the title Doctor is conferred on the medical graduate when he or she is registered as a medical practitioner by the relevant professional body , not merely by the possession of the academic degrees . The reason is found in a parallel tradition for those who are post-graduate specialists in Surgery ; on acceptance into a College of Surgeons , they stop styling themselves Doctor and revert to Mister ( Mr ) , Miss , Muz ( Ms. ) or Missus ( Mrs ) . This curious situation , where an elevation in professional rank is signified by dropping the title of Doctor , came about because historically a surgeon was an ordinary workman , usually a Barber , not trained in medicine but performing dissections and surgery under the direction of a gowned academic who was the actual Doctor . Despite their styling as two degrees , Bachelor of Medicine and Bachelor of Surgery are usually conferred together . At some institutions , such as Oxford and Cambridge , it was possible in the past to be awarded the two degrees in different years . In many countries , the degrees are awarded after an undergraduate course lasting five or six years . In some cases , a graduate in another discipline may subsequently enter a special graduate-entry medical course , reduced in duration to account for relevant material covered or learning skills acquired during the first degree . In some cases the old first year courses ( for six year degrees ) in the basic sciences of physics , chemistry and biology have been abolished , and that standard has to be reached by means of school examinations before entry . However , in most countries a newly graduated Bachelor of Medicine and Surgery must spend a specified period in internship before they can obtain full registration as a licensed medical practitioner . # Naming # The specific names and abbreviations given to these degrees depend on the particular institution , awarding body or country , and vary widely ; this is mostly for reasons of tradition rather than to indicate any particular difference between the relative levels of the degrees , and they are considered equivalent . If the awarding body titles the degrees in Latin , the degrees are commonly named ' ' Medicinae Baccalaureus , Chirurgiae Baccalaureus ' ' , ' ' Medicinae Baccalaureus et Chirurgiae Baccalaureus ' ' , or ' ' Baccalaureus in Medicina et in Chirurgia ' ' , abbreviated as MB ChB , MB BCh or otherwise . If titled in English , they are named ' ' Bachelor of Medicine , Bachelor of Surgery ' ' , ' ' Bachelor of Medicine and Bachelor of Surgery ' ' , or ' ' Bachelor of Medicine and Surgery ' ' , usually abbreviated as MB BS , and sometimes as BM BS , even though most MB BS-awarding institutions do not use Latin to name their degrees . Below are described the specific names used , arranged by country . # Australia # Historically Australian medical schools have followed the British tradition by conferring MBBS degrees to medicine graduates . The notable exception is the Bachelor of Medicine ( BMed ) joint program of the University of Newcastle and the University of New England . Australian MBBS degrees can be either undergraduate-entry ( i.e. after high school ) programs of 5 or 6 years duration , or graduate-entry programs of 4 years duration . Recently , some universities have begun to rename the MBBS to Doctor of Medicine ( MD ) . This new MD is not to be confused with the traditional MD in the Australian medical education hierarchy , which is a terminal research degree akin to a Doctor of Philosophy ( PhD ) . These programs are required to conform to the Australian Qualifications Framework Level 9 ( Extended Masters ) requirements , particularly in relation to research publication . The University of Melbourne was the first to rename their MBBS to MD , with University of New South Wales and Griffith University following suit , and University of Queensland expected to follow . Currently accredited basic medical qualifying degrees are listed below ( as at 31 May 2014 ) : # Bahrain # The Medical University of Bahrain or RCSI-Bahrain , is a constituent university of the Royal College of Surgeons in Ireland ( RCSI ) and awards its graduates the MB/BCh BAO , the same degree awarded to graduates at RCSI. # Bangladesh # All medical schools in Bangladesh award ' ' MBBS ' ' . The MD is awarded as a postgraduate research degree in select medical colleges , following the medical tradition of Commonwealth countries . As per the declaration of overseas registration of the General Medical Council , the awarded MBBS degree from some of the institutions is eligible to apply for registration in United Kingdom . In Bangladesh , Allopathic and Alternative Medicine related medical education at the undergraduate and graduate level is provided by medical colleges . The colleges are under the jurisdiction of the Ministry of Health , and are affiliated with a university in the respective region . Until the early 1990s , all medical colleges were established by the government . Since then , several private medical colleges have been set up . # Egypt # All Egyptian medical schools , public and private , award an MBBCh as the basic medical degree after completion of 6 academic years . The MBBCh is comparable to the M.D. in US and Canada . Advanced research degrees such as Master and PhD can be further pursued and are often a requirement for tenured positions in the medical schools . # England , Wales and Northern Ireland # Due to the UK code for higher education , first degrees in medicine comprise an integrated programme of study and professional practice spanning several levels . While the final outcomes of the qualifications themselves typically meet the Expectations of the descriptor for higher education qualification at level 7 ( the UK master 's degree ) . These degrees may retain , for historical reasons , Bachelor of Medicine , Bachelor of Surgery and are abbreviated to MBChB or MBBS . Various abbreviations are used for these degrees in these areas :  ' ' MB ChB ' ' are used at the universities of Birmingham , Bristol , Lancaster , Leeds , Leicester , Liverpool , Keele , Manchester , Sheffield , and Warwick .  ' ' MB BCh ' ' is used by the Welsh universities - Swansea University and Cardiff University .  ' ' MB , BCh , BAO ' ' are used at the Queen 's University , Belfast .  ' ' MB BS ' ' are used at all medical schools currently or previously part of the University of London ( Imperial College School of Medicine , UCL Medical School , King 's College London School of Medicine , Barts and The London School of Medicine and St George 's , University of London ) , University of East Anglia , Hull York Medical School , and Newcastle University .  ' ' BM BCh ' ' is awarded by the University of Oxford .  ' ' BM BS ' ' are used at the University of Nottingham , Peninsula College of Medicine and Dentistry ( Exeter Medical School and Plymouth University Peninsula Schools of Medicine and Dentistry ) , and Brighton and Sussex Medical School  ' ' BM ' ' is awarded at the University of Southampton . Although no degree in surgery is formally awarded by Southampton , this degree is equivalent to the MB ChB , and students may go on to a career in surgery the same as any other graduates in medicine and surgery .  ' ' MB BChir ' ' are awarded by the University of Cambridge . At the University of St Andrews , pre-clinical study leads to the award of a BSc ( Hons ) degree . Students then progress to other institutions to complete their MBChB . At the Universities of Oxford and Cambridge , the preclinical course leads to an additional Bachelor of Arts ( ' ' BA ' ' ) , degree ( upgradable after three or four years to Master of Arts ) , after which most students used to go elsewhere ( but usually to one of the London teaching hospitals ) to complete clinical training . They could then take the degrees of their new university : they used to have the options of returning to their old university to take the clinical examinations , or taking one of the old non-university qualifying examinations . Most students at Oxford and Cambridge now remain in place to take their clinical training . The Conjoint diplomas : ' ' LRCP , MRCS ' ' , and the alternative diploma ' ' LMSSA ' ' were non-university qualifying examinations in medicine and surgery awarded jointly by the Royal College of Physicians of London , Royal College of Surgeons of England and Society of Apothecaries through the United Examining Board from 1994 until 1999 , when the General Medical Council withdrew permission . Prior to 1994 , the English Conjoint diploma of ' ' LRCP , MRCS ' ' was awarded for 110 years , and the ' ' LMSSA ' ' was a distinct and sometimes less-esteemed qualification . These diplomas slowly became less popular among British medical students , but as recently as 1938 only a half of them qualified with university degrees . The diplomas came to be taken mostly by those who had already qualified in medicine overseas . # Ghana # All Ghanaian medical schools award an MBChB as the basic medical degree after 6 academic years . These medical schools are Kwame Nkrumah University of Science and Technology , University of Ghana , University for Development Studies and University of Cape Coast . # Guyana # The University of Guyana awards ' ' MB BS ' ' . Other offshore United-States-linked schools in the country award the North American MD . Recently , the University of Guyana acquired accreditation by CAAM-HP , establishing itself as a credible institute and teaching standards in comparison with University of West Indies . Texila American University awards Doctor of Medicine ( MD ) # Hong Kong # The awarding of qualifications in Hong Kong follows the British tradition . The dual degree is awarded as :  ' ' MBBS ' ' at The University of Hong Kong ; and  ' ' MBChB ' ' at The Chinese University of Hong Kong . # India # Medical colleges in India , accredited by the Medical Council of India , all title the degrees as ' ' MBBS ' ' . The students complete a course of four and a half years followed by one year of a compulsory rotatory internship before applying for the degree . Regulating Authority is planning to reduce course by six month means it will be four year duration with credit based system . The course is divided into four parts with only the second part lasting one and a half years . Students take an examination at the end of each part . The first part comprises pre-clinical subjects anatomy , physiology and biochemistry . The second part includes para-clinical subjects pharmacology , microbiology , pathology and forensic medicine . The third part comprises clinical subjects is divided into part I and part II comprising preventive and social medicine , ophthalmology , otorhinolaryngology and general medicine , general surgery &amp; orthopedics , pediatrics and obstetrics and gynecology respectively . The 12 month internship is compulsory to attain both the degrees and registration with the Medical Council of India . Following MBBS they can apply for post graduate ( specialty ) courses which will be for 2 to 3 years they will receive a degree as MD , MS , DNB depending on the subjects . Following this they can also further do super specialty courses in cardiology , neurology , oncology , nephrology , gastroenterology , endocrinology , immunology , etc. for 3 more years , they will be awarded the degree as DM ( medical ) , MCh ( surgical ) , DNB ( medical/surgical ) . MBBS is course after 10+2 , which is related to medical study . # Indonesia # In Indonesia , medicine is an undergraduate study . The Bachelor of Medicine program is completed in 3.5 up to 4 years and graduating students are awarded the degree of ' ' S.Ked ' ' ( ' ' Sarjana Kedokteran ' ' / Bachelor of Medicine ) . At this point , the graduate is not yet a doctor , but he or she may choose to work directly as a scientist or other non-clinician professions ( usually still health-related ) . However , most S.Ked graduates will pursue the conventional path , which is to enroll in the clerkship program for another 1.5 up to 2 years . This makes the total duration of medical school 5 or 6 years . After they finish clerkship , they will take their Hippocratic Oath and be awarded the title of ' ' dr. ' ' ( medical doctor , equivalent to M.D. in United States ) . Graduates who hold this title are licensed and may now practice medicine . Note that this title is written in lowercase d , as opposed to uppercase D , ' ' Dr. ' ' , which in Indonesia refers to a Ph.D . # Iran # Medical education begins after high school in Iran . No pre-med course or B.Sc. degree is required . The eligibility is determined through the rank applicants obtain in the national university entrance exam being held every year . The entry to medical school is so competitive and only students with the highest rank are accepted into medical program . The primary medical degree is completed in 7-7.5 years . Medical graduates are awarded a certificate in general medicine , called Professional Doctorate in Medicine validated by the Ministry of health and Medical Education of Iran . All physicians will obtain licence and medical council registration number from the Medical Council of Iran before they officially begin to practice . They may subsequently specialize in a specific medical field at medical schools offering the necessary qualifications . Academically , Degree of Professional Doctorate in Medicine is evaluated as Master 's degree in Iran and graduates are allowed to enroll in PhD programs directly after obtaining medical degree . # Iraq # All medical schools in Iraq award ' ' MB ChB ' ' . # Ireland # The medical schools in both the Republic of Ireland and Northern Ireland - Queen 's University Belfast , the University of Dublin ( Trinity College ) , some constituent institutions of the National University of Ireland ( University College Dublin , University College Cork and National University of Ireland , Galway ) , and the Royal College of Surgeons in Ireland award the degrees of ' ' MB BCh BAO ' ' . The letters ' ' BAO ' ' stand for ' ' Baccalaureus in Arte Obstetricia ' ' ( Bachelor of Obstetrics ) , a degree unique to Ireland which the Irish universities added in the 19th century as the legislation at the time insisted on a final examination in obstetrics . This third degree is an anachronism which is not registerable with the Irish Medical Council nor the British General Medical Council ( GMC ) . The only exception is the University of Limerick graduate school of medicine which awards ' ' BM BS ' ' for Bachelor of Medicine and Bachelor of Surgery . At the University of Dublin the preclinical course leads to an additional Bachelor of Arts ( BA ) degree ( upgradable after three or four years to Master of Arts ) in the Natural Science Moderatorship ; as originally after this most students used to go elsewhere to complete clinical training . ' ' LRCPI LRCSI ' ' , or simply ' ' LRCP&amp;SI ' ' , denotes a holder of the historical non-university qualifying licenciates awarded jointly by the Royal College of Physicians of Ireland and the Royal College of Surgeons in Ireland to students of the RCSI 's medical school under the ' ' Irish Conjoint Scheme ' ' . Unlike the corresponding licentiates awarded by the Royal Colleges in Scotland and England ( which were external qualifications ) , these qualifications are still registerable with the Irish Medical Council , but not with the British GMC . Students at RCSI still receive these licenciates but now also receive the degrees ' ' MB BCh BAO ' ' , due to RCSI 's status as a recognised college of the National University of Ireland . The RCSI students also received a Licence in Midwifery ( LM ) from each college , in the same way that the Irish universities granted BAO degrees , so their qualifications were sometimes expressed as ' ' L &amp; LM , RCPI , L &amp; LM , RCSI ' ' or more misleadingly as ' ' LLM , RCP&amp;SI . ' ' ' ' LAH ' ' formerly denoted a licentiate of the now-defunct Apothecaries ' Hall , Dublin , and is no longer awarded . # Jordan # The ' ' Bachelor of Medicine and Surgery ' ' ' ' ( MBBS ) ' ' degree is awarded in Jordan after completion of six years comprising three years of medical sciences and three clinical years . Currently , four state supported universities grant the degree which are : Jordan University of Science and Technology University of Jordan Mutah University Hashemite University # Kenya # The national universities with medical faculties in Kenya , namely Egerton University , University of Nairobi , Kenyatta University , Moi University , Maseno University and Kenya Methodist University award ' ' MB ChB ' ' . Mount Kenya University awards a different degree , the Bachelor of Clinical Medicine and Community Health . # Libya # There are three major public medical universities in Libya , University of Tripoli ( Tripoli ) and University of Benghazi ( formerly Garyounis ) ( Benghazi ) and ( ( university of alzaweyah ) ( ( alzaweyah ) . the schools award MBBCh . The is an accredited private medical university which awards an MBChB to its graduates . # Malaysia # The MBBS is awarded by 5 Public &amp; 14 Private Universities : Public Universiti Malaya ( UM ) - October 1949  Universiti Islam Antarabangsa Malaysia ( UIAM ) - May 1995 Universiti Teknologi MARA ( UiTM ) - June 2003 Universiti Sains Islam Malaysia ( USIM ) - July 2005 Universiti Sultan Zainal Abidin ( UniSZA ) - July 2009 Private International Medical University ( IMU ) - February 1999 Asian Institute of Medicine , Science &amp; Technology ( AIMST ) University - May 2001 Monash University Malaysia Campus - February 2007 Universiti Kuala Lumpur ( UniKL-RCMP ) - July 2008 Melaka Manipal Medical College ( MMMC ) Cyberjaya University College of Medical Sciences ( CUCMS ) Management &amp; Science University International Medical School ( MSU-IMS ) MAHSA University College Taylor 's University College Newcastle University Medicine Malaysia Universiti Tunku Abdul Rahman ( UTAR ) Masterskill University College of Health Sciences ( MUCH ) SEGI University College Insaniah University College # Myanmar # All five medical schools ( UM1 , UM 2 , DSMA , UMDY , UMG ) in Myanmar award ' ' MB BS ' ' . # Nepal # There are 18 Medical Schools in Nepal that award MBBS degree . Nepal Medical Council ( NMC ) is the regulatory board in Nepal that give recognition to medical institutions for providing formal studies in medical science and training . Kathmandu University ( KU ) and Affiliated colleges :  Kathmandu University , School of Medical Sciences ( KUSMS ) , Dhulikhel , Kavre  Manipal College of Medical Sciences ( MCOMS ) , Pokhara , Kaski  College of Medical Sciences ( CMS ) , Bharatpur , Chitwan  Kathmandu Medical College ( KMC ) , Sinamangal , Kathmandu  Nepal Medical College ( NMC ) , Jorpati , Kathmandu  Nepalgunj Medical College ( NGMC ) , Chisapani , Nepalgunj  Lumbini Medical College ( LMC ) , Tansen , Palpa  Nobel Medical College , Biratnagar Tribhuvan University ( TU ) and Affiliated colleges :  Tribhuvan University , Institute of Medicine ( IOM ) , Maharajgunj , Kathmandu  Universal College of Medical Sciences ( UCMS ) , Bhairawaha  National Medical College , Birgunj  Janaki Medical College , Janakpur  KIST Medical College , Imadol , Lalitpur  Chitwan Medical College ( CMC ) , Bharatpur , Chitwan  Gandaki Medical College ( GMCTHRC ) , Pokhara , Kaski  Mahendranagar Medical College , Mahendranagar , Kanchanpur Medical School not affiliated to universities or having their own board :  B.P. Koirala Institute Of Health Sciences ( BPKIHS ) , Ghopa , Dharan  Patan Academy of Health Sciences ( PAHS ) , Patan , Lalitpur  National Academy of Medical Sciences ( NAMS ) , Kathmandu is a NMC recognized medical college that have post-graduate residency training programs but do not award MBBS degree . # New Zealand # The two New Zealand medical schools , Auckland and Otago , style their degrees as ' ' MBChB ' ' . # Pakistan # All Ninety One ( 41 Public Sector and 50 Private Sector ) medical institutes award MBBS ( 5 years program ) , including the famous institutes of Nishtar Medical College , Multan , AYUB MEDICAL COLLEGE , ABBOTTABAD , CMH Lahore Medical And Dental College and Institute of Dentistry , Service Institute Of Medical Sciences ( SIMS ) , Shifa College of Medicine , Army Medical College , Frontier Medical College , Abbottabad , King Edward Medical University , The Aga Khan University , Dow University of Health Sciences and University of Health Sciences , Lahore , Khyber Medical University . University of Health Sciences , Lahore awards M.B , B.S degree to all the medical colleges of the Punjab including private sector as well . # People 's Republic of China # In the People 's Republic of China , medical graduates are traditionally awarded a Bachelor of Medicine ( BMed ) for a course of study lasting five or six years . However , as of 2011 , 49 universities , including its frequently top-ranked medical schools , have been authorized by the government to award the MBBS degree as an equivalent to the BMed . However 2014-15 list is not published by Ministry of Education China . The universities listed in 2011 are : Anhui Medical University Beihua University Capital Medical University Central South University China Medical University Chongqing Medical University Dalian Medical University Fudan University Fujian Medical University Guangxi Medical University Guangzhou Medical College Harbin Medical University Hebei Medical University Huazhong University of Science and Technology Jiamusi University Jiangxi University of Traditional Chinese Medicine Jilin University Jining Medical University Nanchang University Nankai University Nanjing Medical University Nantong University Ningbo University Ningxia Medical University Peking University Health Science Center Qingdao University Shandong University Shanghai Jiao Tong University Shantou University Sichuan University School of Medicine Soochow University Southeast University Southern Medical University Taishan Medical University Tianjin Medical University Tongji University Wenzhou Medical University Wuhan University Xiamen University Xian Jiaotong University Xinjiang Medical University yichun university Zhejiang University Zhengzhou University Weifang Medical University  Luzhou Medical College  Sichuan Medical College Shihezi University - School of Medicine www.shzuni.com # Saudi Arabia # Medical schools in Saudi Arabia award ' ' MBBS ' ' Government sponsored medical schools :  Riyadh  Riyadh  Jeddah  Ahsa  Dammam  Abha  Riyadh  Makkah  Jazan Aljouf University , College of Medicine . Taif University , College of Medicine . Private medical schools : # Somalia # Medical schools in Somalia award the MBBS : Amoud University , College of Medicine and Medical Sciences Benadir University Bosasso School of Nursing Burao Institute of Health Sciences East Africa University Edna Adan Maternity Hospital Hargeisa Institute of Health Sciences Hargeisa University Indian Ocean University Kismayo University Mogadishu Private School of Nursing Mogadishu Public School of Nursing Mogadishu University Nugaal University Plasma University Puntland School of Nursing Somaliland University of Technology University of Burao University of Hargeisa # Scotland # All medical schools in Scotland ( Aberdeen , Dundee , Edinburgh and Glasgow ) award ' ' MB ChB ' ' . The University of St Andrews School of Medicine awarded ' ' MB ChB ' ' until the early 1970s , but since the incorporation of its clinical medical school into the University of Dundee , St Andrews now only awards a pre-clinical ' ' BSc ' ' or ' ' BSc ( Hons ) ' ' , and students go to a Partner Medical School ( Aberdeen , Dundee , Edinburgh , Glasgow , or Manchester where they are awarded an ' ' MB ChB ' ' after a further three years ' study ) . The ' ' Scottish Triple Conjoint Diploma ' ' of ' ' LRCPE , LRCSE , LRCPSG ' ' ( earlier LRCPE , LRCSE , LRFPSG ) is an old non-university qualifying examination in medicine and surgery awarded jointly by the Royal College of Physicians of Edinburgh , Royal College of Surgeons of Edinburgh and Royal College of Physicians and Surgeons of Glasgow , previously through a Conjoint Board and from 1994 through the United Examining Board . These qualifications are still registrable with the GMC , but permission to award them was withdrawn by the Privy Council of the UK in 1999. # South Africa # The University of Pretoria , University of Cape Town , University of the Free State , University of Stellenbosch , University of KwaZulu-Natal and MEDUNSA all award MBChB , whereas the University of the Witwatersrand styles its degree as MBBCh. # Singapore # The Yong Loo Lin School of Medicine at the National University of Singapore confers ' ' MB BS ' ' . The American Duke University also has a medical programme based in Singapore ( Duke-NUS Graduate Medical School ) , but it follows the North-American model of styling its degree Doctor of Medicine ( MD ) at masters degree level . # Sri Lanka # The University of Sri Jayewardenepura , University of Colombo , University of Peradeniya , University of Kelaniya ( Ragama ) , University of Ruhuna , Rajarata University , University of Jaffna , General Sir John Kotelawala Defence University and Eastern University of Sri Lanka , hold the authority to award MBBS in Sri Lanka . # Sudan # All Sudanese medical schools award the MBBS. # #South Sudan# # The University of Juba in South Sudan awards the MBBS degree after the successful completion of six academic years . # United States # # #Wisconsin# # The Wisconsin Medical Society defends the use of the M.D. title by physicians who graduated with an MBBS and are licensed to practice medicine in Wisconsin . # Uganda # The five universities in Uganda which have medical schools that teach undergraduate courses , namely Makerere University , Mbarara University , Gulu University , Kampala International University and Busitema University , all award the MBChB degree , after 5 years of study . # Zambia # All schools in Zambia that award the MBChB degree : Government sponsored medical schools : University of Zambia ( UNZA ) , Copperbelt University ( CBU ) Private Sponsored medical schools : Cavendish University Zambia ( CUZ ) , Lusaka Apex Medical University ( LAMU ) # Zimbabwe # In Zimbabwe the Bachelor of Medicine and Bachelor of Surgery degree is done at Undergraduate level . Entry into a Zimbabwean medical school is highly competitive due to the strict system . The University of Zimbabwe College of Health Sciences offers the five-year MBChB degree . This is the largest and oldest University in Zimbabwe . Applicants submit their applications early in February every year for the August intake and shortlisted candidates are required to pass an interview in order to be admitted into this programme . The first two years of this programme provide basic education in Biochemistry , Anatomy and Physiology . The following three years then provide clinical training in Paediatrics , Gyenacology and Obstretics , Phsychiatry , Pathology , Epidemiology , etc. , along with clinical rotations at Parirenyatwa Hospital in Harare . The National University of Science and Technology offers the five-and-a-half year MBBS degree . Admission policy as well as curriculum are similar to that of the University of Zimbabwe . Clinical rotations are done at Mpilo Hospital in Bulawayo . # Wales # Both universities in Wales that have medical schools , namely Cardiff University and Swansea University , award ' ' MB BCh ' ' . # West Indies # All constituent countries of the University of the West Indies ( UWI ) confer ' ' MB BS ' ' , due to the historical affiliation of UWI to the University of London . There are other medical schools in the West Indies , but these follow the North-American system leading to ' ' MD ' ' . # Classification # Medical degrees differ from other undergraduate degrees in that they are professional qualifications which lead holders to enter a particular career upon receipt . This is not the case with most other undergraduate degrees , so whilst the Bachelor of Medicine and Bachelor of Surgery are undergraduate or graduate degrees ( depending on the institution ) , they are perhaps more accurately conceptualised as a so-called first professional degree . Other professions whose qualifications follow a similar pattern include : Chiropractic Dentistry Denturitry Education Engineering Environmental Health Occupational Therapy Optometry Pharmacy Physical Therapy Law Veterinary Medicine Osteopathy Physician Assistant Bachelor of Medicine , Bachelor of Surgery are usually awarded as general/ordinary degrees , not as honours degrees , and as such the graduate is not classified as for honours degrees in other subjects . However , at many institutions ( for example the University of Birmingham , University of Sheffield , University of Liverpool , University of Leicester and University of Manchester in England and the University of Dundee in Scotland ) it is possible for the degrees to be awarded with Honours ( i.e. MB ChB ( Hons. ) or with Commendation , if the board of examiners recognises exceptional performance throughout the degree course . Very few of these are awarded . More often , it is possible to study one subject for an extra year for an intercalated honours degree . This is usually a Bachelor of Science ( BSc ) , Bachelor of Medical Science ( BMedSci ) , Bachelor of Medical Biology ( BMedBiol ) or similar : at Oxford and Cambridge in England and Dublin in Ireland Bachelor of Arts degrees are awarded . At a few universities most medical students obtain an ordinary degree in science as well : when the University of Edinburgh had a six year course , the third year was followed by award of an ordinary BSc(MedSci) . In Australia , The University of Melbourne in Australia offers an Arts Degree ( BA ) to a medical student on the completion of two extra years of undergraduate study , and Monash University offers a Law degree ( LLB ) ; if the optional Law degree is undertaken , on completion of their degree the student may choose to do a one-year internship at a hospital and become a doctor , or spend one year doing articles to practise thereafter as a lawyer . At the University of Nottingham and the University of Southampton , both in England , all medical students on the five year course obtain a Bachelor of Medical Sciences ( BMedSci ) degree without an extra intercalated year . At Imperial College London and University College London , certain medical students are able to extend their intercalated year to an extra three years , thus temporarily exiting the MBBS course to complete a PhD . Upon completion of the PhD , the student is required to sit the remaining 2 years of the medicine course in order to receive his/her MBBS degeee . The University of the West Indies , Mona in Kingston , Jamaica automatically awards a Bachelor of Medical Sciences ( BMedSci ) degree to all students who have successfully completed three years of their MBBS programme . # Progression # Medical school graduates are only entitled to use the courtesy title Doctor upon registration as a medical practitioner with the relevant regulatory body in their respective country . Medical graduates are also eligible to sit various postgraduate examinations , including examinations for membership and fellowship of professional institutions . Among the latter are the Membership of the Royal College of Surgeons , postgraduate Masters degrees ( such as a Master of Surgery or Master of Medicine ) , and a postgraduate doctorate in medicine ( such as Doctor of Medicine or Doctor of Science , if earned in Ireland , the UK or Commonwealth nations , and board certification examinations ) . 
@@990505 Mental health is a level of psychological well-being , or an absence of a mental disorder ; it is the psychological state of someone who is functioning at a satisfactory level of emotional and behavioural adjustment . From the perspective of positive psychology or holism , mental health may include an individual 's ability to enjoy life , and create a balance between life activities and efforts to achieve psychological resilience . According to World Health Organization ( WHO ) mental health includes subjective well-being , perceived self-efficacy , autonomy , competence , intergenerational dependence , and self-actualization of ones intellectual and emotional potential , among others . WHO further states that the well-being of an individual is encompassed in the realization of their abilities , coping with normal stresses of life , productive work and contribution to their community . However , cultural differences , subjective assessments , and competing professional theories all affect how mental health is defined . A person struggling with his or her behavioral health may face stress , depression , anxiety , relationship problems , grief , addiction , ADHD or learning disabilities , mood disorders , or other psychological concerns . Counselors , therapists , life coaches , psychologists , nurse practitioners or physicians can help manage behavioral health concerns with treatments such as therapy , counseling , or medication . The new field of global mental health is the area of study , research and practice that places a priority on improving mental health and achieving equity in mental health for all people worldwide . # History # In the mid-15th century , William Sweetzer was the first to clearly define the term mental hygiene which can be seen as the precursor to contemporary approaches to work on promoting positive mental health . Isaac Ray , one of the thirteen founders of the American Psychiatric Association , further defined mental hygiene as an art to preserve the mind against incidents and influences which would inhibit or destroy its energy , quality or development . Dorothea Dix ( 18021887 ) was an important figure in the development of mental hygiene movement . Dix was a school teacher who endeavored throughout her life to help those suffering from mental illness , and to bring to light the deplorable conditions into which they were put . This was known as the mental hygiene movement . Before this movement , it was not uncommon that people affected by mental illness in the 19th century would be considerably neglected , often left alone in deplorable conditions , barely even having sufficient clothing . Dix 's efforts were so great that there was a rise in the number of patients in mental health facilities , which sadly resulted in these patients receiving less attention and care , as these institutions were largely understaffed . At the beginning of the 20th century , Clifford Beers founded the National Committee for Mental Hygiene and opened the first outpatient mental health clinic in the United States of America . The mental hygiene movement , related to the social hygiene movement , had at times been associated with advocating eugenics and sterilisation of those considered too mentally deficient to be assisted into productive work and contented family life . After year 1945 , references to mental hygiene were gradually replaced by the term ' mental health ' . # Significance # Evidence from the World Health Organization suggests that nearly half of the world 's population are affected by mental illness with an impact on their self-esteem , relationships and ability to function in everyday life . An individual 's emotional health can also impact physical health and poor mental health can lead to problems such as substance abuse . Maintaining good mental health is crucial to living a long and healthy life . Good mental health can enhance one 's life , while poor mental health can prevent someone from living an enriching life . According to Richards , Campania , &amp; Muse-Burke ( 2010 ) There is growing evidence that is showing emotional abilities are associated with prosocial behaviors such as stress management and physical health ( 2010 ) . It was also concluded in their research that people who lack emotional expression are inclined to anti-social behaviors . These behaviors are a direct reflection of their mental health . Self-destructive acts may take place to suppress emotions . Some of these acts include drug and alcohol abuse , physical fights or vandalism . # Perspectives # # Mental well-being # Mental health can be seen as an unstable continuum , where an individual 's mental health may have many different possible values . In the United Kingdom , the Royal College of Psychiatrists organized the campaign ' ' Changing Minds ' ' ( 19982003 ) to help reduce stigma . Many mental health professionals are beginning to , or already understand , the importance of competency in religious diversity and spirituality . The American Psychological Association explicitly states that religion must be respected . Education in spiritual and religious matters is also required by the American Psychiatric Association . # Emotional issues around the world # Emotional mental disorders are a leading cause of disabilities worldwide . Investigating the degree and severity of untreated emotional mental disorders throughout the world is a top priority of the World Mental Health ( WMH ) survey initiative , which was created in 1998 by the World Health Organization ( WHO ) . Neuropsychiatric disorders are the leading causes of disability worldwide , accounting for 37% of all healthy life years lost through disease.These disorders are most destructive to low and middle-income countries due to their inability to provide their citizens with proper aid . Despite modern treatment and rehabilitation for emotional mental health disorders , even economically advantaged societies have competing priorities and budgetary constraints . The World Mental Health survey initiative has suggested a plan for countries to redesign their mental health care systems to best allocate resources . A first step is documentation of services being used and the extent and nature of unmet needs for treatment . A second step could be to do a cross-national comparison of service use and unmet needs in countries with different mental health care systems . Such comparisons can help to uncover optimum financing , national policies , and delivery systems for mental health care . Knowledge of how to provide effective emotional mental health care has become imperative worldwide . Unfortunately , most countries have insufficient data to guide decisions , absent or competing visions for resources , and near constant pressures to cut insurance and entitlements . WMH surveys were done in Africa ( Nigeria , South Africa ) , the Americas ( Colombia , Mexico , U.S.A ) , Asia and the Pacific ( Japan , New Zealand , Beijing and Shanghai in the Peoples Republic of China ) , Europe ( Belgium , France , Germany , Italy , Netherlands , Spain , Ukraine ) , and the middle east ( Israel , Lebanon ) . Countries were classified with World Bank criteria as low-income ( Nigeria ) , lower middle-income ( China , Colombia , South Africa , Ukraine ) , higher middle-income ( Lebanon , Mexico ) , and high-income . The coordinated surveys on emotional mental health disorders , their severity , and treatments were implemented in the aforementioned countries . These surveys assessed the frequency , types , and adequacy of mental health service use in 17 countries in which WMH surveys are complete . The WMH also examined unmet needs for treatment in strata defined by the seriousness of mental disorders . Their research showed that the number of respondents using any 12-month mental health service was generally lower in developing than in developed countries , and the proportion receiving services tended to correspond to countries ' percentages of gross domestic product spent on health care . High levels of unmet need worldwide are not surprising , since WHO Project ATLAS ' findings of much lower mental health expenditures than was suggested by the magnitude of burdens from mental illnesses . Generally , unmet needs in low-income and middle-income countries 
@@1119701 Physical medicine and rehabilitation ( PM&amp;R ) , also known as physiatry or rehabilitation medicine , is a branch of medicine that aims to enhance and restore functional ability and quality of life to those with physical impairments or disabilities . A physician having completed training in this field is referred to as a physiatrist or rehabilitation medicine specialist . Physiatrists specialize in restoring optimal function to people with injuries to the muscles , bones , tissues , and nervous system ( such as stroke patients ) . # Scope of the field # Common conditions that are treated by the rehabilitation therapists include amputation , spinal cord injury , sports injury , stroke , musculoskeletal pain syndromes such as low back pain , fibromyalgia , and traumatic brain injury . Cardiopulmonary rehabilitation involves optimizing function in those afflicted with heart or lung disease . Chronic pain management is achieved through a multidisciplinary approach involving psychologists , physical therapists , occupational therapists , exercise therapists , anesthesiologist , and interventional procedures when indicated . In addition to the previous methodology , stroke is often treated with the help of a speech therapist and recreational therapist when possible . # History # The term ' physiatry ' was coined by Dr. Frank H. Krusen in 1938 . The term was accepted by the American Medical Association in 1946 . The field grew notably during World War II to accommodate the large number of injured soldiers . # Treatment # The major concern that PM&amp;R deals with as a medical field is the ability of a person to function optimally within the limitations placed upon them by a disabling impairment or disease process for which there is no known cure . The emphasis is not on the full restoration to the premorbid level of function , but rather the optimization of the quality of life for those not able to achieve full restoration . A team approach to chronic conditions is emphasized to coordinate care of patients . Comprehensive Rehabilitation is provided by specialists in this field , who act as a facilitator , team leader , and medical expert for rehabilitation . # Training # # Subspecialties # Six formal sub-specializations are recognized by the field in the United States :  Hospice and Palliative Medicine  Neuromuscular Medicine  Pain Medicine  Pediatric Rehabilitation  Spinal Cord Injury Medicine  Sports Medicine Other subspecialties within the field that are recognized include the following :  Musculoskeletal pain management  Intervention physiatry  Surgical rehabilitation  Rheumatological rehabilitation  Obesity and other lifestyle disease modifications  Cardiopulmonary rehabilitation  Amputee care  Electrodiagnostics  Traumatic brain injury ( TBI ) 
@@1147690 Residency is a stage of graduate medical training . A resident physician or resident or resident medical officer is a person who has received the title of physician ( usually a D.O. , M.D. or foreign medical degree MBBS , MBChB , BMed ) or in some circumstances , another health sciences terminal degree ( such as psychology or dentistry ) who practices medicine usually in a hospital or clinic . The definition of Residency varies worldwide by country and structure of the medical industry . In the US , it is classically associated with physicians ( D.O . or M.D. ) , the training programs of pharmacists , physical therapists , physician assistants , veterinarians , podiatrists , medical physicists , optometrists , and dentists may also involve a period of training referred to as a residency . A residency may follow the internship year or include the internship year as the first year of residency . The residency can also be followed by a fellowship , during which the physician is trained in a specialty or a sub-specialty . Successful completion of residency training is a requirement to practice medicine in many jurisdictions . Whereas medical school teaches physicians a broad range of medical knowledge , basic clinical skills , and limited experience practicing medicine , medical residency gives in-depth training within a specific branch of medicine . A physician may choose a residency in anesthesiology , ophthalmology , dermatology , emergency medicine , family medicine , internal medicine , neurology , obstetrics and gynecology , pathology , pediatrics , plastic and reconstructive surgery , psychiatry , physical medicine and rehabilitation , radiology , radiation oncology , neurosurgery , Oral and Maxillofacial Surgery , surgery , or other specialties . # Terminology # A ' ' resident physician ' ' is more commonly referred to as a ' ' resident ' ' , ' ' senior house officer ' ' ( in Commonwealth countries ) , or alternatively as a ' ' senior resident medical officer ' ' or ' ' house officer ' ' . Residents have graduated from an accredited medical school and hold a medical degree ( MD , DO , DPM , MBBS , MBChB ) . The residents collectively are the ' ' house staff ' ' of a hospital . This term comes from the fact that resident physicians traditionally live the majority of their training in house , i.e. , the hospital . Duration of most residencies can range from three years to seven years for a specialized field such as neurosurgery . A year in residency begins between late June to early July depending on the individual program , and ends one calendar year later . A first-year resident is often termed an intern , although this term is quickly being changed to first year resident . Depending on the number of years a specialty requires , the term junior resident refers to residents that have not completed half their residency . ' ' Senior residents ' ' are residents in their final year of residency . Some residency programs refer to residents in their final year as ' ' chief residents ' ' ( typically in surgical branches ) . Alternatively , a ' ' chief resident ' ' may describe a resident who has been selected to extend his or her residency by one year and organize the activities and training of the other residents ( typically in internal medicine and pediatrics ) . If a physician finishes a residency and decides to further his or her education in a fellowship , he or she is referred to as a fellow . Post-residency physicians are referred to as ' ' attending physicians , ' ' or ' ' consultants ' ' ( in Commonwealth countries ) . However , the above nomenclature applies strictly only to educational institutes in whom the period of training is specified in advance . In privately owned , non-training hospitals , in certain countries , the above terminology may reflect the level of responsibility held by a physician rather than their level of education . # History # Residency as an opportunity for advanced training in a medical or surgical specialty evolved in the late 19th century from brief and informal programs for extra training in a special area of interest . The first formal residency programs were established by Sir William Osler and William Stewart Halsted at the Johns Hopkins Hospital . Residencies elsewhere then became formalized and institutionalized for the principal specialties in the early 20th century . But even mid-century , residency was not seen as necessary for general practice and only a minority of primary care physicians participated . By the end of the 20th century in North America though , very few new doctors went directly from medical school into independent , unsupervised medical practice , and more state and provincial governments began requiring one or more years of postgraduate training for medical licensure . Residencies are traditionally hospital-based , and in the middle of the twentieth century , residents would often live ( or reside ) in hospital-supplied housing . Call ( night duty in the hospital ) was sometimes as frequent as every minute or third night for up to three years . Pay was minimal beyond room , board , and laundry services . It was assumed that most young men and women training as physicians had few obligations outside of medical training at that stage of their careers . The first year of practical patient-care-oriented training after medical school has long been termed internship . Even as late as the middle of the twentieth century , most physicians went into primary care practice after a year of internship . Residencies were separate from internship , often served at different hospitals , and only a minority of physicians did residencies. # Argentina # In Argentina , the residency ( Spanish , ' ' residencia ' ' ) consists of a three to four years of practical and research activities in the field selected by both the candidate and already graduated medical practitioners . Specialized fields such as neurosurgery or cardio-thoracic surgery require longer training . Through these years , consisting of internships , social services , and occasional research , the resident is classified according to their residency year as an R1 , R2 , R3 or R4 . After the last year , the R3 or R4 Resident obtains the specialty ( ' ' especialidad ' ' ) in the selected field of medicine . # France # In France , students attending clinical practice are known as externes and newly qualified practitioners training in hospitals are known as internes . The Residency , called Internat , lasts from three to five years and follows a competitive national examination . It is customary to delay submission of a thesis . As in most other European countries , many years of practice at a junior level may follow . French Residents can not be called Doctor during their residency . They are still considered as students and become M.D. only at the end of their residency and after submitting a thesis . # Mexico # In Mexico , after presenting the most competitive medical exam in Latin America , the annual residency exam ( Spanish , ' ' examen nacional de residencias medicas ' ' ) , the physician applies to residency programs in the field he or she wishes to specialise in at ( usually ) several hospitals . The usual duration of the residency program is four years for Internal Medicine , Pediatrics and Family Medicine but may vary from program to program . More specialised fields , such as surgery , obstetrics and gynecology , also require four years ' training . After completing the residency , the applicant can continue training as a sub-specialist ( in Mexico , the term fellow is not used ) . # Pakistan # In Pakistan after completing MBBS and then a further period of a year in house job ( internship ) , doctors can enroll in two types of postgraduate residency programs . First is MS/MD program run by various medical universities throughout country . It is 4-5 year program depending upon speciality . Second is fellowship program ( FCPS ) by The College of Physicians and Surgeons ( CPSP ) . It is Also 4-5 years depending upon speciality . In addition there are post fellowship programs by CPSP as a second fellowship in sub specialities . Both these programs are equal to any international standard program . # United Kingdom # In the United Kingdom , house officer posts used to be optional for those going into general practice , but almost essential for progress in hospital medicine . The Medical Act of 1956 made satisfactory completion of one year as house officer necessary to progress from provisional to full registration as a medical practitioner . These pre-registration house officer posts lasted six months , and it was necessary to complete one surgical and one medical post . Obstetrics could be substituted for either . In principle , general practice in a Health Centre was also allowed , but this was almost unheard of . The posts did not have to be in general medicine : some teaching hospitals had very specialised posts at this level , so it was possible for a new graduate to do neurology or orthopaedics , for a year before having to go onto more broadly based work . The pre-registration posts were nominally supervised by the General Medical Council , which in practice delegated the task to the medical schools , who left it to the consultant medical staff . The educational value of these posts varied enormously . On call work in the early days was full-time , with frequent night shifts and weekends on call . One night in two was common , and later one night in three . This meant weekends on call started at 9 am on Friday and ended at 5 pm on Monday ( 80 hours ) . The European Union 's controversial Working Time Directive conflicted with this : at first the UK negotiated an opt-out for some years , but working hours needed reform . On call time was unpaid until 1975 ( the year of the interns ' one-day strike ) , and for a year or two depended on certification by the consultant in charge - a number of them refused to sign . On call time was at first paid at 30% of the standard rate . Before paid on call was introduced , there would be several house officers in the house at any one time and the second on call house officer could go out , provided they kept the hospital informed of their telephone number at all times . A pre-registration house officer would go on to work as a senior house officer for at least one year before seeking a registrar post . SHO posts could last six months to a year , and junior doctors often had to travel around the country to attend interviews and move house every six months while constructing their own training scheme for general practice or hospital specialisation . Organised schemes were a later development , and do-it-yourself rotations became rare in the 1990s . Outpatients were not usually a junior house officer 's responsibility , but such clinics formed a large part of the workload of more senior trainees , often with little real supervision . Registrar posts lasted one or six years , and sometimes much longer outside an academic setting . It was common to move from one registrar post to another . Fields such as psychiatry and radiology used to be entered at the registrar stage , but the other registrars would usually have passed part one of a higher qualification , such as a Royal College membership or fellowship . Part two was necessary to obtain a senior registrar post , usually linked to a medical school , but many left hospital practice at this stage rather than wait years for promotion . Most British clinical diplomas ( requiring one or two years ' experience ) and membership or fellowship exams are not tied to particular training grades , though the length of training and nature of experience may be specified . Participation in an approved training scheme is required by some of the Royal Colleges . The sub-specialty exams in surgery , for Fellowship of the Royal College of Surgeons , were originally limited to senior registrars . These rules prevent many of those in non-training grades from qualifying to progress . Once a Senior Registrar , depending on specialty , it could take anything from one to six years to go onto a permanent consultant and/or senior lecturer appointment . It might be necessary to obtain an MD or ChM degree and to have substantial published research . Transfer to general practice or a less favoured specialty could be made at any stage along this pathway : Lord Moran famously referred to general practitioners as those who had fallen off the ladder . There are also permanent non-training posts at sub-consultant level : previously Senior Hospital Medical Officer and Medical Assistant ( both obsolete ) and now Staff Grade and Associate Specialist . The regulations do not call for much experience or any higher qualifications , but in practice both are common , and these grades have high proportions of overseas graduates , ethnic minorities and women . Research fellows and PhD candidates are often clinical assistants , but a few were senior or specialist registrars . A large number of Trust Grade posts have been created by the new NHS Trusts for the sake of the routine work , and many juniors have to spend time in these posts before moving between the new training grades , although no educational or training credit is given for them . Holders of these posts may work at various levels , sharing duties with a junior or middle grade practitioner or with a consultant . British medical training is constantly being reorganised . House officers and senior house officers have been replaced by two years of Foundation Year training ( FY1 and FY2 ) . Registrar and Senior Registrar grades were merged in 1995/6 as the Specialist Registrar ( SpR ) grade ( entered after a longer period as a senior house officer , after obtaining a higher qualification , and lasting up to six years ) , with regular local assessments panels playing a major role , and these posts have in turn been replaced in 2007 by Specialty Registrars , who may be in post up to eight years , depending on the field . Recent changes in postgraduate medical training , collectively organised under the Modernising Medical Careers ( MMC ) , have created new labels for equivalent training grades . Foundation Year 1 is equivalent to the ( junior ) house officer grade ; Foundation Year 2 is equivalent to the senior house officer grade . ST1/ST2 ( short for specialty trainee ) are also part of the senior house officer grade if the trainee is in Internal Medicine ( undergoing the so-called core medical training ) or Surgery ( undergoing core surgical training ) or Anaesthesia . It is customary for trainees to sit their Membership/Fellowship examinations ( either for the Royal College of Physicians ( MRCP ) or Royal College of Surgeons or Royal College ( FRCS ) of Anaesthetists ( FRCA ) in order to progress and compete for designated sub-specialty training programmes that attract a national training number as Specialty Training year 3 ( ST3 ) and beyond - up to ST 9 depending on the particular training specialty . After ST2 grade , if in Medicine or Surgery , doctors undergo a compulsory subspecialty training ( whilst maintaining service provision in the main specialty ) , and starting at ST3 grade , are called registrars . For non-medical/non-surgical specialties ( i.e. , radiology , dermatology , etc. ) they are called registrars from ST1 level . The UK grade equivalent of a US fellow in medical/surgical subspecialties is the specialty registrar ( ST3 - ST9 ) grade of sub-specialty training , but note that while US fellowship programmes are generally 23 years in duration after completing the residency , UK trainees spend 47 years . This generally includes service provision in the main specialty ; this discrepancy lies in the competing demands of NHS service provision and UK postgraduate training stipulating that even specialist registrars must be able to accommodate the general acute medical takealmost equivalent to what dedicated attending internists perform in the United States ( they still remain minimally supervised for these duties ) . # United States # In some states of the United States , physicians may usually obtain a general medical license to practice medicine without supervision after completing one year of internship in the state of their license . Many residents have medical licenses and do legally practice medicine without supervision ( moonlight ) in settings such as urgent care centers and rural hospitals . However , in most residency-related settings , residents are supervised by attending physicians who must approve of their decision-making . # Interviews # The interview process involves separate interviews at hospitals around the country . Frequently , the individual applicant pays for travel and lodging expenses , but some programs may subsidize applicants ' expenses . Generally , an interview begins with a dinner the night before in a relaxed , meet-and-greet setting with current residents and/or staff . Formal interviews with attendings and senior residents are then held the next day , and the applicant tours the program 's facilities . Interview questions are primarily related to the applicant 's interest in the program and specialty . The purpose of these tasks is to force an applicant into a pressured setting and less to test his or her specific skills . To defray the cost of residency interviews , social networking sites have been devised to allow applicants with common interview dates to share travel expenses . Nonetheless , additional loans are often required for residency and relocation . International medical students may participate in a residency program within the United States as well but only after completing a program set forth by the Educational Commission for Foreign Medical Graduates ( ECFMG ) . Through its program of certification , the ECFMG assesses the readiness of international medical graduates to enter residency or fellowship programs in the United States that are accredited by the Accreditation Council for Graduate Medical Education ( ACGME ) . # Matching # Access to graduate medical training programs such as residencies is a competitive process known as the Match . Senior medical students usually begin the application process at the beginning of their ( usually ) fourth and final year in medical school . After they apply to programs , programs review applications and invite selected candidates for interviews held between October and February . After the interview period is over , students submit a rank-order list to a centralized matching service ( currently the National Resident Matching Program , abbreviated NRMP ) by February . Similarly , residency programs submit a list of their preferred applicants in rank order to this same service . The process is blinded , so neither applicant nor program will see each other 's list . Aggregate program rankings can be found here , and are tabulated in real time based on applicants ' anonymously submitted rank lists . The two parties ' lists are combined by an NRMP computer , which creates stable ( a proxy for optimal ) matches of residents to programs using an algorithm . On the third Friday of March each year ( Match Day ) these results are announced in Match Day ceremonies at the nation 's 155 U.S. medical schools . By entering the Match system , applicants are contractually obligated to go to the residency program at the institution to which they were matched . The same applies to the programs ; they are obligated to take the applicants who matched into them . On the Monday prior to Match Day , candidates find out from the NRMP if ( but not where ) they matched . If they have matched , they must wait until the Match Day ( later in the week ) to find out where . If they have not secured a position through the Match , the locations of remaining unfilled residency positions are released to unmatched applicants the following day . These applicants are given the opportunity to contact the programs about the open positions . This is what is known as The scramble . This frantic , loosely structured system forces soon-to-be medical school graduates to choose programs not on their original Match list . In 2012 , the NRMP introduced an organized scramble system . As part of the transition , Match Day was also moved from the third Thursday in March to the third Friday . Inevitably , there will be discrepancies between the preferences of the student and programs . Students may be matched to programs very low on their rank list , especially when the highest priorities consist of competitive specialties like radiology , neurosurgery , plastic surgery , dermatology , ophthalmology , orthopedics , otolaryngology , radiation oncology , and urology . A similar but separate osteopathic match exists which announces its results in February , before the NRMP . Osteopathic physicians ( DOs ) may participate in either match , filling either M.D. positions ( traditionally obtained by physicians with the M.D. degree or international equivalent including the MBBS or MBChB degree ) accredited by the Accreditation Council for Graduate Medical Education ( ACGME ) , or D.O . positions accredited by the American Osteopathic Association ( AOA ) . Military residencies are filled in a similar manner as the NRMP however at a much earlier date ( usually mid-December ) to allow for students who did not match to proceed to the civilian system . In 20002004 the matching process was attacked as anti-competitive by resident physicians represented by class-action lawyers . ' ' See , e.g. , Jung v. Association of American Medical Colleges et al. , ' ' 300 F.Supp.2d 119 ( D.D.C . 2004 ) . Congress reacted by carving out a specific exception in antitrust law for medical residency . ' ' See ' ' Pension Funding Equity Act of 2004 207 , Pub . L. No. 108-218 , 118 Stat. 596 ( 2004 ) ( codified at ) . The lawsuit was later dismissed under the authority of the new act . The matching process itself , has also been scrutinized as limiting the employment rights of medical residents , namely where upon acceptance of a match , medical residents pursuant to the matching rules and regulations , are required to accept any and all terms and conditions of employment imposed by the health care facility , institution or hospital . The USMLE Step 1 or COMLEX Level 1 score is just one of many factors considered by residency programs in selecting applicants . Although it varies from specialty to specialty , Alpha Omega Alpha membership , clinical clerkship grades , letters of recommendation , class rank , research experience , and school of graduation are all considered when selecting future residents . # History of long hours # Medical residencies traditionally require lengthy hours of their trainees . Early residents literally resided at the hospitals , often working in unpaid positions during their education . During this time , a resident might always be on call or share that duty with just one other practitioner . More recently , 36-hour shifts were separated by 12 hours of rest , during 100+ hour weeks . The American public , and the medical education establishment , recognized that such long hours were counter-productive , since sleep deprivation increases rates of medical errors . This was noted in a landmark study on the effects of sleep deprivation and error rate in an Intensive-care unit . The Accreditation Council for Graduate Medical Education ( ACGME ) has limited the number of work-hours to 80 hours weekly ( averaged over 4 weeks ) , overnight call frequency to no more than one overnight every third day , and 10 hours off between shifts . Still , a review committee may grant exceptions for up to 10% , or a maximum of 88 hours , to individual programs . Duty periods for postgraduate year 1 must not exceed 16 hours per day , while postgraduate year 2 residents and in those in subsequent years can have duty periods up to a maximum of 24 hours of continuous duty . While these limits are voluntary , adherence has been mandated for the purposes of accreditation , though lack of adherence to hour restrictions is not uncommon . Most recently , the Institute of Medicine ( IOM ) built upon the recommendations of the ACGME in the December 2008 report While keeping the ACGME 's recommendations of an 80-hour work week averaged over 4 weeks , the IOM report recommends that duty hours should not exceed 16 hours per shift , unless an uninterrupted five-hour break for sleep is provided within shifts that last up to 30 hours . The report also suggests residents be given variable off-duty periods between shifts , based on the timing and duration of the shift , to allow residents to catch up on sleep each day and make up for chronic sleep deprivation on days off . Critics of long residency hours trace the problem to the fact that a resident has no alternatives to positions that are offered , meaning residents must accept all conditions of employment , including very long work hours , and that they must also , in many cases , contend with poor supervision . This process , they contend , reduces the competitive pressures on hospitals , resulting in low salaries and long , unsafe work hours . Supporters of traditional work hours contend that much may be learned in the hospital during the extended time . Furthermore , it remains unclear whether patient safety is enhanced or harmed by a reduction in work hours which necessarily lead to more transitions in care . Some of the clinical work traditionally performed by residents has been shifted to healthcare workers : ward clerks , nurses , laboratory personnel , phlebotomists . It has also resulted in a shift of some resident work towards home work , where residents will complete paperwork and other duties at home as to not have to log the hours . # Adoption of working time restrictions # United States federal law places no limit on resident work hours . Regulatory and legislative attempts at limiting resident work hours have been proposed , but have yet to be passed . Class action litigation on behalf of the 200,000 medical residents in the US has been another route taken to resolve the matter . Dr. Richard Corlin , president of the American Medical Association , has called for re-evaluation of the training process , declaring We need to take a look again at the issue of why the resident is there . On November 1 , 2002 , an 80-hour work limit went into effect in residencies accredited by the American Osteopathic Association ( AOA ) . The decision also mandates that interns and residents in AOA-approved programs may not work in excess of 24 consecutive hours exclusive of morning and noon educational programs . It does allow up to six hours for inpatient and outpatient continuity and transfer of care . However , interns and residents may not assume responsibility for a new patient after 24 hours . The U.S. Occupational Safety and Health Administration ( OSHA ) rejected a petition filed by the Committee of Interns &amp; Residents/SEIU , a national union of medical residents , the American Medical Student Association , and Public Citizen that sought to restrict medical resident work hours . OSHA instead opted to rely on standards adopted by ACGME , a private trade association that represents and accredits residency programs . On July 1 , 2003 , the ACGME instituted for all accredited residency programs , limiting the work week to 80 hours a week averaged over a period of four weeks . These standards have been voluntarily adopted by residency programs . Though re-accreditation may be negatively impacted and accreditation suspended or withdrawn for program non-compliance , the number of hours worked by residents still varies widely between specialties and individual programs . Some programs have no self-policing mechanisms in place to prevent 100+ hour work-weeks while others require residents to self-report hours . In order to effectuate complete , full and proper compliance with maximum hour work hour standards , there are proposals to extend U.S. federal whistle-blower protection to medical residents . Criticisms of limiting the work week include disruptions in continuity of care and limiting training gained through involvement in patient care . Similar concerns have arisen in Europe , where the Working Time Directive limits doctors to 48 hours per week averaged out over a 6-month reference period . Recently , there has been talk of reducing the work week further , to 57 hours . In the specialty of neurosurgery , some authors have suggested that surgical subspecialties may need to leave the ACGME and create their own accreditation process , because a decrease of this magnitude in resident work hours , if implemented , would compromise resident education and ultimately the quality of physicians in practice . It should be noted , however , that in other areas of medical practice , like internal medicine , pediatrics and radiology , reduced resident duty hours may be not only feasible but advantageous to trainees because this more closely resembles the practice patterns of these specialties , though it has never been determined that trainees should work fewer hours than graduates . In 2007 , the Institute of Medicine was commissioned by Congress to study the impact of long hours on medical errors . New ACGME rules went into effect on July 1 , 2011 limiting first-year residents to 16-hour shifts . The new ACGME rules were criticized in the journal ' ' Nature and Science of Sleep ' ' for failing to fully implement the IOM recommendations . # Research requirement # The Accreditation Council for Graduate Medical Education clearly states the following three points in the Common Program Requirements for Graduate Medical Education : #The curriculum must advance residents knowledge of the basic principles of research , including how research is conducted , evaluated , explained to patients , and applied to patient care . #Residents should participate in scholarly activity . #The sponsoring institution and program should allocate adequate educational resources to facilitate resident involvement in scholarly activities . Research remains a nonmandatory part of the curriculum and many residency programs do not enforce the research commitment of their faculty leading to a non-Gaussian distribution of the Research Productivity Scale . # Financing residency programs # The Department of Health and Human Services , primarily Medicare , funds the vast majority of residency training in the US . This tax-based financing covers resident salaries and benefits through payments called Direct Medical Education or DME payments . Medicare also uses taxes for Indirect Medical Education or IME payments , a subsidy paid to teaching hospitals that is tied to admissions of Medicare patients in exchange for training resident physicians in certain selected specialties . Overall funding levels , however , have remained frozen over the last ten years , creating a bottleneck in the training of new physicians in the US , according to the AMA . On the other hand , some argue that Medicare subsidies for training residents simply provide surplus revenue for hospitals which recoup their training costs by paying residents salaries ( roughly $45,000 per year ) that are far below the residents ' market value . Nicholson concludes that residency bottlenecks are not caused by a Medicare funding cap , but rather , by Residency Review Committees ( which approve new residencies in each specialty ) which seek to limit the number of specialists in their field to maintain high incomes . In any case , hospitals trained residents long before Medicare provided additional subsidies for that purpose . A large number of teaching hospitals fund resident training to increase the supply of residency slots , leading to the modest 4% total growth in slots from 19982004. # Changes in postgraduate medical training # Many changes have occurred in postgraduate medical training in the last fifty years : #Nearly all physicians now serve a residency after graduation from medical school . In many states , full licensure for unrestricted practice is not available until graduation from a residency program . Residency is now considered standard preparation for primary care ( what used to be called general practice ) . #While physicians who graduate from osteopathic medical schools can choose to complete a one-year rotating clinical internship prior to applying for residency , the internship has been subsumed into residency for MD physicians . Many DO physicians do not undertake the rotating internship as it is now uncommon for any physician to take a year of internship before entering a residency , and the first year of residency training is now considered equivalent to an internship for most legal purposes . Certain specialties , such as ophthalmology , radiology , anesthesiology , and dermatology , still require prospective residents to complete an additional internship year , prior to starting their residency program training . #The number of separate residencies has proliferated and there are now dozens . For many years the principal traditional residencies included internal medicine , pediatrics , general surgery , obstetrics and gynecology , neurology , ophthalmology , orthopaedics , neurosurgery , otolaryngology , urology , physical medicine and rehabilitation , and psychiatry . Some training once considered part of internship has also now been moved into the 4th year of medical school ( called a subinternship ) with significant basic science education being completed before a student even enters medical school ( during their undergraduate education before medical school ) . #Pay has increased , but residency compensation continues to be considered extremely low when one considers the hours involved . The average annual salary of a first year resident is $45,000 for 80 hours a week of work , which translates to $11.25 an hour . This pay is considered a living wage , but it is far lower pay than that of the average first-year college graduate . Unlike most attending physicians ( that is , those who are not residents ) , they do not take call from home ; they are usually expected to remain in the hospital for the entire shift . #Call hours have been greatly restricted . In July 2003 , strict rules went into effect for all residency programs in the US , known to residents as the work hours rules . Among other things , these rules limited a resident to no more than 80 hours of work in a week ( averaged over 4 weeks ) , no more than 24 hours of clinical duties at a stretch with an additional 6 hours for transferring patient care and educational requirement ( with no new patients in the last six ) , and call no more often than every third night . In-house call for most residents these days is typically one night in four ; surgery and obstetrics residents are more likely to have one in three call . A few decades ago , in-house call every third night or every other night was the standard . While on paper this has decreased hours , in many programs there has been no decrease in resident work hours , only a decrease in hours recorded . Even though many sources cite that resident work hours have decreased , residents are commonly encouraged or forced to hide their work hours to appear to comply with the 80 hour limits . #For many specialties an increasing proportion of the training time is spent in outpatient clinics rather than on inpatient care . Since in-house call is usually reduced on these outpatient rotations , this also contributes to the overall decrease in the total number of on-call hours . #For all ACGME accredited programs since 2007 , there was a call for adherence to ethical principles . # Relation to personal debt # In a survey of more than 15,000 residents in internal medicine , approximately 19% of residents with more than $200,000 in debt designated their quality of life as bad , compared with approximately 12% of those with no debt . Also , residents with more than $200,000 in loans scored 5 points lower on Internal Medicine In Training Exam than those who were debt-free. # Following a successful residency # In Australia and New Zealand it leads to eligibility for fellowship of the Royal Australasian College of Physicians , the Royal Australasian College of Surgeons , or a number of similar bodies . In Canada it leads to eligibility for certification by and fellowship of the Royal College of Physicians and Surgeons of Canada , or The College of Family Physicians of Canada . In Mexico after finishing the residency the physician obtains the degree of Specialist and it leads to eligibility for certification ( depending the field ) and eligibility for fellowship . In South Africa it leads to board certification as a specialist with the Health Professions Council and eligibility for fellowship of the Colleges of Medicine of South Africa . In the United States it leads to eligibility for board certification and membership/fellowship of several specialty colleges and academies. 
@@1339063 championships = 1987 &amp; 1988 Memorial Cup Champions 1973 , 1987 , 1988 , 2004 , 2007 WHL Champions The Medicine Hat Tigers are a junior ice hockey team in the Western Hockey League ( WHL ) who play out of Medicine Hat , Alberta , Canada . Established in 1970 by George E. Maser , the team has won two national Memorial Cups , five WHL League Championships and seven Division Titles , and continues to rally for the Cup annually . Maser consistently recruited top talent to the team , and his children continue to do the same today . The Tigers play at the Medicine Hat Arena . They had a sell-out streak at The Arena dating back 197 games ( as of May 15 , 2007 ) . The Tigers lost the 2007 Memorial Cup 31 on May 27 , 2007 , against the Vancouver Giants , which was hosted by Vancouver at the Pacific Coliseum . This was after beating the Giants in double overtime in Game 7 of the WHL Finals two weeks earlier . # Season-by-season record # ' ' Note : GP = Games played , W = Wins , L = Losses , T = Ties , OTL = Overtime losses , Pts = Points , GF = Goals for , GA = Goals against ' ' class= wikitable # WHL Championship history # 197273 : Win , 3-0-2 vs Saskatoon 198586 : Loss , 1-4 vs Kamloops 198687 : Win , 4-3 vs Portland 198788 : Win , 4-2 vs Kamloops 200304 : Win , 4-0 vs Everett 200607 : Win , 4-3 vs Vancouver # Team records # align=left border= 1 cellpadding= 3 cellspacing= 1 bgcolor= #ffffff style= border : 1px #aaaaaa solid ; border-collapse : collapse ; ! Statistic ! ! Total ! ! Season align=right border= 1 cellpadding= 3 cellspacing= 1 bgcolor= #ffffff style= border : 1px #aaaaaa solid ; border-collapse : collapse ; ! Statistic ! ! Player ! ! Total ! ! Season # NHL alumni # Johnathan Aitken Ron Areshenkoff Cam Barker Doug Barkley Bob Bassen Hank Bassen Craig Berube Tim Bothwell Derek Boogaard Jay Bouwmeester Neil Brady Rod Buskas Brian Carlin Greg Carroll Jason Chimera Shane Churla Dean Chynoweth Martin Cibak Al Conroy David Cooper Murray Craven Barry Dean Rob DiMaio Derek Dorsett Rocky Dundas Tyler Ennis Vernon Fiddler Mark Fitzpatrick Ron Flockhart Val Fonteyne Troy Gamble Bob Gassoff Brad Gassoff Josh Green Travis Green Bruce Greig Kevan Guy Len Haley Darren Helm Brian Hill John Hilworth Justin Hocking Ken Holland Ryan Hollweg Doug Houda Kelly Hrudey Jamie Huscroft Gord Hynes Eddie Johnstone Matt Keetley Dan Kordic Dale Kushner Mark Lamb Jamie Linden Trevor Linden Morris Lukowich Joffrey Lupul Ron Lyons Tom Lysiak Clarke MacArthur David Mackey Mike MacWilliam Merlin Malinowski Milan Marcetta Bryan Maxwell Alan May Wayne McBean Bryan McCabe Jim McCrimmon Lanny McDonald Ryan McGill John McKenzie Tom McMurchy Barry Melrose Stefan Meyer Jason Miller Don Murdoch Rob Niedermayer Jim Nill Jaroslav Obsut Chris Osgood Allen Pedersen Mark Pederson Pete Peeters Mike Rathje Stacy Roest Kris Russell Paxton Schafer David Schlemko Don Smith Ken Solheim Brent Thompson Rocky Thompson Rocky Trottier Greg Vaydik Stan Weir Neil Wilkinson Mike Zanier Richard Zemlak 
@@1365637 system = Musculoskeletal subdivisions = tests = Musculoskeletal tests Sports medicine , also known as sport and exercise medicine , is a branch of medicine that deals with physical fitness and the treatment and prevention of injuries related to sports and exercise . Although most sports teams have employed team physicians for many years , it is only since the late 20th century that sports medicine has emerged as a distinct field of health care . # Scope # Sport and Exercise Medicine doctors are specialist physicians who have completed medical school , residency training in a specialty such as physiatry or orthopedic surgery , and then gone on to complete additional fellowship training in Sport and Exercise Medicine . Specialising in the treatment of athletes and other physically active individuals , they have extensive education in musculoskeletal medicine . SEM doctors treat injuries such as muscle , ligament , tendon and bone problems , but may also treat chronic illnesses that can affect physical performance , such as asthma and diabetes . SEM doctors also advise on managing and preventing injuries . Specialists in SEM diagnose and treat any medical conditions which regular exercisers or sports persons encounter . The majority of a SEM Physicians ' time is therefore spent treating musculoskeletal injuries , however other conditions include Female athlete triad , Unexplained Underperformance Syndrome , Exercise-induced asthma , screening for Cardiac Abnormalities , Diabetes in Sport . In addition Team Physicians working in Elite Sport often play a role in performance medicine , whereby an athletes physiology is monitored , and aberrations corrected , in order to achieve peak physical performance . SEM consultants also deliver clinical physical activity interventions , negating the burden of disease directly attributable to physical inactivity and the compelling evidence for the effectiveness of exercise in the primary , secondary and tertiary prevention of disease # Exercise medicine # The Foresight Report issued by the Government Office for Science , 17 October 2007 , highlighted the unsustainable health and economic costs of a nation that continues to be largely sedentary . It forecasts that the incremental costs of this inactivity will be 10 billion per year by 2050 and the wider costs to society and businesses 49.9billion . Physical inactivity inevitably leads to ill-health and it forecasts the cost of paying for this impact will be unsustainable in the future . No existing group of medical specialists is equipped with the skills and training to deal with this challenge . The concept of Exercise as Health tool or is becoming increasingly important . SEM Physicians are able to evaluate medical patients co-morbidities , perform exercise testing and provide an exercise prescription , together with a motivational programme and exercise classes . # Public health # SEM physicians are frequently involved in promoting the therapeutic benefits of physical activity , exercise and sport for the individuals and communities . SEM Physicians in the UK spend a period of their training in public health , and advise public health physicians on matters relating to physical activity promotion . An example of published work includes the Royal College of publication # Common sports injuries # Concussion - caused by severe head trauma where the brain moves violently within the skull so that brain cells all fire at once , much like a seizure Muscle Cramps - a sudden tight , intense pain caused by a muscle locked in spasm . Muscle cramps are also recognized as an involuntary and forcibly contracted muscle that does not relax ACL Sprains - The anterior cruciate ligament ( ACL ) is a ligament involved in knee stabilization . An ACL rupture can occur when the foot is planted and the knee twists to change direction . ACL Tears - The anterior cruciate ligament ; one of four major knee ligament necessary for comfortable knee movement , tears , causing major pain and causes the knee to give out . The knee ACL can tear for a number of reasons causing the knee to never be the same . Ankle Sprain - The ligaments that hold the ankle bones in place can easily be overstretched . Shin Splints - The tissue that attaches the muscles of your lower leg to the shin bone may be pulling away from the bone , or it may be inflamed from overuse . Muscle Strains - tears in muscle that cause pain and loss of function # History # In recent years Western society has increasingly recognized the dangers of physical inactivity , and significant efforts have been made within the public health community to encourage the nation to become more physically active . To reflect this paradigm shift BASM has renamed itself BASEM ( British Association of Sport and Exercise Medicine ) and the speciality itself has rebranded from Sports Medicine to Sport &amp; Exercise Medicine . Since 2007 several deaneries across the UK have established training programmes in SEM , and recurrent funding for 50 National Training Numbers ( NTNs ) is available . # Organizations #  American College of Sports Medicine ( ACSM ) Founded in 1954 , the American College of Sports Medicine is the largest and most prominent sports medicine and exercise science organization in the world . ACSM has more than 45,000 International , National and Regional Chapter members .  American Orthopaedic Society for Sports Medicine ( AOSSM ) The American Orthopaedic Society for Sports Medicine is a world leader in sports medicine education , research , communication , and fellowship . Founded in 1972 , AOSSM is an international organization of orthopaedic surgeons and other allied health professionals dedicated to sports medicine . Essentially every professional and collegiate team has a team physician who is a member of the AOSSM.  Canadian Academy of Sport and Exercise Medicine The Canadian Academy of Sport and Exercise Medicine ( CASEM ) is an organization of physicians committed to excellence in the practice of medicine as it applies to all aspects of physical activity . Our mission is to forge a strong , collective voice for sport medicine ; to be a leader in advancing the art and science of sport medicine , including health promotion and disease prevention , for the benefit of all Canadians through advocacy , education , research and service .  American Medical Society for Sports Medicine ( AMSSM ) Founded in 1991 , AMSSM is a multi-disciplinary organization of physicians whose members are dedicated to education , research , collaboration and fellowship within the field of Sports Medicine . It now comprises over 2100 Sports Medicine Physicians whose goal is to provide a link between the rapidly expanding core of knowledge related to sports medicine and its application to patients in a clinical setting .  National Athletic Trainers ' Association(NATA) Founded in 1950 , the mission of the National Athletic Trainers Association is to enhance the quality of health care provided by certified athletic trainers and to advance the athletic training profession .  Canadian Athletic Therapists ' Association(CATA) Founded in 1965 . The Canadian Athletic Therapists Association ( CATA ) is an organization devoted to the comprehensive health care of an individual at any level of physical ability by Certified Athletic Therapists .  American Medical Association(AMA) The American Medical Association recognized Athletic Training(AT) as an allied health profession in 1990. 
@@1375281 numseasons = 6 ' ' Strong Medicine ' ' is a medical drama with a focus on feminist politics , health issues and class conflict , that aired on the Lifetime network from 2000 to 2006 . The series was created and produced in part by comedian and activist Whoopi Goldberg , who made a couple of cameos in the series , and Tammy Ader . The series starring Janine Turner , Rosa Blasi , and Patricia Richardson . ' ' Strong Medicine ' ' was highest-rated original drama on basic cable in 2001. # Overview # Strong Medicine brings together the worlds of two completely different doctors , Dr. Luisa Lu Delgado , and Dr. Dana Stowe . Lu is a single mother running a free clinic in the inner-city . Dana is a Harvard graduate and top female health specialist . The two come together when Dr. Lydia Emerson wants to combine Rittenhouse Hospitals practice with Lus financially failing clinic to provide the best care for the patients of both doctors . The staff and its visitors tend to be racially , politically , and economically diverse . A core class/political duality in the episodes ' storylines tend to be driven by comparisons and contrasts ( and often cooperation ) between liberal Delgado , and her fellow women 's health practitioner across the lobby , who sees paying patients and generally has more conservative values . When Dr. Dana Stowe leaves , Lus partners include Dr. Andy Campbell and Dr. Dylan West . The show often places the characters in ironic , soul-searching situations in which they are forced to question the solidity of their personal beliefs or else cause them to fight for what they believe in. # Cast and characters # # Main cast #  Dr. Luisa Lu Magdalena Delgado ( Rosa Blasi ) Born November 18 , 1970 . Delgado runs the free clinic ( first the South Philly Health Clinic and , since the pilot , the Rittenhouse Health Center ) , and hosts a support group . Both as a friend and a doctor to many lower-class patients , Lu regularly comes face-to-face with bitterly ironic situations involving the difficulties of the lower class with government , debt , drug abuse , and exploitation . Her character exhibits a perennial cleverness which allows her to wheedle or persuade positive outcomes from seemingly hopeless cases of victimization . After her mother died of breast cancer when she was ten years-old , she was raised by her grandmother , Isabel Santana , who now lives in Puerto Rico . Lu has a son , Marc , who she had when she was 16 and raised alone . Until recently , Delgado has had no luck with a relationship . Her first boyfriend , Radio show host Harry Burr ( Don Michael Paul ) had to leave her because his ex-wife was using their relationship to gain custody of his daughter Erin , who was also her son Marc 's girlfriend . In fact , shades of Lu 's past came back to haunt her when Marc and Olivia face a pregnancy scare . Soon after , she survived being raped by the Rittenhouse 's new Head of Surgery , Dr. Randolf Kilner . She lost her first serious boyfriend , fireman Miguel Mickey Arenas ( Julian Acosta ) , to a murder perpetrated by one of her patients , forcing her to face her moral objection to the death penalty . Ironically , in an earlier episode , Lu thought Miguel had died on the job , when there was a fire at the local mall . It turns out the only reason he did n't die , is because he switched duties with friend and ended up driving the fire truck . Lu later becomes involved with Ben Sanderson ( Grant Show ) , an administrator brought on after Rittenhouse is bought by a health care conglomerate , Octavian . Sanderson later left to be reassigned to a facility in Miami . He asked Lu to come with him but , after thinking about it , she refused because her patients are there . Soon after , she became involved with Jonas Rey ( Nestor Carbonell ) , a local self-made millionaire with a good heart but a large soulless corporation . In the 20052006 season she and Jonas get married , and Lu struggles to get accustomed to a wealthier life , while trying to reconcile it with her inner-city loyalties . After Lu discovered she was pregnant with Jonas ' baby , Jonas is plagued by an embezzlement scandal at his company , bringing his fortune into doubt . In the series finale , they decided to move to Jonas ' childhood home , but while he was showing it to Lu , they were affected by an explosion and got caught in the ruined basement . Lu was injured and her placenta detached . She asked Jonas to perform an emergency C-Section to save her and the baby , but she fainted during the procedure . Luckily , the firemen arrived and called Dylan , who completed the C-Section , and Lu gave birth to their daughter , who was named Milagro ( which means miracle in Spanish ) .  Dr. Dana Stowe ( Janine Turner ) , an ambitious doctor and scientist seeking a cure for breast cancer ; she is rigid and stoic , but cares deeply about her patients . Like her successor Andy Campbell , she was good friends with Jackson . She had a short-lived relationship with resident doctor Nick Biancavilla , which she broke up when he was n't willing to have children . Her character left the show at the end of the 20012002 season after adopting two challenged children ( an HIV-positive infant and her older sister ) , choosing to put her medical ambitions aside to pursue a successful motherhood .  Dr. Andy Campbell ( Patricia Richardson ) A former military doctor with the rank of Colonel , Campbell came on the staff during the third season to replace the much more ambitious and strict Dr. Dana Stowe . Her patients tend to be upper-middle-class , and often include minor local celebrities and professionals . Her character ostensibly lives the almost typical suburban nuclear family lifestyle , aside from her status as breadwinner . She has two teenage daughters , Jesse and Lizzy . Campbell kicked out her husband , Leslie , after he hit her during a domestic dispute , forcing her to examine domestic abuse issues as well as single motherhood . Campbell and Leslie had been married for thirty years without any violence in the home , and Leslie is presented as changing from a loving husband to a violent maniac over the course of a single episode . She later becomes involved with another doctor , cardiac surgeon Dr. Milo Morton but he dies in a car accident ( a development forced by the death of actor Richard Biggs due to an undiagnosed heart condition ) . Campbell was named United States Surgeon General ( which was also a stated ambition of her predecessor ) at the end of the fifth season and left the show .  Marco Antonio Marc Delgado ( Chris Marquette ) , Lu 's teenage son , whom she had when she was a teenager . He lived with his mother , but saw his father Bill ( who was married with young twin girls ) regularly . He once saved his great-grandmother Isabel Santana 's life with a bone marrow transplant . He left for college in the middle of season 5 , after graduating one year in advance but returned once for Lu 's wedding , and walked her to the altar .  Lana Hawkins ( Jenifer Lewis ) Hawkins serves as the front receptionist for the RWHC , or the Rittenhouse Women 's Health Center . A former drug addict and streetwalker long since rehabilitated , she met Lu at the same bar Peter and his band were playing at . After a fire destroyed the bar and the owner rented the locale to Lu for her clinic , she gave Lana a job . She has two sons , Harry , an officer in the Navy and Maurice , a con artist who once pretended he had a wife and son to trick his mother out of money . Hawkins is the hospital 's eyes and ears , i.e. chief gossip , as well as matchmaker , and general benevolent schemer and rule-bender . Lana often refers to herself in the third person . Lana went back to school , earned her high school diploma and went to college , earning a degree in psychology . Afterwards , Lu enlisted her to consult for her women 's group , as volunteer work towards her Master 's degree . She was maid of honor at Lu 's wedding .  Peter Riggs ( Joshua Cox ) A registered nurse and midwife , Peter is generally progressive , open-minded , and an eager advice-giver . He practices Buddhism and believes in the principles of holistic medicine . He is often a kindred spirit to Delgado . Often , Riggs ' character makes a balanced sociopolitical observation that influences a positive action by one of the two doctors ; other times he is the protagonist of action . He was also the nurse union representative . When he met Lu , he almost ran over her with his van . He played the Bass Guitar in a band until his girlfriend Simone ( the lead singer ) dumped him during a fire , and Lu gave him a job in her new free clinic . Often shown as a ladies man with several girlfriends ( ironically , his mother is convinced he 's gay due to his vocation ) , he finally has settled into a relationship with Kayla , to whom he proposes in the series finale .  Dr. Robert Bob Jackson ( Philip Casnoff ) Chief of staff of Rittenhouse Hospital , he is the stoic , administrative figure and also ultimately in charge of decisions regarding funding , especially to the women 's clinic . Jackson had once been a top surgeon but when a young girl died during surgery due to a mislabeled drug dosage , Jackson lost his nerve for the operating room and moved to administration . Jackson considers himself a personal friend of Dr. Campbell ( as he was with Dr. Stowe ) , but generally is more impersonal and sometimes butts heads with Dr. Delgado over financial or liability issues , and with Lana over administrative issues . He was married with two daughters , Lauren and Paige . A recurring subplot throughout the series was Jackson dealing with his wife Susan 's advancing MS condition . He even briefly left her , but eventually went back to her . Jackson 's character was laid off by hospital owner Octavian prior to the start of the sixth season .  Dr. Nick Biancavilla ( Brennan Elliott ) , an ER doctor at Rittenhouse who had a brief relationship with Dr. Stowe . He has four older sisters--one of whom is Francine Biancavilla , a lesbian whose life-partner he married in order to get her the critical medical care she desperately needed . Dr. Jackson found out , but Nick gave Francine a medical insurance plan as a wedding gift that covered existing illnesses . Nick left at the end of Season 4 when he transferred to Manhattan General .  Dr. Kayla Thornton ( Tamera Mowry ) A new doctor and young medical prodigy , Thornton is a fast study at Rittenhouse , entering residency in the beginning of the 20042005 season and becoming a depended-upon ER regular by the end of that season , despite occasional disbelief by patients that she is a qualified doctor . As she becomes a main character to the show , her personality can be compared to that of a young Dr. Delgado with her ambition and hard work . She decided to become a doctor as a young girl when a brother was shot in the chest by a friend when playing with a hunting rifle . While the friend ran for help , Kayla cradled her dying brother . The nearest doctor was 25 miles away , so therefore Kayla 's brother died in her arms . She then decided to become a doctor . Throughout the medical drama 's seasons , Thornton rooms with various fellow staff members in her search for affordable housing . First she moves into Dr. Campbell 's house , where she spends some of her time helping with Andy 's two daughters . After Andy 's departure , she rooms with Lana . She was later on selected as Chief Resident after narrowly missing it due to a complex emergency house call . We find out that she has a twin sister , Keisha ( played by real-life twin sister Tia Mowry ) who ends up needing 24-hour care for a schizophrenic mental disorder , because she felt that Kayla always had a perfect life and had a depression when they were younger .  Dr. Dylan West ( Rick Schroder ) Replacing Dr. Campbell 's role is Dr. Dylan West , a male women 's health specialist . His gender raises initial eyebrows , especially with Delgado , who has also had past negative experiences with him as a resident . He has his own troubled past and seems to be seeking to redeem himself from something in his past . He is a diabetic , which becomes a recurring plot device . Dylan has tremendously bad luck in romance . One such former love interest arrives at Rittenhouse needing a new heart to survive ; West is unable to save her life , but gains a teenaged half-Japanese daughter , Araya ( Eileen Boylan ) , he never knew he had . His relationship with his daughter is troubled at first , but slowly they get to know each other .  Jonas Rey ( Nestor Carbonell ) A local self-made billionaire with a good heart but a large soulless corporation . He first appeared on Rittenhouse when his mother was brought to ER due an accident . While his mother was in the hospital , he saw Lu interacting with several of her patients . Even before he exchanged a single word with Lu , he told his mother he 'll marry her . He met and pursued Lu until she agreed to date him . They got married in the middle of the 20052006 season . After personally bringing sick South American children to Rittenhouse for treatment , Jonas is plagued by an embezzlement scandal at his company , bringing his fortune and stability into doubt . After discovering that Lana had stock of his company , he decided to sell most of his assets and pay the shareholders back a part of their money . He and Lu moved to his childhood home , but while he was showing it to Lu , they were affected by an explosion and got caught in the ruined basement . Lu convinced him to perform an emergency C-Section to save her and the baby , but she fainted during the procedure . Luckily , Dylan arrives to deliver their daughter . # Recurring cast #  Whoopi Goldberg as Dr. Lydia Emerson Grant Show as Ben Sanderson Gregory Harrison as Dr. Randolf Kilner Nestor Carbonell as Jonas Ray Julian Acosta as Miguel Arenas Richard Biggs as Dr. Milo Morton Morgan Flynn as Lizzy Campbell Michelle Horn as Jesse Campbell Matthew Yang King as Dr. Matt Linn # Seasons # # DVD release # Sony Pictures Home Entertainment released Strong Medicine : The Complete First Season , a 5-disc set , on 10 January 2006 . It is unknown if the remaining 5 seasons will be released at some point . # ' ' First Response ' ' spinoff # Near the end of the 2004-2005 season , a special episode First Response aired , prominently featuring three new characters : Katie and Zack , both EMTs , and Dr. Vanessa Burke , head of the new Rittenhouse Trauma Center and adopted black sister of Katie . The TV Home website reports that this episode was meant as the pilot to a potential ' ' Strong Medicine ' ' spinoff series , ' ' Strong Medicine : First Response ' ' . Such a series would have been the first spin-off to an existing Lifetime original series . Lifetime did not order the new series into production after the ratings for the pilot were not what was expected . 
@@1562949 The Harvard School of Public Health ( HSPH ) is one of the professional graduate schools of Harvard University , located in the Longwood Area of Boston , Massachusetts neighborhood of Mission Hill , which is next to Harvard Medical School . HSPH is considered a significant school focusing on health in the United States . Harvard School of Public Health grew out of the Harvard-MIT School for Health Officers , the nation 's first graduate training program in population health , which was founded in 1913 and became Harvard School of Public Health in 1922 . Julio Frenk , the Minister of Health of Mexico from 2000 to 2006 and a former executive director of the World Health Organization ( WHO ) , became the new dean of HSPH in January 2009 . As one of the most selective and prestigious public health schools in the world , the middle 50 percent of the class that entered in 2006 had an incoming GPA between 3.50 and 3.75 ( out of 4.0 ) . About half of HSPH students already hold a medical doctorate ( M.D. or D.O. ) , with many of the rest holding another advanced degree ( typically a DPM , DDS/DMD , PhD , JD , or MBA ) . HSPH students are drawn from around the world , with about 40 percent of the student body coming from outside of the United States . Overall , HSPH is ranked third after the University of North Carolina School of Public Health in the 2011 , ' ' U.S. News &amp; World Report ' ' . The Johns Hopkins Bloomberg School of Public Health was ranked first in the same report . ' ' U.S. News ' ' consistently ranks Harvard #1 in Health Policy and Management . The School 's objectives are to provide the highest level of education to health scientists , practitioners , and leaders , to foster new discoveries leading to improved health for the people of this country and all nations , and to strengthen health capacities and services for communities . # History # The School traces its origins to the Harvard-MIT School for Health Officers , founded in 1913 ; Harvard calls it the nation 's first graduate training program in public health . In 1922 , the School for Health Officers became the Harvard School of Public Health , and in 1946 it was split off from the medical school and became a separate faculty of Harvard University . # Curriculum # The Master 's in Public Health Program - MPH offers seven degree concentrations :  Clinical Effectiveness ( CLE )  Family and Community Health ( FCH )  Health Care Management and Policy ( CMP )  Global Health ( GH )  Law and Public Health ( LPH )  Occupational and Environmental Health ( OEH )  Quantitative Methods ( QM ) Degree programs offered by specific departments :  Biostatistics : ScM , PhD  Environmental Health : ScM , PhD , ScD , MOH , DPH  Epidemiology : ScM , ScD , DPH  Genetics and Complex Diseases : PhD  Health Policy and Management : ScM , ScD , PhD  Immunology and Infectious Diseases : ScD , PhD  Nutrition : ScD , DPH , PhD  Global Health : : : Health Economics ( ScD ) : : Health Systems ( ScD ) : : Population and Reproductive Health ( ScD )  Social and Behavioral Sciences : ScM , ScD , DPH PhD programs are offered under the aegis of the Harvard University Graduate School of Arts and Sciences # Research Projects #  The Nurses Health Study and Nurses Health Study II , which have followed the health of over 100,000 nurses from 1976 to the present ; its results have been used in hundreds of published papers .  The Health Professionals Followup Study , a similar study of over fifty thousand male health professionals seeking to connect diet , exercise , smoking , and medications taken to frequency of cancer and cardiovascular disease .  The International Health Systems Program , which has provided training or technical assistance to projects in 21 countries , and conducts health policy research  The Program in Health Care Financing , which studies the economics of national health care programs ; evaluates the health care programs of China , Hong Kong , Taiwan , and other countries ; studies the effects of bringing HMO-like hospital reimbursement practices to developing countries ; and applies hedonimetrics to health care .  The Program on Humanitarian Policy and Conflict Research ( HPCR ) , which studies public health and humanitarian law and policy in the context of conflict-torn regions like the Gaza Strip and transnational issues like terrorism .  The Lung Cancer S.O.S. study , examining the risk factors for and prognosis of lung cancer in terms of genetics and environment .  The College Alcohol Study , which examines the causes of college binge drinking and approaches to prevention and harm reduction .  The Program on the Global Demography of Aging , which studies policy issues related to economics of aging with a focus on the developing world .  The Superfund Basic Research Program ( see Superfund ) , studying toxic waste management . # Notable Faculty ( and past faculty ) # Alberto Ascherio , neuroepidemiologist Katherine Baicker , economist , a former member of the Council of Economic Advisers Robert Blendon , political strategy of health and public opinion expert David Bloom , economist David Canning , economist Arnold Epstein , department chair for health policy and management Max Essex , HIV researcher Julio Frenk , dean of school of public health and former Secretary of Health of Mexico Atul Gawande , general and endocrine surgeon Sue Goldie , physician and decision scientist , Macarthur fellowship recipient John Graham , policy and decision scientist , former director of the Office of Information and Regulatory Affairs Laurie Glimcher , immunologist Alice Hamilton , occupational health and toxicology ; first woman appointed to the faculty of Harvard University David Hemenway , economist and injury prevention expert William Hsiao , economist Howard Koh , public health researcher , the 14th Assistant Secretary for Health at the U.S. Department of Health and Human Services . Petros Koutrakis , environmentalist , Head of the Exposure , Epidemiology and Risk Program and Director of the EPA/Harvard University Center for Ambient Particle Health Effects Nan Laird , biostatistician , former head of department Alexander H. Leighton , psychiatric epidemiologist Jun Liu , biostatistician and mathematician , 2002 COPPS presidents ' award recipient Xihong Lin , biostatistician and mathematician , 2006 COPPS presidents ' award recipient*Bernard Lown , co-founded the Nobel Prize-winning group Physicians for Social Responsibility ; founder of the Lown Cardiovascular Research Foundation Adetokumbo Lucas , former director of Tropical Diseases Research at the World Health Organization ( WHO ) Brian MacMahon , cancer epidemiologist Sezan Mahmud , Writer and university professor Christopher Murray , physician and health economist Joseph Newhouse , economist and director of the RAND Health Insurance Experiment James Robins , epidemiologist and biostatistician Amartya Sen , economist , Nobel laureate in Economics Andrew Spielman , public health entomologist Thomas Weller , Nobel laureate in Physiology and Medicine George C. Whipple , cofounder of School in 1922 James Whittenberger , Department of Physiology Walter Willett , physician and nutrition researcher # Notable alumni # Gro Harlem Brundtland , former Prime Minister of Norway , former Director-General of the World Health Organization Humayun Chaudhry , President and CEO of the Federation of State Medical Boards Winston Dang , head of Taiwan 's Environmental Protection Administration from 2004 to 2008 James O. Mason , former Acting Surgeon-General of the USA , former Director of the CDC Jonathan Mann , former head of the World Health Organization global HIV/AIDS program Anthony Irvine Adams , 2001 Alumni Award of Merit for a distinguished service in public health practice Sue Goldie , MacArthur Fellow and decision scientist David J. Sencer , longest-serving Director of the CDC James B. Aguayo-Martel , pioneer in ophthalmology Eli Capilouto , provost of the University of Alabama at Birmingham and incoming president of the University of Kentucky William Foege , MPH 1965 , physician , former director of the Centers for Disease Control Atul Gawande , surgical safety pioneer , MacArthur Fellow , Rhodes Scholar Timothy Johnson , chief medical correspondent for ABC News Karl Lauterbach , German Politician ( SPD ) Jonathan Fielding , Director Los Angeles County Department of Public Health , editor Annual Review of Public Health Endang Rahayu Sedyaningsih , former Minister of Health of Indonesia Steven K. Galson , former Acting Surgeon General of the United States Hrishikesh Polisetti , MPH 1960 , former Director of Medical and Health Services , Government of Andhra Pradesh , 
@@1617671 campus = Urban The New York University School of Medicine is one of the graduate schools of New York University . Founded in 1841 as the University Medical College , the NYU School of Medicine is one of the foremost medical schools in the United States , ranking 19th in research according to ' ' U.S. News &amp; World Report ' ' . The School of Medicine is part of NYU Langone Medical Center , named after Kenneth Langone , the investment banker and financial backer of the Home Depot . It is located at 550 First Avenue in New York City . The School of Medicine has 1,177 full-time faculty and 3,091 part-time faculty . Additionally , there are 104 endowed professorships , 1,078 residents/fellows , 68 M.D./Ph.D. candidates and 400 postdoctoral fellows . The NYU Medical Center is home to the School of Medicine , the Sackler Institute of Graduate Biomedical Sciences , and the Charles C. Harris Skin &amp; Cancer Pavilion--one of the most prestigious dermatology institutes in the United States . In 2012-13 , NYU Langone Medical Center was recognized on the ' ' U.S. News &amp; World Report ' ' Best Hospitals Honor Roll , ranking 11th among the top hospitals in the nation with 13 nationally ranked specialties including cancer , cardiology &amp; heart surgery , neurology &amp; neurosurgery , orthopedics , diabetes &amp; endocrinology , nephrology , geriatrics , gastroenterology , ear , nose &amp; throat , rehabilitation , pulmonology , rheumatology , and urology. # Medical education # New York University School of Medicine has recently implemented the curriculum for the 21st century . The new curriculum consists of 18 months of basic science and two and a half years of clinical training . Students take the USMLE Step 1 exam after the clerkship year ( with the exception of MD/PhD students , who take it before starting their PhD work ) . This allows students additional time to take electives , conduct research , or go on away rotations . Other features of the curriculum include NYU3T ( a joint program with the New York University College of Nursing ) and PLACE ( Patient-Based Longitudinal Ambulatory Care Experience ) . The NYU School of Medicine also offers several 5-year joint degree programs , some of which can be optionally completed in 4 years. :  MD/MPA in Health Policy and Management ( with the Robert F. Wagner Graduate School of Public Service )  MD/MPH in Global Health  MD/MBA in General Management ( with the New York University Stern School of Business )  MD/MA in Bioethics  MD/MSc in Clinical Investigation Since 1964 , NYU School of Medicine has offered MD/PhD dual degree training through the Medical Scientist Training Program ( MSTP ) . # Admissions # Admission to NYU School of Medicine is among the most selective in the country . For the Class of 2017 , NYU received 8,835 applications and interviewed 905 applicants for a class of 159 medical students . The matriculating class had an average GPA of 3.79 and an average MCAT score of 35.4. # Facilities # The main NYU Langone Medical Center campus is located at the East River waterfront at 1st Ave . between 30th and 34th street . It hosts the NYU School of Medicine , Tisch Hospital and the Howard A. Rusk Institute of Rehabilitation Medicine . Other NYU Langone Medical Center facilities across the city include the Hospital for Joint Diseases Orthopaedic Institute , the NYU Cancer Center on 34th Street , and Woodhull Hospital in Brooklyn . NYU Langone Medical Center also has a long-standing affiliation with the Bellevue Hospital , NYU 's principal teaching hospital , of the New York City Health and Hospitals Corporation , and with the Manhattan Veteran 's Affairs Hospital . Most recently , the NYU School of Medicine opened a new emergency simulation center at Bellevue Hospital in a joint effort with the City University of New York . Medical students , nurses , EMTs , and other medical staff will be able to practice and refine their skills on state-of-the-art mannequins , as well as actors playing standardized patients . Research facilities include the Sackler Institute of Graduate Biomedical Sciences and the Skirball Institute of Biomolecular Medicine . # History # New York University College of Medicine was established in 1841 . The medical school merged with Bellevue Medical College in 1898 to form the University and Bellevue Hospital Medical College . The present name was adopted in 1960 . The NYU School of Medicine is home to many key advancements in medical education . In 1854 , human dissection in New York was legalized due to efforts of the faculty . In 1884 , the Carnegie Laboratory , the first facility in the U.S. devoted to teaching and research in bacteriology and pathology , was established at NYU . In 1932 , the first department of forensic medicine in the U.S. was established at NYU . In 1941 , NYU opened the first department of physical medicine and rehabilitation in the U.S. The Institute and Department of Environmental Medicine were established in 1964 . In 1980 , NYU professor Saul Krugman , M.D. , developed the first vaccine against hepatitis B. In 1866 , NYU professors produced a report for the Council of Hygiene and Public Health which led to establishment of New York City 's Health Department . The same year , NYU opened the first outpatient clinic in the United States . In 1872 , NYU Professor Steven Smith founded the American Public Health Association . In 1899 , NYU graduate Walter Reed discovered the mosquito transmission of yellow fever . The 1993 construction of the Skirball Institute of Biomolecular Medicine is the largest building project in history of NYU . During World War II , NYU College of Medicine was one of 131 colleges and universities nationally that took part in the V-12 Navy College Training Program which offered students a path to a Navy commission . # Relationship with Mount Sinai School of Medicine # In 1998 , the Mount Sinai-NYU Health System was established when the NYU Medical System merged with Mount Sinai Hospitals . The joint organization included Mount Sinai Hospital , Mount Sinai Hospital of Queens , Tisch Hospital , Rusk Institute of Rehabilitation Medicine , Hospital for Joint Diseases Orthopaedic Institute , NYU Downtown Hospital , and Mount Sinai School of Medicine . The merger made NYU the only private university in the country with two medical schools . The union dissolved in 2003 while confronting a shared debt of $665.6 million , but NYU continued to award Mount Sinai 's degrees . In 2010 , however , the Mount Sinai School of Medicine was accredited by the Middle States Commission on Higher Education and became an independent degree-granting institution without a university affiliation for the first time in its history . # Evolution of the New York University School of Medicine # 1841 - University Medical College organized as the Medical Department of the University of the City of New York 1861 - Bellevue Hospital Medical College Founded 1882 - New York Post-Graduate Medical School and Hospital founded ( incorporated in 1886 ) 1896 - Name of the University of the City of New York changed to New York University 1898 - University and Bellevue Hospital Medical College formed by merging of the University Medical College and Bellevue Hospital Medical College 1935 - Name changed to New York University College of Medicine 1945 - Post-graduate Division of New York University College of Medicine established 1948 - New York University Post-Graduate Medical school formed , representing a union of the Postgraduate Division of the College of Medicine and the New York Post-Graduate Medical School 1960 - Name of New York University-Bellevue Medical Center changed to New York University Medical Center - Name of New York University College of Medicine changed to New York University School of Medicine 2008 - New York University Medical Center Hospitals and School of Medicine renamed NYU Langone Medical Center # Important milestones # 1841 : The New York University College of Medicine opens , ten years after the founding of the university . Among the original faculty is John Revere , son of patriot Paul Revere , and Valentine Mott , probably the foremost surgeon of his day . 1854 : Human dissection in New York is legalized due to efforts of faculty at the NYU College of Medicine . The first successful resection of a hip joint is performed by Lewis A. Sayre , M.D. , the first professor of orthopedic surgery in the United States . 1861-65 : Faculty members of the NYU Medical College play a leading role in treating soldiers wounded during the Civil War , chiefly through work on the United States Sanitary Commission . 1866 : NYU professors of medicine produce a Report for the Council of Hygiene and Public Health . It leads to the establishment of New York City 's Health Department . 1867 : Established the first clinical professorship devoted to dermatology . The first outpatient clinic in the United States opens at NYU. 1872 : NYU 's Stephen Smith , M.D. , founds the American Public Health Association . 1884 : The Carnegie Laboratory , the first facility in the United States devoted to teaching and research in bacteriology and pathology , is established at NYU. 1897 - Merged with the New York Skin and Cancer Hospital 1899 : Dr. Walter Reed discovers the mosquito transmission of yellow fever . 1911 : The first outpatient cardiac clinic in New York is established by NYU 's Hubert V. Guile , M.D. 1931 : Albert Sabin , who later developed a live-virus vaccine against polio , received his M.D. degree at NYU. 1932 : The first department of forensic medicine in the United States is established at NYU . NYU organizes one of the nation 's first interdisciplinary research efforts , the Rheumatic Diseases Study Group , helping to usher in the era of modern rheumatology. 1933 : William S. Tillett , M.D. conducts groundbreaking studies of enzymes involved in blood clotting . His work leads to the development of streptokinase , used to combat heart attacks . 1939 : Jonas Salk , developer of the first vaccine against polio , receives his M.D. degree at NYU. 1941 : The first department of physical medicine and rehabilitation in the United States is established at NYU. 1941-45 : During the war years , NYU-trained Julius Axelrod , M.D. , works with James Shannon , M.D. , and other faculty members in the Medical Schools malaria program . Dr. Axelrod is later awarded the Nobel Prize for medicine . 1947 : A site for a new Medical Center , consisting of the NYU School of Medicine , the Post-Graduate Medical School , University ( now Tisch ) Hospital , and the Rusk Institute of Rehabilitation Medicine , is selected . The Institute of Industrial Medicine is established . 1948 : University Hospital is created through a merger of the New York Post-Graduate Hospital and New York Skin and Cancer Hospital . 1954 : Lewis Thomas , M.D. , assumes chairmanship of the Department of Pathology . 1955 : The Medical Science Building and the Henry W. and Albert Berg Institute opens at NYU. 1957 : The Hall of Research and Alumni Hall are constructed . 1959 : The Nobel Prize for medicine is awarded to NYU faculty member Severo Ochoa , M.D. , for his seminal study of biochemical genetics and nucleic acids. 1960 : The Clinical Research Center , funded by the NIH , is established at NYU. 1960s : NYU pathologist Baruj Benacerraf , M.D. , conducts pioneering research on genetic regulation of the immune system , for which he is later awarded the Nobel Prize in medicine in 1980. 1963 : The new University Hospital opens . 1964 : NYU establishes one of the first three Medical Scientist Training Programs ( dual MD/PhD graduate programs funded by the NIH ) in the United States . 1964 : The Institute and Department of Environmental Medicine are established . 1975 : One of the first designated national cancer centers is established at NYU , later named the Rita and Stanley H. Kaplan Center . 1980 : Saul Krugman , M.D. , professor of pediatrics , develops the first vaccine against hepatitis B. Earlier , he had been honored for his research work in rubella . 1981 : NYU scientists present the first evidence linking rare cancer , Kaposi 's sarcoma , with immune deficiency in a distinct population of homosexual men , a key step in identifying AIDS. 1992 : NYU Medical Center opens Women 's Health Services under the auspices of the Departments of Obstetrics and Gynecology and Radiology. 1993 : The School of Medicine 's Skirball Institute of Biomolecular Medicine , the largest building project in history of NYU , is opened as an uncompromising commitment to the advancement and understanding of molecular approaches for the treatment of various important diseases . 1995 : The Sir Harold Acton Society is established to recognize donors of $1 million or more . 1998 : NYU Medical Center is restructured , creating the NYU Hospitals Center ( including Tisch Hospital and Rusk Institute ) , the NYU Health System ( consisting of NYU Hospitals Center , Hospital for Joint Diseases and NYU Downtown Hospital ) , and the NYU School of Medicine which remains an administrative unit of New York University . 2004 : The NYU Clinical Cancer Center is opened . 2006 : The School of Medicine 's Joan and Joel Smilow Research Center is opened and houses 9 dedicated programmatic areas : Cancer , Cardiovascular Biology , Dermatology/Cutaneous Biology , *28;1054;TOOLONG , Medicine/Infectious Disease , Medicine/Renal Medicine , Microbial Pathogenesis , Integrated Neuroscience , and Stem Cell Biology . 2006 : NYU Medical Center won a grant of $26.7 million . This was the largest grant rewarded by any school in NYU . It was rewarded on behalf of Dr. Jonathan Ship # Institutional Pedigrees # *61;1084;div width= 100% cellspacing= 0 cellpadding= 0 *104;1147;caption Institutional Pedigree of the New York University School of Medicine </caption> </div> *61;1253;div width= 100% border= 0 cellspacing= 0 cellpadding= 0 *104;1316;caption Institutional Pedigree of the New York University Hospital </caption> </div> # Notable people # # Notes # 
@@1656748 Family medicine ( FM ) , formerly family practice ( FP ) , is a medical specialty devoted to comprehensive health care for people of all ages ; the specialist is named a family physician , family doctor , or formerly family practitioner . In Europe the discipline is often referred to as general practice and a practitioner as a General Practice Doctor or GP ; this name emphasises the holistic nature of this speciality , as well as its roots in the family . It is a division of primary care that provides continuing and comprehensive health care for the individual and family across all ages , genders , diseases , and parts of the body . It is based on knowledge of the patient in the context of the family and the community , emphasizing disease prevention and health promotion . According to the World Organization of Family Doctors ( Wonca ) , the aim of family medicine is to provide personal , comprehensive and continuing care for the individual in the context of the family and the community . The issues of values underlying this practice are usually known as primary care ethics . # Scope of practice # Family physicians in the United States may hold either an M.D. or a D.O . degree . Physicians who specialize in family medicine must successfully complete an accredited three-year family medicine residency in the United States in addition to their medical degree . They are then eligible to sit for a board certification examination , which is now required by most hospitals and health plans . American Board of Family Medicine requires its Diplomates to maintain certification through an ongoing process of continuing medical education , medical knowledge review , patient care oversight through chart audits , practice-based learning through quality improvement projects and retaking the board certification examination every 7 to 10 years . The American Osteopathic Board of Family Physicians requires its Diplomates to maintain certification and undergo the process of recertification every 8 years . Physicians certified in family medicine in Canada are certified through the College of Family Physicians of Canada , after two years of additional education . Continuing education is also a requirement for continued certification . The term family medicine is used in many European and Asian countries , instead of general medicine or general practice . In Sweden , certification in family medicine requires five years working with a tutor , after the medical degree . In India , those who want to specialize in family medicine must complete a three-year family medicine residency , after their medical degree ( MBBS ) . They are awarded either a D.N.B. or an M.D. in family medicine . Similar systems exist in other countries . Family physicians deliver a range of acute , chronic and preventive medical care services . In addition to diagnosing and treating illness , they also provide preventive care , including routine checkups , health-risk assessments , immunization and screening tests , and personalized counseling on maintaining a healthy lifestyle . Family physicians also manage chronic illness , often coordinating care provided by other subspecialists . Many American family physicians deliver babies and provide prenatal care . In the U.S. , family physicians treat more with back pain than any other physician subspecialist , and about as many as orthopedists and neurosurgeons combined . Family medicine and family physicians play a very important role in the healthcare system of a country . In the U.S. , for example , nearly one in four of all office visits are made to family physicians . That is 208 million office visits each year nearly 83 million more than the next largest medical specialty . Today , family physicians provide more care for Americas underserved and rural populations than any other medical specialty. # Family medicine in the United States # # History # Following World War II , two events shaped the advent of family medicine . First , medical specialties and subspecialties increased in popularity , having an adverse effect on the number of physicians in general practice . At the same time , many medical advances were being made and there was concern within the general practitioner or GP population that four years of medical school plus a one-year internship was no longer adequate preparation for the breadth of medical knowledge required of the profession . Many of these doctors wanted to see a residency program added to their training ; this would not only give them additional training , knowledge , and prestige , but would allow for board certification , which was increasingly required to gain hospital privileges . In 1969 , family medicine ( then known as family practice ) was recognized as a distinct specialty in the U.S. # Education and training # Family physicians complete an undergraduate degree , medical school , and three more years of specialized medical residency training in family medicine . Their residency training includes rotations in internal medicine , pediatrics , obstetrics-gynecology , psychiatry , and geriatrics . The specialty focuses on treating the whole person , acknowledging the effects of all outside influences , through all stages of life . Family physicians will see anyone with any problem , but are experts in common problems . Many family physicians deliver babies in addition to taking care of patients of all ages . In order to become board certified , family physicians must complete a residency in family medicine , possess a full and unrestricted medical license , and take a written cognitive examination . Between 2003 and 2009 , the process for maintenance of board certification in family medicine is being changed ( as well as all other American Specialty Boards ) to a series of yearly tests on differing areas . The American Board of Family Medicine , as well as other specialty boards , are requiring additional participation in continuous learning and self-assessment to enhance clinical knowledge , expertise and skills . The Board has created a program called the Maintenance of Certification Program for Family Physicians ( MC-FP ) which will require family physicians to continuously demonstrate proficiency in four areas of clinical practice : professionalism , self-assessment/lifelong learning , cognitive expertise , and performance in practice . Three hundred hours of continuing medical education within the prior six years is also required to be eligible to sit for the exam . Family physicians may pursue fellowships in several fields , including adolescent medicine , geriatric medicine , sports medicine , sleep medicine , and hospice and palliative medicine . The American Board of Family Medicine and the American Osteopathic Board of Family Medicine both offer Certificates of Added Qualifications ( CAQs ) in each of these topics . Recently , new fellowships in International Family Medicine have emerged . These fellowships are designed to train family physicians working in resource poor environments . # Shortage of family physicians # While many sources cite a shortage of family physicians ( and also other primary care providers , i.e. internists , pediatricians , and general practitioners ) , the per capita supply of primary care physicians has actually increased about 1 percent per year since 1998 . Additionally , a recent decrease in the number of M.D. graduates pursuing a residency in primary care , has been offset by the number of D.O . graduates and graduates of international medical schools ( IMGs ) who enter primary care residencies . Still , projections indicate that by 2020 the demand for family physicians will exceed their supply . The number of students entering family medicine residency training has fallen from a high of 3,293 in 1998 to 1,172 in 2008 , according to National Residency Matching Program data . Fifty-five family medicine residency programs have closed since 2000 , while only 28 programs have opened . In 2006 , when the nation had 100,431 family physicians , a workforce report by the American Academy of Family Physicians indicated the United States would need 139,531 family physicians by 2020 to meet the need for primary medical care . To reach that figure 4,439 family physicians must complete their residencies each year , but currently the nation is attracting only half the number of future family physicians that we will need . The waning interest in family medicine is likely due to several factors , including the lesser prestige associated with the specialty , the lesser pay , and the increasingly frustrating practice environment in the U.S. Salaries for family physicians in the United States are respectable , but lower than average for physicians , with the average being $159,564 # Current practice # Most family physicians in the US practice in solo or small-group private practices or as hospital employees in practices of similar sizes owned by hospitals . However , the specialty is broad and allows for a variety of career options including education , emergency medicine or urgent care , inpatient medicine , international or wilderness medicine , public health , sports medicine , and research . Others choose to practice as consultants to various medical institutions , including insurance companies . # Family medicine in India # Family Medicine ( FM ) came to be recognized as a medical specialty in India only in the late 1990s . According to the National Health Policy - 2002 , there is an acute shortage of specialists in family medicine . As family physicians play very important role in providing affordable and universal health care to people , the Government of India is now promoting the practice of family medicine by introducing post graduate training through DNB ( Diplomate National Board ) programs . There is a severe shortage of post graduate training seats , causing lot of struggle , hardship and a career bottle neck for newly qualified doctors , just passing out of medical school . The Family Medicine Training seats should ideally fill this gap and make allow more doctors to pursue Family Medicine careers . However , the uptake , awareness and developement of this specialty is slow . Although family medicine is sometimes called general practice , they are not identical in India . A medical graduate who has successfully completed the Bachelor of Medicine , Bachelor of Surgery ( MBBS ) course and has been registered with Indian Medical Council or any state medical council is considered a general practitioner . A family physician , however , is a primary care physician who has completed specialist training in the discipline of family medicine . The Medical Council of India requires three-year residency for family medicine specialty , leading to the award of Doctor of Medicine ( MD ) in Family Medicine or Diplomate of National Board ( DNB ) in Family Medicine . The National Board of Examinations conducts family medicine residency programmes at the teaching hospitals that it accredits . On successful completion of a three-year residency , candidates are awarded Diplomate of National Board ( Family Medicine ) . The curriculum of DNB ( FM ) comprises : ( 1 ) medicine and allied sciences ; ( 2 ) surgery and allied sciences ; ( 3 ) maternal and child health ; ( 4 ) basic sciences and community health . During their three-year residency , candidates receive integrated inpatient and outpatient learning . They also receive field training at community health centres and clinics . The Medical Council of India permits accredited medical colleges ( medical schools ) to conduct a similar residency programme in family medicine . On successful completion of three-year residency , candidates are awarded Doctor of Medicine ( Family Medicine ) . Govt. medical college , Calicut had started this MD ( FM ) course in 2011 . A few of the AIIMS institutes have also started a course called MD in community and family medicine in recent years . Even though there is an acute shortage of qualified family physicians in India , further progress has been slow The Indian Medical Associations College of General Practitioners , offers a one-year Diploma in Family Medicine ( DFM ) , a distance education programme of the Postgraduate Institute of Medicine , University of Colombo , Sri Lanka , for doctors with minimum five years of experience in general practice . Since the Medical Council of India requires three-year residency for family medicine specialty , these diplomas are not recognized qualifications in India . As Indias need for primary and secondary levels of health care is enormous , medical educators have called for systemic changes to include family medicine in the undergraduate medical curriculum . Recently , the residency-trained family physicians have formed the Academy of Family Physicians of India ( AFPI ) AFPI is the academic association of family physicians with formal full-time residency training ( DNB Family Medicine ) in Family Medicine . Currently there are about two hundred family medicine residency training sites accredited by the National Board of Examination India , providing around 700 training posts annually . However , there are various issues like academic acceptance , accreditation , curriculum development , uniform training standards , faculty development , research in primary care , ' ' etc. ' ' in need of urgent attention for family medicine to flourish as an academic specialty in India . The government of India has declared Family Medicine as focus area of human resource development in health sector in the National Health Policy 2002 *32;13762;TOOLONG . There is discussion ongoing to employ multi-skilled doctors with DNB family medicine qualification against specialist posts in NRHM ( National Rural Health Mission ) . Three possible models of how family physicians will practise their specialty in India might evolve , namely ( 1 ) private practice , ( 2 ) practising at primary care clinics/hospitals , ( 3 ) practising as consultants at secondary/tertiary care hospitals . # See also # ATC codes Anatomical Therapeutic Chemical Classification System Classification of Pharmaco-Therapeutic Referrals CPR  Family nurse practitioner General practice ICD-10 International Classification of Diseases ICPC-2 PLUS International Classification of Primary Care ICPC-2 Primary care Referral ( medicine ) 
@@1914245 The Royal Society of Medicine ( RSM ) is a British charitable organisation whose main purpose is as a provider of medical education , running over 350 meetings and conferences each year . # History # The society was originally founded on 22 May 1805 as the Medical and Chirurgical Society of London when leading members of the Medical Society of London split from the society to form a new society that would bring together branches of the medical profession for the purpose of conversation on professional subjects , for the reception of communications and for the formation of a library . It adopted the current name of Royal Society of Medicine in 1907 when a number of independent societies , including the Epidemiological Society of London founded in 1850 , whose members had included John Snow , and the Pathological Society of London merged with the society under a new Royal Charter . The full list of the 17 specialist societies which merged with the Royal Society of Medicine at that time was :  Pathological Society of London ( founded 1846 - merged 1907 ) ,  Epidemiological Society of London ( 1850-1907 ) ,  Odontological Society of Great Britain ( 1856-1907 ) ,  Obstetrical Society of London ( 1858-1907 ) ,  Clinical Society of London ( 1867-1907 ) ,  Dermatological Society of London ( 1882-1907 ) ,  British Gynaecological Society ( 1884-1907 ) ,  Neurological Society of London ( 1886-1907 ) ,  British Laryngological , Rhinological and Otological Association ( 1888-1907 ) ,  Laryngological Society of London ( 1893-1907 ) ,  Society of Anaesthetists ( 1893-1908 ) ,  Dermatological Society of Great Britain and Ireland ( 1894-1907 ) ,  British Balneological and Climatology Society ( 1895-1909 ) ,  Otological Society of the United Kingdom ( 1899-1907 ) ,  Society for the Study of Diseases in Children ( 1900-1908 ) ,  British Electrotherapeutic Society ( 1901-1907 ) ,  Therapeutical Society ( 1902-1907 ) . # The Society today # The present headquarters of the RSM are in an Edwardian baroque building completed in 1912 by John Belcher at , London and contain one of the largest postgraduate medical libraries in Europe . The Society publishes an eponymous Journal , the JRSM . For those potentially interested in becoming a doctor and wanting to know what it entails , the society also publishes a comprehensive guide to medical school application , entitled . The society also owns the nearby Chandos House , designed by the 18th century architect Robert Adam , which it runs as a venue facility . Scientists are elected to the Society following nomination and committee review . It takes members from a wide range of professions including medicine , dentistry , veterinary sciences and allied healthcare specialities . It also welcomes students members of medicine , dentistry and veterinary science to join . An elite group of physicians or scientists are elected annually to fellowship or as Honorary Fellows . Elected fellows correspond to members of the Institute of Medicine in the USA . It is not to be confused with the older Medical Society of London ( 1770 ) , Royal Medical Society ( Edinburgh , 1737 ) , Royal Society ( 1660 ) or ( Worshipful ) Society of Apothecaries of London ( 1617 ) . # Presidents #  2014-Present Babulal Sethia  20122014 Professor Sir Michael Rawlins  20102012 Parveen Kumar  20082010 Robin C. N. Williamson  20062008 Ilora Finlay , Baroness Finlay of Llandaff  20042006 Sir John Lilleyman  20022004 Sir Barry Jackson  20002002 Deirdre Hine  19982000 Lord Soulsby of Swaffham  19961998 Sir Christopher Paine  19941996 Sir Donald Harrison  19921994 Sir George Pinker  19901992 Sir David Innes Williams  19881990 Sir Christopher Booth  19861988 Sir Gordon Robson  19841986 Lord Walton of Detchant  19821984 Sir James Watt  19801982 Sir John Stallworthy  19781980 Sir Rodney Smith  19751978 Sir Gordon Wolstenholme  19731975 Sir John Stallworthy  19711973 Sir Hedley Atkins  19691971 Sir John Richardson  19671969 Sir Hector MacLennan  19661967 Sir Arthur Porritt ( one year only )  19641966 The Lord Cohen of Birkenhead  19621964 Sir Terence Cawthorne  19601962 The Lord Adrian  19561958 Sir Clifford Price Thomas  19541956 Sir Francis Walshe  19501952 The Lord Webb-Johnson  19481950 Sir Henry Hallett Dale  19461948 Sir Maurice Alan Cassidy  19441946 Sir Gordon Gordon-Taylor  19361938 Sir Thomas Clifford Allbutt  19301932 Sir Harry Platt  19261928 Sir James Berry  19241926 Sir St Clair Thomson  19221924 Sir William Hale-White  19201922 Sir John Bland-Sutton  19181920 Sir Humphry Rolleston  19161918 Sir Rickman Godlee  19121914 Sir Francis Champneys  19101912 Sir Henry Morris  19071909 Sir William Selby Church # Honorary Fellowships # The origins of the Society 's Honorary Fellowship may be traced back to the first meeting in 1805 of the Medical and Chirurgical Society of London , when the following resolution was passed : ' That Gentlemen who have eminently distinguished themselves in Sciences connected with Medicine , but who are not of the Medical Profession , or do not practise therein , be admissible as Honorary Members ' . A further resolution elected the following inaugural Honorary Members :  Sir Joseph Banks Bt KB , Sir Charles Blagden , Dr Aikin Humphry Davy Esq , Charles Hatchett Esq , Edward Charles Howard Esq , Smithson Tennant Esq , Dr Wollaston Later Honorary Follows have included : Charles Daubeny Thomas Huxley Richard Owen Charles Darwin Louis Pasteur Sir William Jenner Samuel Wilks Sigmund Freud Sir MacFarlane Burnet : Nobel Prize Winner for Medicine &amp; Physiology Sir Richard Doll : Globally recognised authority on smoking and cancer Sir Donald Acheson : CMO and spearhead of UN medical relief envoy in Sarajevo Prof Jerry Morris : Expert on exercise and cardio-vascular disease Sir George Godber : CMO and leading light in health planning &amp; education Sir Kenneth Calman : CMO and fundamental restructuring of medical education Michael Shepherd CBE eminent psychiatrist and driving force behind the increased role played by NHS general practitioner in the treatment of patients with psychiatric illness . # Edward Jenner Medal # The award was founded in 1896 by the Epidemiological Society of London ( 18501907 ) to commemorate the centenary of Edward Jenners discovery of a means of smallpox vaccination . It is awarded periodically to individuals who have undertaken distinguished work in epidemiological research . The medal was designed in Bronze by Allan Wyon . It features Jenners face on one aspect and the symbol of the Epidemiological Society , the Earth , on the reverse . The medal was re-cast following the evolution of the Society into the Section of Epidemiology at the RSM in 1907 . Photographs of the medal may be found in ' ' The History of the Royal Society of Medicine ' ' published in 2001 . It was first awarded to Sir William Henry Power who was the then Medical Officer for London and had formulated the theory of aerial conveyance of smallpox and chaired the Royal Commission on Tuberculosis . # Recipients include # William Henry Power ( 1st-1896 ) Charles Louis Alphonse Laveran ( 2nd-1902 ) Patrick Manson ( 3rd-1912 ) : Sidney Monckton Copeman ( ? th-1925 or 1935 ) *21;130654;ref Thomas Henry Craig Stevenson ( ? uncertain , before 1933 , see ref )  Arthur Newsholme ( ? th-1938 ) AT Glenny ( ? th-1953 ) : for contributions to diphtheria immunisation Leonard Colebrook ( ? th-1962 ) *22;130677;ref Alexander D Langmuir ( 17th-1979 ) Richard Doll ( ? th-1981 ) : for outstanding studies on the epidemiology of cancer Karel Raka ( 19th-1984 ) : for work towards worldwide eradication of smallpox N Spence Galbraith ( 21st-before 1991 ) Donald Acheson ( ? th-1993 ) : for the advancement of public health Donald Henderson ( ? th-1996 ) : for work towards worldwide eradication of smallpox Rosemary Rue ( ? th-2001 ) : first woman president of the Faculty of Community Medicine ( now the Faculty of Public Health ) and pioneer of women in medicine # Publications # The Royal Society of Medicine Press is the publishing arm of the RSM . Growing rapidly in recent years it is now recognised as one of the leading medical society publishers . RSM Press publishes books , journals and online resources for health professionals in training and in practice .  1809 1907 : ' ' Medico-Chirurgical Transactions ' ' ( Med . Chir . Trans )  1908 1977 : ' ' Proceedings of the Royal Society of Medicine ' ' : Archive versions of the above two journals are available at PubMed Central . See external links section below .  1978present : ' ' Journal of the Royal Society of Medicine ' ' : The journals open access allows for all research articles and the editors column from each issue to be made available online for free , via PubMed Central . All articles are made free to access three years after publication . See external links section below . # Rebranding and One Wimpole Street # The Royal Society of Medicine 's headquarters located at 1 Wimpole Street , has long hosted the society 's medical training program , but in 2008 the space was rebranded to One Wimpole Street , the Home of the Royal Society of Medicine . With the aim of attracting new non-medical business to the venue , it has now become a popular choice for event organisers in London . 
@@1991054 The Johns Hopkins University School of Medicine ( JHUSOM ) , located in Baltimore , Maryland , U.S. , is the academic medical teaching and research arm of Johns Hopkins University . Johns Hopkins has consistently been among the nation 's top medical schools in the number of research grants awarded by the National Institutes of Health . Its major teaching hospital , the Johns Hopkins Hospital , was ranked the best hospital in the United States every year between 1991 and 2011 and again in 2013 by ' ' U.S. News and World Report ' ' . # Overview # The Johns Hopkins School of Medicine is located in the East Baltimore campus of Johns Hopkins University together with the Bloomberg School of Public Health , and the School of Nursing . Known collectively as the Johns Hopkins Medical Institutions ( JHMI ) Campus , it spans several city blocks , radiating outwards from the Billings building of the Johns Hopkins Hospital with its historic dome ( cupola ) . The founding physicians of the Johns Hopkins School of Medicine included pathologist William Henry Welch ( 1850-1934 ) , the first dean of the school and a mentor to generations of research scientists ; internist Sir William Osler ( 1849-1919 ) , sometimes called the Father of Modern Medicine , having been perhaps the most influential physician of the late 19th and early 20th centuries as author of ' ' The Principles and Practice of Medicine ' ' ( 1892 ) , written at the Johns Hopkins Hospital and published for more than a century ; surgeon William Stewart Halsted ( 1852-1922 ) , who revolutionized surgery by insisting on subtle skill and technique , as well as strict adherence to sanitary procedures ; and gynecologist Howard Atwood Kelly ( 1858-1943 ) , a superb gynecological surgeon often credited with establishing gynecology as a specialty and being among the first to use radium to treat cancer . The Johns Hopkins School of Medicine is affiliated with the Johns Hopkins Hospital , its major teaching hospital , as well as several other regional medical centers , including the Johns Hopkins Bayview Medical Center , Howard County General Hospital , Suburban Hospital in Montgomery County , Maryland , and Sibley Memorial Hospital in Washington , D.C. Together they form an academic health science center . # Reputation # For years , Johns Hopkins has been among the nation 's top medical schools in the number of competitive research grants awarded by the National Institutes of Health . According to ' ' U.S. News and World Report ' ' , Johns Hopkins has always ranked in the top 3 research-centered medical schools . Its major teaching hospital , the Johns Hopkins Hospital , was ranked the top hospital in the United States every year from 1991 to 2011 by ' ' U.S. News and World Report ' ' . Askmen.com ranked an M.D. from Johns Hopkins as one of the five most prestigious degrees in the world . According to the Flexner Report , Hopkins has served as the model for American medical education . It was the first medical school to require its students to have an undergraduate degree and was also the first graduate-level medical school to admit women on an equal basis as men . Mary Elizabeth Garrett , head of the Women 's Medical School Fund , was a driving force behind both of these ' ' firsts ' ' . School founder Sir William Osler became the first Professor of Medicine at Johns Hopkins and the Physician-in-Chief at Johns Hopkins Hospital . Osler was responsible for establishing the residency system of postgraduate medical training , where young physicians were required to reside within the hospital to better care for their patients . # The Colleges # Upon matriculation , medical students at the Johns Hopkins School of Medicine are divided into four Colleges named after famous Hopkins faculty members who have had a major impact in the history of medicine ( Florence Sabin , Vivien Thomas , Daniel Nathans and Helen Taussig ) . The Colleges were established to foster camaraderie , networking , advising , mentoring , professionalism , clinical skills , and scholarship . Students are assigned to faculty advisors within their colleges . Each advisor has a group of five students from each of the four years . They instruct these same five students in ' Clinical Skills ' , a core first-year course , and continue advising them throughout their 4 years of medical school . Every year , the Colleges compete in the College Olympics. # Governance # The Johns Hopkins School of Medicine is led by Ronald J. Daniels , the president of Johns Hopkins University , Paul Rothman , CEO and dean of the medical faculty , and Ronald R. Peterson , president of the Johns Hopkins Hospital and health system . The CFO of Johns Hopkins Medicine is Richard A. Grossi , who is also the Senior Associate Dean for Finance and Administration and executive vice president of Johns Hopkins Medicine . Vice deans preside over specific administrative task areas . The vice deans are : William A Baumgartner , Vice Dean for Clinical Affairs ; Janice E. Clements , Vice Dean for Faculty Affairs ; Landon King , Vice Dean for Research ; Daniel E. Ford , Vice Dean for Clinical Investigation ; David G. Nichols , Vice Dean for Education ; and David Hellmann , Vice Dean for the Johns Hopkins Bayview Medical Center . The dean 's office also includes over twenty administrators in the position of associate or assistant dean . # Nobel Laureates # Sixteen Nobel laureates associated with the School of Medicine as alumni and faculty have won the Nobel Prize in Medicine or Chemistry . Carol Greider Faculty , Nobel Prize in Physiology or Medicine , 2009 Oliver Smithies Faculty , Nobel Prize in Physiology or Medicine , 2007 Richard Axel MD 1971 , Nobel Prize in Physiology or Medicine , 2004 Peter Agre MD 1974 , Nobel Prize in Chemistry , 2003 Paul Greengard PhD 1953 , Nobel Prize in Physiology or Medicine , 2000 David Hubel Assistant resident , Nobel Prize in Physiology or Medicine , 1981 Torsten Wiesel Faculty , Nobel Prize in Physiology or Medicine , 1981 Hamilton O. Smith Faculty , MD 1956 , Nobel Prize in Physiology or Medicine , 1978 Daniel Nathans - Faculty , Nobel Prize in Physiology or Medicine , 1978 Haldan Keffer Hartline MD 1927 , Nobel Prize in Physiology or Medicine , 1967 Francis Peyton Rous MD , Nobel Prize in Physiology or Medicine , 1966 Joseph Erlanger MD 1899 , Nobel Prize in Physiology or Medicine , 1944 Herbert Spencer Gasser MD 1915 , Nobel Prize in Physiology or Medicine , 1944 George Richards Minot Assistant in Medicine , Nobel Prize in Physiology or Medicine , 1934 George Hoyt Whipple MD 1905 , Nobel Prize in Physiology or Medicine , 1934 Thomas Hunt Morgan PhD 1890 , Nobel Prize in Physiology or Medicine , 1933 # Notable past and present Faculty/Alumni #  John Jacob Abel Pharmacologist  John Shaw Billings Civil War surgeon , pioneering leader in hygiene  Alfred Blalock Developed field of cardiac surgery  Max Brdel Acclaimed medical illustrator  William R. Brody Radiologist , President of the Salk Institute , former President of Johns Hopkins University  Ben Carson Pediatric Neurosurgeon , awarded the Presidential Medal of Freedom  Denton Cooley Renowned Cardiovascular surgeon  Harvey Cushing Father of modern neurosurgery  Walter Dandy Neurosurgeon  Catherine Clarke Fenselau Biochemist and mass spectrometrist  William Halsted Father of modern surgery  John Eager Howard Endocrinologist  Kay Redfield Jamison Psychologist and Psychiatry professor  Leo Kanner Father of child psychiatry  Howard Kelly Gynecologist  Albert L. Lehninger Biochemist  Paul McHugh Psychiatrist  Victor McKusick Developed field of medical genetics  Adolf Meyer Psychiatrist  Vernon Mountcastle Neuroscientist  William Osler Father of modern medicine  Wilder Penfield - Pioneer of epilepsy neurosurgery ; developed the cortical homunculus  Peter Pronovost Anesthesiologist , MacArthur Fellow  Alfredo Quinones-Hinojosa Neurosurgeon  Dorothy Reed Mendenhall Pathologist  Florence Sabin Anatomist  Mark Schlissel - President-Elect of the University of Michigan  Pamela Sklar - Neuroscientist and psychiatrist  Solomon H. Snyder Neuroscientist  Helen Taussig Pediatric cardiologist  Vivien Thomas Helped develop Blalock-Taussig Shunt  Thomas Turner - Microbiologist , JHUSM Dean 1957-68 , Archivist  Bert Vogelstein Molecular oncologist  David B. Weishampel Paleontologist , author of The Dinosauria 2004  William H. Welch Pathologist  Hugh Hampton Young Urologist  Elias Zerhouni Radiologist , former Director of the NIH # In popular culture # In the Fox television program ' ' House M.D. ' ' , Dr. Gregory House is a world-famous diagnostician who attended Johns Hopkins University for his undergraduate degree and , later , medicine , but was expelled for cheating . Neurologist Dr. Eric Foreman also attended Hopkins . In the movie ' ' Shutter Island ' ' , Dr. John Cawley , the head psychiatrist at the Ashecliff Hospital for the criminally insane , is said to have graduated at the top of his class at Johns Hopkins . In the movie ' ' Step Brothers ' ' , Dr. Robert Doback attends Johns Hopkins for his postgraduate degree . However , this is not good enough for Will Ferrell 's character , who says that he smoked pot with Johnny Hopkins . In the television comedy/drama ' ' Gilmore Girls ' ' the school is mentioned as one of the medical schools the character Paris Geller wants to get accepted to , and eventually is. In the television drama ' ' Grey 's Anatomy ' ' , two of the cardiothoracic surgeons Preston Burke and Erica Hahn graduated from Hopkins Med , coming first and second in their class respectively . Arizona Robbins , the Head of Pediatric Surgery , is also a Hopkins Med graduate . In the television drama ' ' Private Practice ' ' , the character Charlotte King is a graduate of Hopkins Med and Amelia Shepherd trained at Hopkins for residency . In ' ' The Simpsons ' ' , Julius Hibbert is a family physician who graduated from Hopkins Med. Dr . Hannibal Lecter , from ' ' The Silence of the Lambs ' ' and other books , completed his residency training at Hopkins . The character of Alex Cross , created by author James Patterson , is a graduate of Hopkins Med. In ' ' The West Wing ' ' , President Bartlet 's middle daughter Ellie is a student at Hopkins Med. Johns Hopkins is mentioned many times in Tom Clancy 's novels ; Jack Ryan 's wife , Cathy , is an ophthalmology professor there . The ABC documentary series ' ' Hopkins ' ' takes a look at the life of the medical staff and students of the Johns Hopkins Hospital and Health System . This new series is a sequel to the 2000 ABC special ' ' Hopkins 24/7 ' ' . Both ' ' Hopkins ' ' and ' ' Hopkins 24/7 ' ' were awarded the prestigious Peabody Award . In the animated television series ' ' South Park ' ' , Butters Stotch gets sent to Johns Hopkins Hospital for scientific study . The movie ' ' Something the Lord Made ' ' is the story of two men an ambitious white surgeon , head of surgery at the Johns Hopkins Hospital and a gifted black carpenter turned lab technician who defied the racial strictures of the Jim Crow South and together pioneered the field of heart surgery . Dr . Perry Cox , from the television series ' ' Scrubs ' ' , attended Johns Hopkins for medical school . Melanie Barnett from the television series ' ' The Game ' ' often discusses how she gave up Johns Hopkins for professional football player boyfriend Derwin. In the movie ' ' Getting In ' ' , an applicant to the Johns Hopkins School of Medicine who is placed on the waitlist is suspected of murdering other wait-listed applicants to clear his way to admission . In M*A*S*H episode 8.17 ' Heal Thyself ' the visiting surgeon , Dr. Newsome ( Edward Hermann ) , shuts up Charles Winchester by disclosing that he is an alumnus of Johns Hopkins . 
@@2118246 Global health is the health of populations in a global context ; it has been defined as the area of study , research and practice that places a priority on improving health and achieving equity in health for all people worldwide . Problems that transcend national borders or have a global political and economic impact are often emphasized . Thus , global health is about worldwide health improvement , reduction of disparities , and protection against global threats that disregard national borders . Global health is not to be confused with international health , which is defined as the branch of public health focusing on developing nations and foreign aid efforts by industrialized countries . The predominant agency associated with global health ( and international health ) is the World Health Organization ( WHO ) . Other important agencies impacting global health include UNICEF , World Food Programme , and the World Bank . The United Nations has also played a part with declaration the Millennium Development Goals . # Definition # Global health employs several perspectives that focus on the determinants and distribution of health in international contexts :  Medicine describes the pathology of diseases and promotes prevention , diagnosis , and treatment .  Public health emphasizes the health of populations .  Epidemiology helps identify risk factors and causes of health problems .  Demography provides data for policy decisions .  Economics emphasizes the cost-effectiveness and cost-benefit approaches for the optimal allocation of health resources .  Other social sciences such as sociology , development studies , anthropology , cultural studies , and law can help understand the determinants of health in societies . Both individuals and organizations working in the domain of global health often face many questions regarding ethical and human rights . Critical examination of the various causes and justifications of health inequities is necessary to the success of proposed solutions . # History # The 19th century held major discoveries in medicine and public health . The Broad Street cholera outbreak of 1854 was central to the development of modern epidemiology . The microorganisms responsible for malaria and tuberculosis were identified in 1880 and 1882 , respectively . The 20th century saw the development of preventive and curative treatments for many diseases , including the BCG vaccine ( for tuberculosis ) and penicillin in the 1920s . The eradication of smallpox , with the last naturally occurring case recorded in 1977 , raised hope that other diseases could be eradicated as well . Important steps were taken towards global cooperation in health with the formation of the United Nations ( UN ) and the World Bank Group in 1945 , after World War II . In 1948 , the member states of the newly formed United Nations gathered to create the World Health Organization . A cholera epidemic that took 20,000 lives in Egypt in 1947 and 1948 helped spur the international community to action . The WHO published its Model List of Essential Medicines , and the 1978 Alma Ata declaration underlined the importance of primary health care . At a United Nations Summit in 2000 , member nations declared eight Millennium Development Goals ( MDGs ) , which reflected the major challenges facing human development globally , to be achieved by 2015 . The declaration has been matched by unprecedented global investment by donor and recipient countries . The UN report released on July 2 , 2012 revealed that several MDG targets have been met ahead of the 2015 timeline , though progress on some goals are severely lagging . # Measures # Measures of global health include disability-adjusted life year ( DALY ) , quality-adjusted life years ( QALYs ) , and mortality rate . # Disability-adjusted life years # </div> The DALY is a summary measure that combines the impact of illness , disability , and mortality by measuring the time lived with disability and the time lost due to premature mortality . One DALY can be thought of as one lost year of healthy life . The DALY for a disease is the sum of the years of life lost due to premature mortality and the years lost due to disability for incident cases of the health condition . # Quality-adjusted life years # QALYs combine expected survival with expected quality of life into a single number : if an additional year of healthy life is worth a value of one ( year ) , then a year of less healthy life is worth less than one ( year ) . QALY calculations are based on measurements of the value that individuals place on expected years of survival . Measurements can be made in several ways : by techniques that simulate gambles about preferences for alternative states of health , with surveys or analyses that infer willingness to pay for alternative states of health , or through instruments that are based on trading off some or all likely survival time that a medical intervention might provide in order to gain less survival time of higher quality . # Infant and child mortality # Infant mortality and child mortality for children under age 5 are more specific than DALYs or QALYs in representing the health in the poorest sections of a population , and are thus especially useful when focusing on health equity . # Morbidity # Morbidity measures include incidence rate , prevalence , and cumulative incidence , with incidence rate referring to the risk of developing a new health condition within a specified period of time . Although sometimes loosely expressed simply as the number of new cases during a time period , morbidity is better expressed as a proportion or a rate . # Health conditions # The diseases and health conditions targeted by global health initiatives are sometimes grouped under diseases of poverty versus diseases of affluence , although the impact of globalization is increasingly blurring the lines between the two . # Respiratory infections # Infections of the respiratory tract and middle ear are major causes of morbidity and mortality worldwide . Some respiratory infections of global significance include tuberculosis , measles , influenza , and pneumonias caused by pneumococci and ' ' Haemophilus influenzae ' ' . The spread of respiratory infections is exacerbated by crowded conditions , and poverty is associated with more than a 20-fold increase in the relative burden of lung infections . # Diarrheal diseases # Diarrhea is the second most common cause of child mortality worldwide , responsible for 17% of deaths of children under age 5 . Poor sanitation can increase transmission of bacteria and viruses through water , food , utensils , hands , and flies . Dehydration due to diarrhea can be effectively treated through oral rehydration therapy with dramatic reductions in mortality . Important nutritional measures include the promotion of breastfeeding and zinc supplementation . While hygienic measures alone may be insufficient for the prevention of rotavirus diarrhea , it can be prevented by a safe and potentially cost-effective vaccine . # Maternal health # Complications of pregnancy and childbirth are the leading causes of death among women of reproductive age in many developing countries : a woman dies from complications from childbirth approximately every minute . According to the World Health Organization 's 2005 World Health Report , poor maternal conditions are the fourth leading cause of death for women worldwide , after HIV/AIDS , malaria , and tuberculosis . Most maternal deaths and injuries can be prevented , and such deaths have been largely eradicated in the developed world . Targets for improving maternal health include increasing the number of deliveries accompanied by skilled birth attendants . 68 low-income countries tracked by the WHO- and UNICEF-led collaboration ' ' Countdown to 2015 ' ' are estimated to hold for 97% of worldwide maternal and child deaths . # HIV/AIDS # Human immunodeficiency virus ( HIV ) is transmitted through unprotected sex , unclean needles , blood transfusions , and from mother to child during birth or lactation . Globally , HIV is primarily spread through sexual intercourse . The infection damages the immune system , leading to acquired immunodeficiency syndrome ( AIDS ) and eventually , death . Antiretroviral drugs prolong life and delay the onset of AIDS by minimizing the amount of HIV in the body . # Malaria # Malaria is a mosquito-borne infectious disease caused by the parasites of the genus ' ' Plasmodium ' ' . Symptoms may include fever , headaches , chills , and nausea . Each year , there are approximately 500 million cases of malaria worldwide , most commonly among children and pregnant women in developing countries . The use of insecticide-treated bednets is a cost-effective way to reduce deaths from malaria , as is prompt artemisin-based combination therapy , supported by intermittent preventive therapy in pregnancy . # Nutrition # In 2010 , about 104 million children were underweight , and undernutrition contributes to about one third of child deaths around the world . ( Undernutrition is not to be confused with ' ' malnutrition ' ' , which refers to poor ' ' proportion ' ' of food intake and can thus refer obesity . ) Undernutrition impairs the immune system , increasing the frequency , severity , and duration of infections ( including measles , pneumonia , and diarrhea ) . Infection can further contribute to malnutrition . Deficiencies of micronutrient , such as vitamin A , iron , iodine , and zinc , are common worldwide and can compromise intellectual potential , growth , development , and adult productivity . Interventions to prevent malnutrition include micronutrient supplementation , fortification of basic grocery foods , dietary diversification , hygienic measures to reduce spread of infections , and the promotion of breastfeeding . # Violence against women # Violence against women has been defined as : physical , sexual and psychological violence occurring in the family and in the general community , including battering , sexual abuse of children , dowry-related violence , rape , female genital mutilation and other traditional practices harmful to women , non-spousal violence and violence related to exploitation , sexual harassment and intimidation at work , in educational institutions and elsewhere , trafficking in women , forced prostitution and violence perpetrated or condoned by the state . In addition to causing injury , violence may increase womens long-term risk of a number of other health problems , including chronic pain , physical disability , drug and alcohol abuse , and depression . Although statistics can be difficult to obtain as many cases go unreported , it is estimated that one in every five women faces some form of violence during her lifetime , in some cases leading to serious injury or even death . Risk factors for being a perpetrator include low education , past exposure to child maltreatment or witnessing violence between parents , harmful use of alcohol , attitudes accepting of violence and gender inequality . Equality of women has been addressed in the Millennium development goals . # Chronic disease # Approximately 80% of deaths linked to non-communicable diseases occur in developing countries . Increases in refugee urbanization , has led to a growing number of people diagnosed with chronic noncommunicable diseases . In September 2011 , the United Nations is hosting its first General Assembly Special Summit on the issue of non-communicable diseases . Noting that non-communicable diseases are the cause of some 35 million deaths each year , the international community is being increasingly called to take measures for the prevention and control of chronic diseases and mitigate their impacts on the world population , especially on women , who are usually the primary caregivers . For example , the rate of type 2 diabetes , associated with obesity , has been on the rise in countries previously plagued by hunger . In low-income countries , the number of individuals with diabetes is expected to increase from 84 million to 228 million by 2030 . Obesity , a preventable condition , is associated with numerous chronic diseases , including cardiovascular conditions , stroke , certain cancers , and respiratory disease . About 16% of the global burden of disease , measured as DALYs , has been accounted for by obesity. # Health interventions # Global interventions for improved child health and survival include the promotion of breastfeeding , zinc supplementation , vitamin A fortification , salt iodization , hygiene interventions such as hand-washing , vaccinations , and treatments of severe acute malnutrition . The Global Health Council suggests a list of 32 treatments and health interventions that could potentially save several million lives each year . Many populations face an outcome gap , which refers to the gap between members of a population who have access to medical treatment versus those who do not . Countries facing outcome gaps lack sustainable infrastructure . In Guatemala , a subset of the public sector , the ' ' Programa de Accessibilidad a los Medicamentos ' ' ( Program for Access to Medicines ) , had the lowest average availability ( 25% ) compared to the private sector ( 35% ) . In the private sector , highest- and lowest-priced medicines were 22.7 and 10.7 times more expensive than international reference prices respectively . Treatments were generally unaffordable , costing as much as 15 days wages for a course of the antibiotic ceftriaxone . The public sector in Pakistan , while having access to medicines at a lower price than international reference prices , has a chronic shortage of and lack of access to basic medicines . Journalist Laurie Garrett argues that the field of global health is not plagued by a lack of funds , but that more funds do not always translate into positive outcomes . The problem lies in the way these funds are allocated , as they are often disproportionately allocated to alleviating a single disease . In its 2006 World Health Report , the WHO estimated a shortage of almost 4.3 million doctors , midwives , nurses , and support workers worldwide , especially in sub-Saharan Africa . 
@@2159778 Within the framework of the World Health Organization 's ( WHO ) definition of health as a state of complete physical , mental and social well-being , and not merely the absence of disease or infirmity , reproductive health , or sexual health / hygiene , addresses the reproductive processes , functions and system at all stages of life . Reproductive health implies that people are able to have a responsible , satisfying and safer sex life and that they have the capability to reproduce and the freedom to decide if , when and how often to do so . One interpretation of this implies that men and women ought to be informed of and to have access to safe , effective , affordable and acceptable methods of birth control ; also access to appropriate health care services of sexual , reproductive medicine and implementation of health education programs to stress the importance of women to go safely through pregnancy and childbirth could provide couples with the best chance of having a healthy infant . Individuals do face inequalities in reproductive health services . Inequalities vary based on socioeconomic status , education level , age , ethnicity , religion , and resources available in their environment . It is possible for example , that low income individuals lack the resources for appropriate health services and the knowledge to know what is appropriate for maintaining reproductive health . According to the WHO , Reproductive and sexual ill-health accounts for 20% of the global burden of ill-health for women , and 14% for men . Reproductive health is a part of sexual and reproductive health and rights . # Sexual health # An official working definition for sexual health is that Sexual health is a state of physical , emotional , mental and social well-being in relation to sexuality ; it is not merely the absence of disease , dysfunction or infirmity . Sexual health requires a positive and respectful approach to sexuality and sexual relationships , as well as the possibility of having pleasurable and safe sexual experiences , free of coercion , discrimination and violence . For sexual health to be attained and maintained , the sexual rights of all persons must be respected , protected and fulfilled . However , while used by WHO as well as other organizations , this is not an official WHO position , and should not be used or quoted as a WHO definition . Emerging research in the field of sexual and reproductive health ( SRH ) identifies a series of factors that enhance the translation of research into policy and practice . These include discursive changes ( creating spaces for public debate ) ; content changes ( to laws and practices ) ; procedural changes ( influencing how data on SRH are collected ) and behavioural changes ( through partnerships with civil society , advocacy groups and policy makers ) . # Childbearing and health # Early childbearing and other behaviours can have health risks for women and their infants . Waiting until a woman is at least 18 years old before trying to have children improves maternal and child health . If an additional child is to be conceived , it is considered healthier for the mother , as well as for the succeeding child , to wait at least 2 years after the previous birth before attempting to conception . After a fetal fatality , it is healthier to wait at least 6 months . The WHO estimates that each year , 358 000 women die due to complications related to pregnancy and childbirth ; 99% of these deaths occur within the most disadvantaged population groups living in the poorest countries of the world . Most of these deaths can be avoided with improving women 's access to quality care from a skilled birth attendant before , during and after pregnancy and childbirth . # Availability of modern contraception # Modern contraception is often unavailable in certain parts of the world . According to the WHO , about 222 million women worldwide have an unmet need for modern contraception , and the lack of access to modern contraception is highest among the most disadvantaged populations : the poor , those living in rural areas and urban slums , those living with HIV , and those who are internally displaced . In developing parts of the world , the lack of access to contraception is a main cause of unintended pregnancy , which is associated with poorer reproductive outcomes . According to UNFPA , access to contraceptive services for all women could prevent about one in three deaths related to pregnancy and childbirth . # Female genital mutilation # Female genital mutilation ( FGM ) , also known as female genital cutting or female circumcision , comprises all procedures that involve partial or total removal of the external female genitalia , or other injury to the female genital organs for non-medical reasons . The practice is concentrated in 29 countries in Africa and the Middle East ; and more than 125 million girls and women today are estimated to have been subjected to FGM . FGM also takes place in immigrant communities in Western countries , such as the UK . FGM does not have any health benefits , and has negative effects on reproductive and sexual health , including severe pain , shock , hemorrhage , tetanus or sepsis ( bacterial infection ) , urine retention , open sores in the genital region and injury to nearby genital tissue , recurrent bladder and urinary tract infections , cysts , increased risk of infertility , childbirth complications and newborn deaths . FGM procedures that seal or narrow a vaginal opening ( known as type 3 ) lead to a need for future surgeries of cutting open in order to allow for sexual intercourse and childbirth . # Sexually transmitted diseases # Sexually transmitted diseases ( STD ) , also referred to as sexually transmitted infections ( STI ) or venereal diseases ( VD ) , are illnesses that have a significant probability of transmission between humans by means of sexual activity . Common STDs include chlamydia , gonorrhea , herpes , HIV/AIDS , hepatitis B , human papillomavirus ( HPV ) , syphilis , trichomoniasis . Sexually transmitted infections ( STIs ) affect reproductive and sexual health , having a profound negative impact worldwide . Programs aimed at preventing STIs include comprehensive sex education ; STI and HIV pre- and post-test counseling ; safer sex/risk-reduction counseling ; condom promotion ; and interventions targeted at key and vulnerable populations . Having access to effective medical treatment for STIs is very important . # Adolescent health # Issues affecting adolescent reproductive and sexual health are similar to those of adults , but may include additional concerns about teenage pregnancy and lack of adequate access to information and health services . Worldwide , around 16 million adolescent girls give birth every year , mostly in low- and middle-income countries . The causes of teenage pregnancy are diverse . In developing countries girls are often under pressure to marry young and bear children early ( see child marriage ) . Some adolescent girls do not know how to avoid becoming pregnant , are unable to obtain contraceptives , or are coerced into sexual activity . Adolescent pregnancy , especially in developing countries , carries increased health risks , and contributes to maintaining the cycle of poverty . The availability and type of sex education for teenagers varies in different parts of the world . LGBT teens may suffer additional problems if they live in places where homosexual activity is socially disapproved and/or illegal ; in extreme cases there can be depression , social isolation and even suicide among LGBT youth . # International Conference on Population and Development ( ICPD ) , 1994 # The International Conference on Population and Development ( ICPD ) was held in Cairo , Egypt , from 5 to 13 September 1994 . Delegations from 179 States took part in negotiations to finalize a Programme of Action on population and development for the next 20 years . Some 20,000 delegates from various governments , UN agencies , NGOs , and the media gathered for a discussion of a variety of population issues , including immigration , infant mortality , birth control , family planning , and the education of women . In the , ' Reproductive health ' is defined as : # a state of complete physical , mental and social well-being and ... not merely the absence of disease or infirmity , in all matters relating to the reproductive system and its functions and processes . Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if , when and how often to do so . Implicit in this last condition are the right of men and women to be informed about and to have access to safe , effective , affordable and acceptable methods of family planning of their choice , as well as other methods of birth control which are not against the law , and the right of access to appropriate health-care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant . # This definition of the term is also echoed in the , or the so-called Beijing Declaration of 1995 . However , the ICPD Program of Action , even though it received the support of a large majority of UN Member States , does not enjoy the status of an international legal instrument ; it is therefore not legally binding . The Program of Action endorses a new strategy which emphasizes the numerous linkages between population and development and focuses on meeting the needs of individual women and men rather than on achieving demographic targets . The ICPD achieved consensus on four qualitative and quantitative goals for the international community , the final two of which have particular relevance for reproductive health :  Reduction of maternal mortality : A reduction of maternal mortality rates and a narrowing of disparities in maternal mortality within countries and between geographical regions , socio-economic and ethnic groups .  Access to reproductive and sexual health services including family planning : Family planning counseling , pre-natal care , safe delivery and post-natal care , prevention and appropriate treatment of infertility , prevention of abortion and the management of the consequences of abortion , treatment of reproductive tract infections , sexually transmitted diseases and other reproductive health conditions ; and education , counseling , as appropriate , on human sexuality , reproductive health and responsible parenthood . Services regarding HIV/AIDS , breast cancer , infertility , delivery , hormone therapy , sex reassignment therapy , and abortion should be made available . Active discouragement of female genital mutilation ( FGM ) . Key to this new approach is empowering women and providing them with more choices through expanded access to education and health services and promoting skill development and employment . The Programme advocates making family planning universally available by 2015 , or sooner , as part of a broadened approach to reproductive health and rights , provides estimates of the levels of national resources and international assistance that will be required , and calls on Governments to make these resources available . # Millennium Development Goals # Achieving universal access to reproductive health by 2015 is one of the two targets of ' ' Goal 5 ' ' - ' ' Improving Maternal Health ' ' - of the eight Millennium Development Goals . To monitor global progress towards the achievement of this target , the United Nations has agreed on the following indicators : 5.3 : contraceptive prevalence rate 5.4 : adolescent birth rate 5.5 : antenatal care coverage 5.6 : unmet need for family planning According to the MDG Progress Report , regional statistics on all four indicators have either improved or remained stable between the years 2000 and 2005 . However , progress has been slow in most developing countries , particularly in Sub-saharan Africa , which remains the region with the poorest indicators for reproductive health . According to the WHO in 2005 an estimated 55% of women do not have sufficient antenatal care and 24% have no access to family planning services . # Reproductive health and abortion # An article from the World Health Organization calls safe , legal abortion a fundamental right of women , irrespective of where they live and unsafe abortion a silent pandemic . The article states ending the silent pandemic of unsafe abortion is an urgent public-health and human-rights imperative . It also states access to safe abortion improves womens health , and vice-versa , as documented in Romania during the regime of President Nicolae Ceauescu and legalisation of abortion on request is a necessary but insufficient step toward improving womens health citing that in some countries , such as India where abortion has been legal for decades , access to competent care remains restricted because of other barriers . WHOs Global Strategy on Reproductive Health , adopted by the World Health Assembly in May 2004 , noted : As a preventable cause of maternal mortality and morbidity , unsafe abortion must be dealt with as part of the MDG on improving maternal health and other international development goals and targets . The WHO 's Development and Research Training in Human Reproduction ( HRP ) , whose research concerns people 's sexual and reproductive health and lives , has an overall strategy to combat unsafe abortion that comprises four inter-related activities : to collate , synthesize and generate scientifically sound evidence on unsafe abortion prevalence and practices ; to develop improved technologies and implement interventions to make abortion safer ; to translate evidence into norms , tools and guidelines ; and to assist in the development of programmes and policies that reduce unsafe abortion and improve access to safe abortion and high quality post-abortion care During and after the ICPD , some interested parties attempted to interpret the term reproductive health in the sense that it implies abortion as a means of family planning or , indeed , a right to abortion . These interpretations , however , do not reflect the consensus reached at the Conference . For the European Union , where legislation on abortion is certainly less restrictive than elsewhere , the Council Presidency has clearly stated that the Councils commitment to promote reproductive health did not include the promotion of abortion . Likewise , the European Commission , in response to a question from a Member of the European Parliament , clarified : With regard to the US , only a few days prior to the Cairo Conference , the head of the US delegation , Vice President Al Gore , had stated for the record : Some years later , the position of the US Administration in this debate was reconfirmed by US Ambassador to the UN , Ellen Sauerbrey , when she stated at a meeting of the UN Commission on the Status of Women that : # See also #  Sexual intercourse#Health effects  Abortion debate  Demography  ICPD : International Conference on Population and Development  POPLINE : World 's largest reproductive health database * The INFO Project  Reproductive justice Obstetric transition  Organizations : * Association of Reproductive Health Professionals * Centre for Development and Population Activities * EngenderHealth * Guttmacher Institute * German Foundation for World Population * International Planned Parenthood Federation * Marie Stopes International * Reproductive Health Supplies Coalition * United Nations Population Fund # References # 
@@2459566 Health education is the profession of educating people about health . Areas within this profession encompass environmental health , physical health , social health , emotional health , intellectual health , and spiritual health . It can be defined as the principle by which individuals and groups of people learn to behave in a manner conducive to the promotion , maintenance , or restoration of health . However , as there are multiple definitions of health , there are also multiple definitions of health education . The Joint Committee on Health Education and Promotion Terminology of 2001 defined Health Education as any combination of planned learning experiences based on sound theories that provide individuals , groups , and communities the opportunity to acquire information and the skills needed to make quality health decisions . The World Health Organization defined Health Education as comprising of consciously constructed opportunities for learning involving some form of communication designed to improve health literacy , including improving knowledge , and developing life skills which are conducive to individual and community health . # The Role of the Health Educator # From the late nineteenth to the mid-twentieth century , the aim of public health was controlling the harm from infectious diseases , which were largely under control by the 1950s . By the mid 1970s it was clear that reducing illness , death , and rising health care costs could best be achieved through a focus on health promotion and disease prevention . At the heart of the new approach was the role of a health educator Cottrell , Girvan , and McKenzie , 2009 . A health educator is a professionally prepared individual who serves in a variety of roles and is specifically trained to use appropriate educational strategies and methods to facilitate the development of policies , procedures , interventions , and systems conducive to the health of individuals , groups , and communities ( Joint Committee on Terminology , 2001 , p. 100 ) . In January 1978 the Role Delineation Project was put into place , in order to define the basic roles and responsibilities for the health educator . The result was a Framework for the Development of Competency-Based Curricula for Entry Level Health Educators ( NCHEC , 1985 ) . A second result was a revised version of A Competency-Based Framework for the Professional Development of Certified Health Education Specialists ( NCHEC , 1996 ) . These documents outlined the seven areas of responsibilities which are shown below . Responsibility I : Assessing Individual and Community Needs for Health Education  Provides the foundation for program planning  Determines what health problems might exist in any given group  Includes determination of community resources available to address the problem  Community Empowerment encourages the population to take ownership of their health problems  Includes careful data collection and analysis Responsibility II : Plan Health Education Strategies , Interventions , and Programs  Actions are based on the needs assessment done for the community ( see Responsibility I )  Involves the development of goals and objectives which are specific and measurable  Interventions are developed that will meet the goals and objectives  According to Rule of Sufficiency , strategies are implemented which are sufficiently robust , effective enough , and have a reasonable chance of meeting stated objectives Responsibility III : Implement Health Education Strategies , Interventions , and Programs  Implementation is based on a thorough understanding of the priority population  Utilize a wide range of educational methods and techniques Responsibility IV : Conduct Evaluation and Research Related to Health Education  Depending on the setting , utilize tests , surveys , observations , tracking epidemiological data , or other methods of data collection  Health Educators make use of research to improve their practice Responsibility V : Administer Health Education Strategies , Interventions , and Programs  Administration is generally a function of the more experienced practitioner  Involves facilitating cooperation among personnel , both within and between programs Responsibility VI : Serve as a Health Education Resource Person  Involves skills to access needed resources , and establish effective consultive relationships Responsibility VII : Communicate and Advocate for Health and Health Education  Translates scientific language into understandable information  Address diverse audience in diverse settings  Formulates and support rules , policies and legislation  Advocate for the profession of health education # Motivation # Education for health begins with people . It hopes to motivate them with whatever interests they may have in improving their living conditions . Its aim come is to develop in them a sense of responsibility for health conditions for themselves as individuals , as members of families , and as communities . In communicable disease control , health education commonly includes an appraisal of what is known by a population about a disease , an assessment of habits and attitudes of the people as they relate to spread and frequency of the disease , and the presentation of specific means to remedy observed deficiencies . Health education is also an effective tool that helps improve health in developing nations . It not only teaches prevention and basic health knowledge but also conditions ideas that re-shape everyday habits of people with unhealthy lifestyles in developing countries . This type of conditioning not only affects the immediate recipients of such education but also future generations will benefit from an improved and properly cultivated ideas about health that will eventually be ingrained with widely spread health education . Moreover , besides physical health prevention , health education can also provide more aid and help people deal healthier with situations of extreme stress , anxiety , depression or other emotional disturbances to lessen the impact of these sorts of mental and emotional constituents , which can consequently lead to detrimental physical effects. , # Credentialing # Credentialing is the process by which the qualifications of licensed professionals , organizational members or an organization are determined by assessing the individuals or group background and legitimacy through a standardized process . Accreditation , licensure , or certifications are all forms of credentialing . In 1978 , Helen Cleary , the president of the Society for Public Health Education ( SOPHE ) started the process of certification of health educators . Prior to this , there was no certification for individual health educators , with exception to the licensing for school health educators . The only accreditation available in this field was for school health and public health professional preparation programs . Her initial response was to incorporate experts in the field and to promote funding for the process . The director if the Division of Associated Health Professions in the Bureau of Health Manpower of the Department of Health , Education , and Welfare , Thomas Hatch , became interested in the project . To ensure that the commonalities between health educators across the spectrum of professions would be sufficient enough to create a set of standards , Dr. Cleary spent a great amount of time to create the first conference called the Bethesda Conference . In attendance were interested professionals who covered the possibility of creating credentialing within the profession . With the success of the conference and the consensus that the standardization of the profession was vital , those who organized the conference created the National Task Force in the Preparation and Practice of Health Educators . Funding for this endeavor became available in January 1979 , and role delineation became a realistic vision for the future . They presented the framework for the system in 1981 and published entry-level criteria in 1983 . Seven areas of responsibility , 29 areas of competency and 79 sub-competencies were required of health education professionals for approximately 20 years for entry-level educators . In 1986 a second conference was held in Bethesda , Maryland to further the credentialing process . In June 1988 , the National Task Force in the Preparation and Practice of Health Educators became the National Commission for Health Education Credentialing , Inc . ( NCHEC ) . Their mission was to improve development of the field by promoting , preparing and certifying health education specialists . The NCHEC has three division boards that included preparation , professional development and certification of health educator professionals . The third board , which is called the Division Board of Certification of Health Education Specialist ( DBCHES ) , has the responsibility of developing and administering the CHES exam . An initial certification process allowed 1,558 individuals to be chartered into the program through a recommendation and application process . The first exam was given in 1990 . In order for a candidate to sit for an exam they must have either a bachelors , masters , or doctoral degree from an accredited institution , and an official transcript that shows a major in health education , Community Health Education , Public Health Education , or School Health Education , etc . The transcript will be accepted if it reflects 25 semester hours or 37 quarter hours in health education preparation and covers the 7 responsibilities covered in the framework . In 1998 a project called the Competencies Update Project ( CUP ) began . The purpose of the CUP project was to up-date entry-level requirements and to develop advanced-level competences . Through research the CUP project created the requirements for three levels , which included entry-level , Advanced I and Advanced II educators . Recently the Master Certified Health Education Specialist ( MCHES ) is in the process of being created . It is an exam that will measure the knowledge of the advanced levels and sub levels of the Seven Areas of Responsibilities . The first MCHES exam is expected to be given in October 2011 . In order to be eligible to take the MCHES exam you must have at least a Master 's degree in health education or related discipline along with a least 25 credit hours related to health education . In addition , five years of documented information of practice in health education and two recommendations of past/present supervisors must be provided . A vitae/resume must also be submitted . The Competency Update Project ( CUP ) , 1998-2004 revealed that there were higher levels of health education practitioners , which is the reasoning for the advancements for the MCHES . Many health educators felt that the current CHES credential was an entry-level exam . There will be exceptions made for those who have the Certification of Health Education Specialist , that have been active for several consecutive years . They will be required to participate in the MCHES Experience Documentation Opportunity that will omit them from taking the exam . # Teaching # In the United States some forty states require the teaching of health education . A comprehensive health education curriculum consists of planned learning experiences which will help students achieve desirable attitudes and practices related to critical health issues . Some of these are : emotional health and a positive self image ; appreciation , respect for , and care of the human body and its vital organs ; physical fitness ; health issues of alcohol , tobacco , drug use and abuse ; health misconceptions and myths ; effects of exercise on the body systems and on general well being ; nutrition and weight control ; sexual relationships and sexuality , the scientific , social , and economic aspects of community and ecological health ; communicable and degenerative diseases including sexually transmitted diseases ; disaster preparedness ; safety and driver education ; factors in the environment and how those factors affect an individual 's or population 's Environmental health ( ex : air quality , water quality , food sanitation ) ; life skills ; choosing professional medical and health services ; and choices of health careers . # National Health Education Standards # The National Health Education Standards ( NHES ) are written expectations for what students should know and be able to do by grades 2 , 5 , 8 , and 12 to promote personal , family , and community health . The standards provide a framework for curriculum development and selection , instruction , and student assessment in health education . The performance indicators articulate specifically what students should know or be able to do in support of each standard by the conclusion of each of the following grade spans : Pre-KGrade 12 . The performance indicators serve as a blueprint for organizing student assessment . # Health Education Code of Ethics # The Health Education Code of Ethics has been a work in progress since approximately 1976 , begun by the Society of Public Health Education ( SOPHE ) . Various Public Health and Health Education organizations such as the American Association of Health Education ( AAHE ) , the Coalition of National Health Education Organizations ( CNHEO ) , SOPHE , and others collaborated year after year to devise a unified standard of ethics that health educators would be held accountable to professionally . In 1995 , the National Commission for Health Education Credentialing , Inc . ( NCHEC ) proposed a profession-wide standard at the conference : Health Education Profession in the Twenty-First Century : Setting the Stage . Post-conference , an ethics task force was developed with the purpose of solidifying and unifying proposed ethical standards . The document was eventually unanimously approved and ratified by all involved organizations in November 1999 and has since then been used as the standard for practicing health educators . The Code of Ethics that has evolved from this long and arduous process is not seen as a completed project . Rather , it is envisioned as a living document that will continue to evolve as the practice of Health Education changes to meet the challenges of the new millennium . # Health Education Code of Ethics Full Text # PREAMBLE The Health Education profession is dedicated to excellence in the practice of promoting individual , family , organizational , and community health . The Code of Ethics provides a framework of shared values within which Health Education is practiced . The responsibility of each Health Educator is to aspire to the highest possible standards of conduct and to encourage the ethical behavior of all those with whom they work . Article I : Responsibility to the Public A Health Educators ultimate responsibility is to educate people for the purpose of promoting , maintaining , and improving individual , family , and community health . When a conflict of issues arises among individuals , groups , organizations , agencies , or institutions , health educators must consider all issues and give priority to those that promote wellness and quality of living through principles of self-determination and freedom of choice for the individual . Article II : Responsibility to the Profession Health Educators are responsible for their professional behavior , for the reputation of their profession , and for promoting ethical conduct among their colleagues . Article III : Responsibility to Employers Health Educators recognize the boundaries of their professional competence and are accountable for their professional activities and actions . Article IV : Responsibility in the Delivery of Health Education Health Educators promote integrity in the delivery of health education . They respect the rights , dignity , confidentiality , and worth of all people by adapting strategies and methods to the needs of diverse populations and communities . Article V : Responsibility in Research and Evaluation Health Educators contribute to the health of the population and to the profession through research and evaluation activities . When planning and conducting research or evaluation , health educators do so in accordance with federal and state laws and regulations , organizational and institutional policies , and professional standards . Article VI : Responsibility in Professional Preparation Those involved in the preparation and training of Health Educators have an obligation to accord learners the same respect and treatment given other groups by providing quality education that benefits the profession and the public . All versions of the document are available on the Coalition of National Health Education 's site : http : //www.cnheo.org/ . The National Health Education Code of Ethics is the property of the Coalition of National Health Education . # National Organizations for Public Health/Health Education # American Public Health Association ( APHA ) APHA is the main voice for public health advocacy that is the oldest organization of public health sine 1872 . The American Public Health Association aims to protect all Americans and their communities from preventable , serious health threats and strives to assure community-based health promotion and disease preventions . Any individual can become a member and benefit in online access and monthly printed issues of The Nations Health and the American Journal of Public Health Society for Public Health Education ( SOPHE ) The mission of SOPHE is to provide global leadership to the profession of health education and health promotion and to promote the health of society through advances in health education theory and research , excellence in professional preparation and practice , and advocacy for public policies conducive to health , and the achievement of health equity for all . Membership is open to all who have an interest in health education and or work in health education in schools , medical care settings , worksites , community based organizations , state/local government , and international agencies . Founded in 1950 , SOPHE publishes 2 indexed , peer-reviewed journals , ' ' Health Education &amp; Behavior ' ' and ' ' Health Promotion Practice ' ' . American School Health Association ( ASHA ) The American School Health Association was founded in 1972 by a group of physicians that already belonged to the American Public Health Association . This group specializes in school-aged health specifically . Over the years it has snowballed and now includes any person that can be a part of a childs life , from dentists , to counselors and school nurses . The American School Health Association mission is to protect and promote the health of children and youth by supporting coordinated school health programs as a foundation for school success . American Association of Health Education/American Alliance for Health , Physical Education , Recreation , and Dance ( AAHE/AAHPERD ) The AAHE/AAHPERD is said to be the largest organization of professionals that supports physical education ; which includes leisure , fitness , dance , and health promotion . That is only a few ; this incorporates all that is physical movement . This organization is an alliance with five national associations and six districts and is there to provide a comprehensive and coordinated array of resources to help support practitioners to improve their skills and always be learning new things . This organization was first stated in November 1885 . William Gilbert Anderson had been out of medical school for two years and was working with many other people that were in the gymnastic field . He wanted them to get together to discuss their field and this organization was created . Today AAHPERD serves 25,000 members and has its headquarters in Reston , Virginia . Eta Sigma Gamma ( ESG ) Eta Sigma Gamma is a national health education organization founded in 1967 by three professor from Ball State University . The mission of ESG is to promote public health education by improving the standards , ideals , capability , and ethics of public health education professionals . The three key points of the organization are to teach , research , and provide service to the members of the public health professionals . Some of the goals that the Eta Stigma Gamma targets are support planning and evaluation of future and existing health education programs , support and promote scientific research , support advocacy of health education issues , and promote professional ethics . American College Health Association ( ACHA ) The American College Health Association originally began as a student health association in 1920 , but then in 1948 the association changed the name to what its known today . The principal interest of the ACHA is to promote advocacy and leadership to colleges and universities around the country . Other part of the mission 's association is to encourage education , communication , and services to students and campus community in general . The association also promotes advocacy and research . The American College Health Association has three types of membership : institutions of higher education , individual members who are interested in the public health profession , and susbtain members which are profitable and non-profitable organization . The ACHA is connected to 11 organizations located in six regions around the country . Currently , the American College Health Association serves 900 educative institutions and about 2400 individual members in the United States . Directors of Health Promotion and Education ( DHPE ) Founded in 1946 as one of the professional groups of the Health Education Profession . The main goal of the HEPE is to improve the health education standards in any public health agency . As well , build networking opportunities among all public health professionals as a media to communicate ideas for implementing health programs , and to keep accurate information about the latest health news . The DHPE also focus to increase public awareness of health education and promotion by creating and expanding methods of existing health programs that will improve the quality of health . The Directors of Health Promotion and Education is linked to the Association of State and Territorial Health Officials ( ASTHO ) to work on health promotion and disease prevention . National Commission for Health Education Credentialing ( NCHEC ) The National Commission for Health Education Credentialing NCHEC is the national accrediting organization for health educators , promoting the certified and master certified health education specialist ( CHES and MCHES , respectively ) credential . Many government and private sector jobs require that the health educator have at least the CHES credential as a prerequisite qualification for work . NCHEC also administers the affirmation of approved continuing education to maintain these credentials . Both CHES and MCHES are required to take at least 75 continuing education contact hours ( CECH ) every five years to be recertified . The provision and administration of the CHES credential represents the major strategy of NCHEC to fulfill its mission to improve the practice of health education and to serve the public and profession of health education by certifying health education specialists , promoting professional development , and strengthening professional preparation and practice . NCHEC 's quarterly newsletter is The CHES Bulletin . # Health Education Career Opportunities # The terms Public Health Educator , Community Health Educator or Health Educator are all used interchangeable to describe an individual who plans implements and evaluates health education and promotion programs . These individuals play a crucial role in many organizations in various settings to improve our nations health . Just as a Community health educator works work toward population health , a school Health educator generally teaches in our Schools . A community health educator is typically focused on their immediate community striving to serve the public . Health Care Settings : these include hospitals ( for-profit and public ) , medical care clinics , home health agencies , HMOs and PPOs . Here , a health educator teaches employees how to be healthy . Patient education positions are far and few between because insurance companies do not cover the costs . 1 Public Health Agencies : are official , tax funded , government agencies . They provide police protection , educational systems , as well as clean air and water . Public health departments provide health services and are organized by a city , county , state , or federal government . 2 School Health Education : involves all strategies , activities , and services offered by , in , or in association with schools that are designed to promote students ' physical , emotional , and social development . School health involves teaching students about health and health related behaviors . Curriculum and programs are based on the school 's expectations and health . 3 Non Profit Voluntary Health Agencies : are created by concerned citizens to deal with health needs not met by governmental agencies . Missions include public education , professional education , patient education , research , direct services and support to or for people directly affected by a specific health or medical problem . Usually funded by such means as private donations , grants , and fund-raisers. 4 Higher Education : typically two types of positions health educators hold including academic , or faculty or health educator in a student health service or wellness center . As a faculty member , the health educator typically has three major responsibilities : teaching , community and professional service , and scholarly research . As a health educator in a university health service or wellness center , the major responsibility is to plan , implement , and evaluate health promotion and education programs for program participants . 5 Work site Health Promotion : is a combination of educational , organizational and environmental activities designed to improve the health and safety of employees and their families . These work site wellness programs offer an additional setting for health educators and allow them to reach segments of the population that are not easily reached through traditional community health programs . Some work site health promotion activities include : smoking cessation , stress management , bulletin boards , newsletters , and much more . 6 Independent Consulting and Government Contracting : international , national , regional , state , and local organizations contract with independent consultants for many reasons . They may be hired to assess individual and community needs for health education ; plan , implement , administer and evaluate health education strategies ; conduct research ; serve as health education resource person ; and or communicate about and advocate for health and health education . Government contractors are often behind national health education programs , government reports , public information web sites and telephone lines , media campaigns , conferences , and health education materials . 7 # Influential Individuals in Health Education : Past and Present # Dorothy Bird Nyswander Dr. Nyswander was born September 29 , 1894 . She earned her Bachelor 's and Master 's degree at the University of Nevada and received her Doctorate in educational psychology at Berkeley . She is a founder of the School of Public Health at the University of California at Berkeley . Dr. Nysawnder pursued her interest in public health at the Works Progress Administration during the depression . She served with the Federal Works Agency contributing to the establishment of nursery schools and child care centers to accommodate young mothers working in defense plants . She set up these centers in 15 northeastern states . This did not happen quickly so she advocated all over the nation to train people to act as foster parents for the children of working women . Dr. Nyswander became the director of the City health Center in Astoria , Queens in 1939 . She spent her time as director promoting the idea of New York City keeping an eye on the health of children . They would do this by keeping records that would follow them to whatever school they might move to . She wrote Solving School Health Problems which is an analysis of the health issues in New York children . This is still used in public health education courses today . Mayhew Derryberry Dr. Derryberry was born December 25 , 1902 and earned his Bachelor 's degree in chemistry and mathematics at the University of Tennessee . He began his career in 1926 with the American Child Health Association as the director of one of the first large-scale studies of the health status of the nations schoolchildren . A year after his work with the American Child Health Association he earned his Master 's degree in education and psychology at Columbia University . He then went on to earn his doctorate and moved to the New York City Health Department as the secretary to the sanitary superintendent . He finally moved to Washington DC and joined the US Public Health Service as a senior public health analyst . He became chief of the Public Health Service and began assembling a team of behavioral scientists . They studied the nexus of behavior , social factors , and disease . Two scientists and Derryberry conducted the study of the role of health beliefs in explaining utilization of public health screening services . This work contributed to the development of the Health Belief Model . This provided an important theoretical foundation for modern health education . His legacy was very important because he engaged behavioral and social scientists in the problems of public health and gave importance to the role of that health education plays on human health . Elena Sliepcevich Elena Sliepcevich was a leading figure in the development of health education both as an academic discipline and a profession . She graduated from the University of Ireland in 1939 and received her Master 's degree from the University of Michigan in 1949 . She received her doctorate in physical education from Springfield College in 1955 . After completing her schooling , Elena Sliepcevich worked at Ohio State University in 1961 as a professor of health education . There she helped direct the School Health Education Study from 1961 to 1969 , and most health education curricula used in schools today are based on the ten conceptual areas identified by the School Health Education Study . These ten areas of focus include community health , consumer health , environmental health , family life , mental and emotional health , injury prevention and safety , nutrition , personal health , prevention and control of disease , and drug use and abuse . Helen Agnes Cleary Helen Cleary was born March 28 , 1914 at Petersburg , South Australia . She trained as a nurse at the Broken Hill and District Hospital in New South Wales . She became a general nurse in 1941 , and an obstetric nurse in 1942 . She joined the Royal Australian Air Force Nursing Service as a sister on November 15 , 1943 . Along with other RAAF nurses , she would partake in evacuations throughout New Guinea and Borneo , which earned the nurses the nickname the flying angels , and were also known as the glamor girls of the air force . In April 1945 , she was ranked No. 2 Medical Air Evacuation Transport Unit , and began bringing thousands of Australian and British servicemen from prisoner-of-war camps after Japan had surrendered . She and other nurses cared for many patients who suffered from malnutrition and dysentery . During the Korean War , Cleary was charge sister on the RAAF , where she organized medical evacuations of Australians from Korea , fought for better treatment and conditions of the critically wounded , and nursed recently exchanged Prisoners of War . On August 18 , 1967 , Ms. Cleary was made honorary nursing sister to Queen Elizabeth II . She had been appointed an associate of the Royal Red Cross in 1960 , and became a leading member in 1968 for her contributions to the training of medical staff , and for maintaining the high ideals of the nursing profession . She retired on March 28 , 1969 , and later died on August 26 , 1987 . Delbert Oberteuffer A long time health educator , Delbert Oberteuffer definitely made his mark on the physical education and health education world . He was born in Portland , Oregon in 1902 where he remained through college , attending the University of Oregon receiving his Bachelors Degree . His next step took him to the prestigious Columbia University where he obtained his Masters of Arts and Doctor of Philosophy Degree . He furthered his education by becoming a professor at Ohio State University where he taught from 1932 until 1966 . During his time there , he was head of the Men 's Physical Education Department for 25 years . After years of hard work , he was rewarded with numerous jobs including the President of the American School Health Association and The College of Physical Education Association . Unfortunately , he passed away in 1981 at the age of 79 . He is Survived by his wife , Katherine , and his son , Theodore K. Oberteuffer . Howard Hoyman Howard Hoyman is mainly recognized for his work in sex education and introductions of ecology concepts . He is credited for developing the original sex education program for students in grades 1 through 12 . The model Hoyman created heavily influenced the thinking of many health educators . Hoyman received his Bachelors Degree from Ohio State University in 1931 . He then went on to earn his Masters degree in 1932 and Doctorate in 1945 from the University of Colombia . Throughout his career he wrote over 200 articles and was honored many times by multiple organizations such as Phi Beta Kappa and the American Public Health Association . Dr. Hoyman retired in 1970 as A Professor Emeritus . Lloyd Kolbe Lloyd Kolbe received his B.S. form Towson University and then received his Ph.D . and M.Ed. from the University of Toledo during the 1970s . Dr. Kolbe played a huge role in the development of many health programs applied to the daily life of different age groups . He received the award for Excellence in Prevention and Control of Chronic Disease , which is the highest recognition in his department of work , for his work forming the Division of Adolescent and School Health . Dr. Kolbe was the Director of this program for 15 years . He has also taken time to write and publish numerous books such as ' ' Food marketing to Children and Youth and School ' ' as well as ' ' Terrorism Related to Advancing and Improving the Nations Health ' ' . Robert Morgan Pigg University of Florida professor , Robert Morgan Pigg , started his health career in 1969 when he received his Bachelors Degree in Health , Physical Education , and Recreation from Middle Tennessee State University . A year later he received his M.Ed ; also from Middle Tennessee University before moving on to Indian University where he obtained his H.S.D. in 1974 and his M.P.H. in 1980 . He held many jobs at numerous Universities including Western Kentucky University , University of Georgia , Indiana University , and the University of Florida where he currently resides today . Pigg 's main focus of interest is the promotion of health towards children and adolescents . After spending 20 years as Editor for the Journal of Health , he was given the job as Department Chair in 2007 for The University of Florida . Linda Rae Murray Linda Rae Murray holds her MD , and MPH . Currently she is the Chief Officer for the Ambulatory &amp; Community Health Network . She was elected president November 2009 . Dr. Murray has served in a number of Medical settings her most recent being Medical Director of the federally funded health center , Winfield Moody , serving the CabriniGreen public housing project in Chicago . She has also been an active member of the board of national organizations . Along with this she served as Chief Medical Officer in primary care for the twenty three primary care and community health centers . Today Murray serves as the Chief Medical Officer for the Cook County Health &amp; Hospital system . Dr. Murray has also been a voice for social justice and health care as a basic human right for over forty years . Mark J. Kittleson Mark J. Kittleson is a professor at New Mexico State University for Public Health Education . His interests include Educational Technology and Behaviorism ; he attended the University of Akron and received his PhD in Health Education . Dr. Kittleson has experience as owner and founder of the HEDIR a place where people can hold discussions related to health and health education . His honors and awards consist of Scholar of the Year , American Association of Health Education 2008 and he is a member of the American Association of Health Education . Elaine Auld Elaine Auld has been a leading figure for over more than 30 years in the health education field . She attended the University of Michigan , MPH , and Health Behavior/Health Education , from 1976 to 1978 Elaine is the chief executive officer for the Society for Public Health Education ( SOPHE ) and has had many contributions in health promotion and health communications . She has been a certified health specialist since 1989 and in 1996 was an adviser to the first Health Education Graduate Standards . Elaine was involved with the Competency Update Project ( CUP ) , which provided standards for the health education profession . Elaines interest and work are related to health education credentialing and standards , workforce development , public policy , and health equity . For the last decade Elaine has been a site visitor for the Council on Education for Public Health , and also strengthened the accreditation and preparation of future health specialists , which is key to an overall healthy well-being . Elaine has received two awards U of MI SPH Alumni of the Year Award in 2010 and SOPHE Distinguished Fellow in 2008 . Susan Wooley Susan Wooley received her bachelors degree from Case Western Reserve University , a masters degree in health education from the University of North Carolina at Greensboro , and a Ph.D . in health education from Temple University . Susan is the executive director of the American School Health Association and has been a member to ASHA for 31 years . She co-edited Health Is Academic : A Guide to Coordinated School Health Programs and co-authored Give It a Shot , a Toolkit for Nurses and Other Immunization Champions Working with Secondary Schools . Susan has had many previous jobs such as CDCs Division of Adolescent and School Health , Delaware State College , American Association for Health Education and Delaware Department of Public Instruction and is also a certified health specialist . Wooley spent four years on a curriculum development project for elementary schools , Science for Life and Living : Integrating Science , Technology and Health . Now Susan oversees the day-to-day operations of a national professional association and provides consultation and technical assistance to others working toward health education . # Health Education Worldwide # There are many countries which developed a Health Education curriculum . For example : Romania Since 2001 , the Ministry of Education , Research , Youth and Sports developed a national curriculum on Health Education . The National Health Education Programme in Romanian Schools was considered as being a priority for the intervention of the GFATM ( Global Fund ) and UN Agencies . 
@@3172179 A specialty ( or speciality ) in medicine is a branch of medical science . After completing medical school , physicians or surgeons usually further their medical education in a specific specialty of medicine by completing a multiple year residency to become a medical specialist . # History of medical specialization # To a certain extent , medical practitioners have always been specialized . According to Galen , specialization was common among Roman physicians . The particular system of modern medical specialities evolved gradually during the 19th century . Informal social recognition of medical specialization evolved before the formal legal system . The particular subdivision of the practice of medicine into various specialities varies from country to country , and is somewhat arbitrary . # Classification of medical specialization # Medical specialties can be classified along several axes . These are :  Surgical or internal medicine  Age range of patients  Diagnostic or therapeutic  Organ-based or technique-based Throughout history , the most important has been the division into surgical and internal medicine specialties . The surgical specialties are the specialties in which an important part of diagnosis and treatment is achieved through major surgical techniques . The internal medicine specialties are the specialties in which the main diagnosis and treatment is never major surgery . In some countries Anesthesiology is classified as a surgical discipline , since it is vital in the surgical process , though anesthesiologists never perform major surgery themselves . Many specialties are organ-based . Many symptoms and diseases come from a particular organ . Others are based mainly around a set of techniques , such as radiology , which was originally based around X-rays . The age range of patients seen by any given specialist can be quite variable . Paediatricians handle most complaints and diseases in children that do not require surgery , and there are several subspecialties ( formally or informally ) in paediatrics that mimic the organ-based specialties in adults . Paediatric surgery may or may not be a separate specialty that handles some kinds of surgical complaints in children . A further subdivision is the diagnostic versus therapeutic specialties . While the diagnostic process is of great importance in all specialties , some specialists perform mainly or only diagnostic examinations , such as pathology , clinical neurophysiology , and radiology . This line is becoming somewhat blurred with interventional radiology , an evolving field that uses image expertise to perform minimally invasive procedures . # Specialties that are common world-wide # # List of specialties recognized in the European Union and European Economic Area # The European Union publishes a list of specialties recognized in the European Union , and by extension , the European Economic Area . Note that there is substantial overlap between some of the specialties and it is likely that for example Clinical radiology and Radiology refer to a large degree to the same pattern of practice across Europe . # List of North American medical specialities and others # In this table , as in many healthcare arenas , medical specialties are organized into the following groups :  Surgical specialties focus on manually operative and instrumental techniques to treat disease .  Medical specialties that focus on the diagnosis and non-surgical treatment of disease .  Diagnostic specialties focus more purely on diagnosis of disorders . # Physician compensation # The mean annual salary of a medical specialist is $175,011 in the US , and $272,000 for surgeons . However , because of commodity inflation , increasing negligent costs , steep price rise of rental , the annual salary range of a medical specialist varies and is not rising as fast as other professional pay . Often , especially in the United States , physicians practice in groups of specialists within a particular medical specialty . These practice groups are often formed to help reach economies of scales in rental , insurance and staff costs as well as other benefits of practicing with other professionals and are typically governed by various legal documents . The table below details the average range of salaries for physicians of selected specialties as of July 2010 . Also given in the average number of hours worked per week for full-time physicians ( numbers are from 2003 ) . According to a 2010 study , physician and surgeon median annual income was $166,400. # Specialties by country # # Australia and New Zealand # Specialty training in Australia and New Zealand is overseen by the specialty colleges :  Australasian College for Emergency Medicine  Australasian College of Dermatologists  Australasian College of Sports Physicians  Australian and New Zealand College of Anaesthetists  Australian College of Rural and Remote Medicine  College of Intensive Care Medicine  Royal Australasian College of Dental Surgeons ( supervises training of medical practitioners specializing in Oral and Maxillofacial Surgery in addition to its role in the training of dentists )  Royal Australasian College of Medical Administrators  Royal Australasian College of Physicians  Royal Australasian College of Surgeons  Royal Australian and New Zealand College of Obstetricians and Gynaecologists  Royal Australian and New Zealand College of Ophthalmologists  Royal Australian and New Zealand College of Psychiatrists  Royal Australian and New Zealand College of Radiologists  Royal Australian College of General Practitioners  Royal New Zealand College of General Practitioners  Royal College of Pathologists of Australasia # Canada # Specialty training in Canada is overseen by the Royal College of Physicians and Surgeons of Canada # India # Specialty training in India is overseen by the Medical Council of India , which is responsible for recognition of post graduate training and by the National Board of Examinations . And education of Ayurveda in overseen by Central Council of Indian Medicine ( CCIM ) , the council conducts u.g and p.g courses all over India , while Central Council of Homoeopathy does the same in the field of Homeopathy . # United States # There are three agencies or organizations in the United States that collectively oversee physician board certification of MD and DO physicians in the United States in the 26 approved medical specialties recognized in the country . These organizations are the American Board of Medical Specialties ( ABMS ) and the American Medical Association ( AMA ) ; the American Osteopathic Association Bureau of Osteopathic Specialists ( AOABOS ) and the American Osteopathic Association ; the American Board of Physician Specialties ( ABPS ) and the American Association of Physician Specialists ( AAPS ) . Each of these agencies and their associated national medical organization functions as its various specialty academies , colleges and societies . All boards of certification now require that medical practitioners demonstrate , by examination , continuing mastery of the core knowledge and skills for a chosen specialty . Recertification varies by particular specialty between every seven and every ten years . # Other uses # In the U.S. Army , the term medical specialist refers to occupational therapists , physical therapists , dietitians and physician assistants , also known as allied health professionals . Also included in the term medical specialist , but not in the term allied health professional are EMT/combat medics. # Satisfaction # A survey of physicians in the United States came to the result that dermatologists are most satisfied with their choice of specialty followed by radiologists , oncologists , plastic surgeons , and gastroenterologists . In contrast , primary care physicians were the least satisfied , followed by nephrologists , *27;276152;TOOLONG , and pulmonologists. class= wikitable sortable ! Specialty ! ! Overall satisfaction ! ! Feeling of enough compensation ! ! Would have chosen same specialty again 
@@3667850 : ' ' Board of health redirects here . This page describes the defunct bodies in England and Wales which used that name , not any modern ones . ' ' Local boards or Local boards of health were local authorities in urban areas of England and Wales from 1848 to 1894 . They were formed in response to cholera epidemics and were given powers to control sewers , clean the streets , regulate environmental health risks including slaughterhouses and ensure the proper supply of water to their districts . Local boards were eventually merged with the corporations of municipal boroughs in 1873 , or became urban districts in 1894. # Public Health Act 1848 # The first local boards were created under the Public Health Act 1848 ( 11 &amp; 12 Vict. c.63 ) . The aim of the act was to improve the sanitary condition of towns and populous places in England and Wales by placing : the supply of water ; sewerage ; drainage ; cleansing ; paving , and environmental health regulation under a single local body . The act could be applied to any place in England and Wales except the City of London and some other areas in the Metropolis already under the control of sewer commissioners . The Act was passed by the Liberal government of Lord John Russell , in response to the urging of Edwin Chadwick . This was supported by reports , from local branches of the Health of Towns Association ( formed in 1844 ) , of poor and insanitary conditions in many UK cities . # General Board of Health # The act created a General Board of Health as a central authority to administer the act . There were three commissioners : - the president of the board being the First Commissioner of Her Majesty 's Woods and Forests , Land Revenues , Works and Buildings , the other two members being appointed by warrant . The board was originally to be dissolved after five years , but acts of parliament were passed annually allowing for its continuation . Chadwick was appointed a Commissioner , and the Board was strongly associated with him . In 1852 , Edward Gotto was employed to carry out the national General Board of Health Survey . The board finally ceased to exist on 1 September 1858. # Forming a local board of health # Local boards could be formed in two ways :  By a petition of one tenth of the inhabitants rated to relief of the poor in any city , town , borough ( municipal or parliamentary ) , parish or place with a defined boundary not having less than 30 such qualified ratepayers .  By the General Board if the death rate exceeded twenty-three in a thousand in any place . In the latter case a superintending inspector appointed by the General Board would hold an inquiry into the sewerage , drainage , supply of water , state of burial grounds and other matters relating to the sanitary condition of the town , and where necessary define boundaries for the district of the local board . Where the boundaries of a proposed local board 's district were the same as an existing local unit , the act was applied by Order in Council . Where a new district was created this was done by provisional order of the General Board , confirmed by parliament . # Membership of a local board # Members of local boards were either :  Selected by the corporations of municipal boroughs  Elected by owners of property and by rate payers Where a local board district coincided with a borough , or was entirely within a borough 's limits , all the members were selected by the corporation . Where a district was entirely outside a municipality , all the members were elected . In districts which were partly in and partly outside a borough the board had a mixture of selected and elected members . Selected members did not have to be members of the corporation . Borough mayors were ' ' ex officio ' ' board members . Those entitled to elect board members could have multiple votes depending on how much property they owned . This ranged from one vote for owners of property worth less than fifty pounds , to six votes for those holding more than 250 pounds of property . It followed that board members were generally wealthy property owners or members of the professions . # Powers of a local board # The powers and duties of a local board of health were enumerated in the act :  Employees : A local board of health was allowed to appoint a number of employees including a surveyor , a clerk , a treasurer and an officer of health ( who had to be a qualified doctor ) . It was compulsory for the Board to appoint an inspector of nuisances ( sanitary inspector ) to investigate complaints and take action against ' nuisances ' ( nuisances was a very broad concept encompassing a wide range of environmental public health problems : such as insanitary dwellings , accumulations of refuse and sewage , smoke dust and smells and industrial emissions , polluted water , noise , adulterated food , slaughterhouse issues etc )  Sewers : The local board took over ownership of all public sewers in its district . Where private sewers operated for profit , the local board could purchase them .  Street Cleansing : The local board was required to clean the streets in its district , removing dust , ashes , rubbish , filth , dung and soil .  Public Lavatories : The local board could provide public necessities ( as the act called them ) .  Slaughterhouses : The local board was to regulate slaughterhouses , and was allowed to provide such facilities itself .  Street Paving : The local board took over the public streets in the district , and could also require that private streets be paved .  Pleasure Grounds : The local boards were allowed to provide and lay out pleasure grounds .  Water Supply : The local board was allowed to supply water , but only if a private company could not provide the service .  Burials : The local board was allowed to provide houses for the reception of the dead prior to burial . They could also apply to the General Board to have an existing graveyard closed .  Land : The local board could purchase land . # Local Government Act 1858 # The 1848 Act was replaced by the Local Government Act 1858 ( 21 &amp; 22 Vict. c. 98 ) . The act came into force in all existing local board of health districts on 1 September 1858 . The act made some changes to the procedure for constituting a local board and gave them some additional powers . There was also a change in nomenclature : the authorities created by the 1858 act were simply entitled Local Boards and their areas as Local Government Districts . # The Local Government Act Office and the Local Government Board # When the General Board of Health was abolished in 1858 its responsibilities in respect of local government passed to the Secretary of State of the Home Department , in whose department a Local Government Act Office was formed to administer the local boards . In 1871 a separate agency was again formed entitled the Local Government Board , with a President who was frequently a Cabinet member . The Local Government Board also took over the duties of the Poor Law Board . # Constituting local boards # The procedure for adopting the act and constituting a local board was laid out in sections 12 17 of the act , and was similar to that in the 1848 act . Changes made included :  Improvement commissioners could adopt the act for their district , the board of commissioners becoming in addition the local board .  Petitions from ten per cent of the ratepayers of places other than those with a known or defined boundary to adopt the act were now made to the Secretary of State . If one in twenty ratepayers objected to the formation of a local board they now had the right to petition against it .  The power to create a local board where there was excess mortality was abolished . The method of electing members of the board remained the same , although existing or new boards could now be divided into wards . # Additional powers # The Town Police Clauses Act of 1847 had included model clauses for the government of towns which could be adopted in all or in part by existing borough corporations , local boards of health or improvement commissioners . The application of these was very uneven , so they were incorporated into the 1858 act , all local boards gaining these powers . Areas covered by the clauses were :  Removal of obstructions and nuisances in the street  Fires and fire prevention  Provision and control of places of public resort  Regulation of hackney carriages  Provision of public bathing houses  Naming streets and numbering houses  Improving the line of streets  Removal of ruinous or dangerous buildings  Provision of public clocks The local board also took over any lamps , lamp posts and gas posts provided by the Lighting and Watching Act , and was given a new power to provide a market place where one was required or inadequate . # Number of local boards # The number of local boards peaked at 721 in 1873 . In that year the Public Health Act 1872 merged local boards into municipal boroughs and improvement commissioners where they shared the same district . 419 of the local boards had been formed under the Public Health Act 1848 , the remaining 302 under the Local Government Act 1858 . The number of local boards was inflated in 186263 , as communities adopted the act in order to avoid being grouped into highway districts under the Highways Act 1862 . Many of these local government districts had a population of fewer than 500 , and several fewer than 100 . Further legislation was passed in 1863 to limit the population of a new local government district to 3,000 or more . Some of these small authorities survived as urban districts until the County Review Orders of the 1930s. # Sanitary districts and urban districts # The Public Health Act 1875 designated local government districts as urban sanitary districts , with the local board becoming the urban sanitary authority . The titles of the district and board did not change however , the local board assuming extra duties as a sanitary authority . Local boards and local government districts were finally abolished by the Local Government Act 1894 , when all urban sanitary districts became urban districts . A new urban district council was to govern the district . The new council was to be directly elected by all those entitled to voted in parliamentary elections , replacing the weighted property voting system used for local boards . 
@@4421272 A chronic condition is a human health condition or disease that is persistent or otherwise long-lasting in its effects or a disease that comes with time . The term ' ' chronic ' ' is usually applied when the course of the disease lasts for more than three months . Common chronic diseases include arthritis , asthma , cancer , COPD , diabetes and HIV/AIDS . In medicine , the opposite of chronic is acute . A chronic course is further distinguished from a recurrent course ; recurrent diseases relapse repeatedly , with periods of remission in between . The non-communicable diseases are also usually lasting medical conditions but are separated by their non-infectious causes . In contrast , some chronic diseases , such as HIV/AIDS , are caused by transmissible infections . Chronic diseases constitute a major cause of mortality and the World Health Organization ( WHO ) reports chronic non-communicable conditions to be by far the leading cause of mortality in the world , representing 35 million deaths in 2005 and over 60% of all deaths . Chronic illnesses cause about 70% of deaths in the US and in 2002 chronic conditions ( heart disease , cancers , stroke , chronic respiratory diseases , diabetes , Alzheimers disease , mental illness and kidney diseases ) were 6 of the top ten causes of mortality in the general US population . 90% of seniors have at least one chronic disease , and 77% have two or more chronic conditions . # Types # Examples of chronic diseases and health conditions include :  Alzheimer 's disease , Parkinson 's disease and other neurodegenerative diseases  Autoimmune diseases , such as ulcerative colitis , lupus erythematosus , Crohn 's Disease and Coeliac Disease  Blindness  Cancer / neoplastic diseases not amenable to be cured  Cardiovascular diseases : cerebrovascular disease , heart failure , ischemic cardiopathy  Myalgic encephalomyelitis  Chronic graft-versus-host disease ( GVHD )  Chronic hepatitis  Cerebral palsy ( all types )  Chronic pain syndromes , such as post-vasectomy pain syndrome  Chronic osteoarticular diseases : osteoarthritis , rheumatoid arthritis  Chronic renal failure , Chronic Kidney Disease  Chronic respiratory diseases : asthma , chronic obstructive pulmonary disease ( COPD ) , pulmonary hypertension  Deafness and hearing impairment  Hypertension  Diabetes mellitus  Endometriosis  Fibromyalgia  Epilepsy  Mental illness  Osteoporosis  Periodontal disease  Sickle Cell Anemia and other hemoglobin disorders  Lyme Disease  Blood Pressure # Risk factors # While risk vary with age and gender , most of the common chronic diseases are caused by dietary , lifestyle and metabolic risk factors , that are also responsible for the resulting mortality . Therefore these conditions might be prevented by behavioral changes , such as quitting smoking , adopting a healthy diet , and increasing physical activity . Social determinants of health # Prevention # A growing body of evidence supports that prevention is effective in reducing the effect of chronic conditions ; in particular , early detection results in less severe outcomes . Clinical preventive services include screening for the existence of the disease or predisposition to its development , counseling and immunizations against infectious agents . Despite their effectiveness , the utilization of preventive services is typically lower than for regular medical services . In contrast to their apparent cost in time and money , the benefits of preventive services are not directly perceived by patient because their effects are on the long term or might be greater for society as a whole than at the individual level . Therefore public health programs are important in educating the public , and promoting healthy lifestyles and awareness about chronic diseases . While those programs can benefit from funding at different levels ( state , federal , private ) their implementation is mostly in charge of local agencies and community-based organizations Studies have shown that public health programs are effective in reducing mortality rates associated to cardiovascular disease , diabetes and cancer , but the results are somewhat heterogeneous depending on the type of condition and the type of programs involved . For example , results from different approaches in cancer prevention and screening depended highly on the type of cancer . The rising number of patient with chronic diseases has renewed the interest in prevention and its potential role in helping control costs . A report from the Trust for Americas Health suggests that investing $10 per person annually in community-based programs of proven effectiveness and promoting healthy lifestyle ( increase in physical activity , healthier diet and preventing tobacco use ) could save more than $16 billion annually within 5 years . # Epidemiology # In the United States , nearly one in two Americans ( 133 million ) has at least one chronic medical condition , with most subjects ( 58% ) between the ages of 18 and 64 . The number is projected to increase by more than one percent per year by 2030 , resulting in an estimated chronically ill population of 171 million . The most common chronic conditions are high blood pressure , arthritis , respiratory diseases like emphysema , and high cholesterol . According to research by the Centers for Disease Control and Prevention , chronic disease is also especially a concern in the elderly population in America . Chronic diseases like stroke , heart disease , and cancer were among the leading causes of death among Americans aged 65 or older in 2002 , accounting for 61% of all deaths among this subset of the population . While the majority of chronic conditions are found in individuals between the ages of 18 and 64 , it is estimated that at least 80% of older Americans are currently living with some form of a chronic condition , with 50% of this population having two or more chronic conditions . The two most common chronic conditions in the elderly are high blood pressure and arthritis , with diabetes , coronary heart disease , and cancer also being reported among the elder population . In examining the statistics of chronic disease among the living elderly , it is also important to make note of the statistics pertaining to fatalities as a result of chronic disease . Heart disease is the leading cause of death from chronic disease for adults older than 65 , followed by cancer , stroke , diabetes , chronic lower respiratory diseases , influenza and pneumonia , and , finally , Alzheimers disease . Though the rates of chronic disease differ by race for those living with chronic illness , it is interesting to note that the statistics for leading causes of death among elderly are nearly identical across racial/ethnic groups . # Economic impact # Chronic diseases are a major factor in the continuous growth of medical care spending . Healthy People 2010 reported that more than 75% of the $2 trillion spent annually in US medical care are due to chronic conditions ; spending are even higher in proportion for Medicare beneficiaries ( aged 65 years and older ) . Spending growth is driven in part by the greater prevalence of chronic illnesses , and the longer life expectancy of the population . Also improvement in treatments has significantly extended the life spans of patients with chronic diseases but results in additional costs over long period of time . A striking success is the development of combined antiviral therapies that led to remarkable improvement in survival rates and quality of life of HIV-infected patients . In addition to direct costs in health care , chronic diseases are a significant burden to the economy , through limitations in daily activities , loss in productivity and loss of days of work . A particular concern is the rising rates of overweight and obesity in all segments of the US population . Obesity itself is a medical condition and not a disease , but it constitutes a major risk factor for developing chronic illnesses , such as diabetes , stroke , cardiovascular disease and cancers . Obesity results in significant health care spending and indirect costs , as illustrated by a recent study from the Texas comptroller reporting that obesity alone cost Texas businesses an extra $9.5 billion in 2009 , including more than $4 billion for health care , $5 billion for lost productivity and absenteeism , and $321 million for disability . # Chronic diseases and US Health Care Reform # The Patient Protection and Affordable Care Act includes a comprehensive plan aiming to reduce the burden of chronic diseases by investing in prevention and promotion of healthy living in communities http : *49;61700;TOOLONG . Four broad directions are defined in the National Prevention Strategy calling for initiatives at the community level :  building healthier and safer environments in the communities ,  expanding preventive services of proven effectiveness and benefits ,  eliminating health disparities ,  helping individuals in making healthy choices . While public awareness and education are essential , another important part of this process is to facilitate healthy choices by making them both accessible and affordable for all . Other aspects of the Health Care Reform that should help patients with chronic diseases include :  increasing coverage and access to medical services ,  expanding coverage for clinical preventive services recommended on the base of their proven health benefits ,  reducing health disparities ,  funding programs in research and data collection to document outcomes of treatment ,  encouraging the coordination of medical care with the development of patient-centered medical homes and accountable care organizations . 
@@4686701 In the United Kingdom , Republic of Ireland , and parts of the Commonwealth , consultant is the title of a senior hospital-based physician or surgeon who has completed all of his or her specialist training and been placed on the specialist register in their chosen speciality . Their role is entirely distinct to that of general practitioners , or GPs . Consultants accept ultimate responsibility for the care of all the patients referred to them , <ref> cite webtitle=The role of the consultant A physician must be on the Specialist Register before he or she may be employed as a substantive consultant in the National Health Service ( NHS ) . This usually entails holding a Certificate of Completion of Training ( CCT ) in any of the recognised specialities , but academics with substantial publications and international reputation may be exempted from this requirement , in the expectation that they will practice at a tertiary level . Locum consultant appointments of limited duration may be given to those with clinical experience , with or without higher qualifications . Virtually all consultants in the UK are employed by the NHS , rendering the NHS a virtual monopoly of career opportunities for the senior hospital physician community in the UK , and apart from one or two specialities there are virtually no opportunities for consultants to earn a living completely outside of the NHS . Their salaries are dictated by the UK Government , who are the ultimate employer of UK Consultants , and who wield considerable power over the pay and conditions of hospital doctors . A consultant typically leads a firm ( team of doctors ) which comprises Specialty Registrars , and Foundation Doctors , all training to work in the consultant 's speciality , as well as other career grade doctors such as clinical assistants , clinical fellows , Speciality Doctors , Associate Specialists and staff grade doctors . They also have numerous other key roles in the functioning of hospitals and the wider health service . <ref> cite webtitle=Role of the doctor : Role of the consultant The time required to become a consultant depends upon a number of factors , but principally the speciality chosen . Certain specialities require longer training , or are more competitive , and therefore becoming a consultant can take longer . Other specialities are relatively easy to progress through , and it is possible for a doctor to become a consultant much earlier in his or her career . After Modernising Medical Careers came into operation ( in early 2007 ) , the length of training was fixed for the majority of doctors , at about nine years . Most consultants work on a long-term contract with one or more hospital trusts , and these posts are known as ' ' substantive consultant ' ' positions . Various titles ( such as senior consultant , clinical director , medical director , lead thereof . UK Consultants have the right to undertake private medical work outside of their contracted hours of work for the NHS . Other doctors - some without a CCT , a few who have only just obtained that qualification , others who have retired from substantive appointments , and others who wish to use some of their annual leave to generate additional earnings - may be employed as ' ' locum consultants ' ' , who have the same clinical responsibility , but are typically on fixed , short-term contracts . 
@@6131155 The American Public Health Association ( APHA ) is Washington , D.C.-based professional organization for public health professionals in the United States . Founded in 1872 by Dr. Stephen Smith , APHA has more than 30,000 members worldwide . The Association defines itself as being the oldest and most diverse organization of public health professionals in the world . It defines its mission as : The Association aims to protect all Americans and their communities from preventable , serious health threats and strives to assure that community-based health promotion and disease prevention activities and preventative health services are universally accessible in the United States . # Member Groups and State Affiliates # APHAs 30,000 members represent a broad array of health officials , educators , students , environmentalists , policy-makers and other health providers at all levels , working both within and outside governmental organizations and educational institutions . # Organizational Components : Sections and SPIGs # Sections serve as the primary professional units of the Association and conduct activities that promote the mission and fulfill the goals of APHA . There are 27 Sections that represent major public health disciplines or public health programs . These sections are designed to allow members with shared interests to come together to develop scientific program content , policy papers in their areas of interest or fields of practice , provide for professional and social networking , career development and mentoring . Sections include : Maternal and Child Health , HIV/AIDS , Community Planning and Policy Development , Occupational Health and Safety , International Health and School Health Education and Services . Special Primary Interest Groups ( SPIGs ) are an open group of self-selected APHA members who share a common occupational discipline or program area interest and elect no primary Section affiliation . SPIGs include : Alternative and Complementary Health Practices , Ethics , Health Law , Laboratory , Physical Activity and Veterinary Public Health . # Public Health Education and Health Promotion Section # The Public Health Education and Health Promotion Section is one of 27 primary sections and special interest groups within APHA . In fact , PHEHP is the largest section , with around 3,000 members . Like all sections within APHA , PHEHP is governed by a group of elected volunteers who hold offices for terms of varying length . Section officers include a chair , chair-elect , secretary , secretary-elect and immediate past chair . Section councilors and governing councilors represent the members and concerns of the section within the larger organization . Section committees , led by volunteers from the Section , are where the work of the Section is accomplished . Explore this website to learn about these and other opportunities to get involved in PHEHP. # Awards # National APHA Awards The accomplishments of public health leaders are recognized through an awards program . APHA presents its national awards during its annual meeting . Section Awards Being honored by your professional peers has very special meaning to people . Acknowledge some of the professionals who have been important to your career or who , in your mind , have made important contributions to the field by nominating them for one of these prestigious awards . The Public Health Education and Health Promotion section recognizes individuals in six award categories . The awards include : Current Section Members Eligible 1 . Distinguished Career Award for outstanding contribution to the practice and profession of health education , health promotion and/or health communications . The awardee must have earned a terminal degree 10 years or more prior to receiving the award . 2 . Early Career Award for outstanding contribution to the practice and profession of health education , health promotion and/or health communications . The awardee must have earned a terminal degree less than 10 years prior to receiving the award . Current Section and/or APHA member eligible 1 . Mayhew Derryberry Award for outstanding contribution of behavioral scientists to the field of health education , health promotion and/or health communications research or theory . 2 . Mohan Sing Award for the use of humor to promote better health education , health promotion and/or health communications practice . 3 . Sarah Mazelis Award for an outstanding practitioner in health education . The awardee will have spent at least five years as a health education , health promotion and/or health communications practitioner . 4 . Rogers Award for outstanding contribution to advancing the study and/or practice of public health communication . Sponsored Awards Rema Lapouse Award sponsored by the Mental Health , Epidemiology , and Statistics Sections , this award is granted to an outstanding scientist in the area of psychiatric epidemiology. # Publications # The American Public Health Association publishes periodicals and more than 70 public health books . Several of these are the reference source for their specialty within public health practice . Some publication titles include :  Control of Communicable Diseases Manual  Standard Methods for the Examination of Water and Wastewater  American Journal of Public Health  The Nation 's Health Additionally , they are an active partner in the release of America 's Health Rankings ; working with United Health Foundation and Partnership for Prevention . # Annual Meeting # The APHA Annual Meeting and Exposition is the largest meeting of public health professionals in the world . The meeting draws more than 13,000 attendees , offers 700 booths of exhibits and features more than 1,000 scientific sessions . Presentations cover new research and trends in public health science and practice . # National Public Health Week # National Public Health Week is an observance organized annually by APHA during the first full week of April . The weeks activities are designed to highlight issues that are important to improving the publics health . # Leadership #  Georges C. Benjamin , MD , FACP , FACEP ( E ) , Executive Director  Carmen Rita Nevarez , MD , MPH , President # Campaign for Children 's Health Care # The APHA is a partner in the Campaign for Children 's Health Care , a multi-year campaign to raise awareness about the problem of uninsured children in America a growing social concern . # Climate Change and Public Health # In 2007 , the APHA issued a policy statement entitled ' ' Addressing the Urgent Threat of Global Climate Change to Public Health and the Environment ' ' : : The long-term threat of global climate change to global health is extremely serious and the fourth IPCC ( Intergovernmental Panel on Climate Change ) report and other scientific literature demonstrate convincingly that anthropogenic GHG emissions are primarily responsible for this threat .... US policy makers should immediately take necessary steps to reduce US emissions of GHGs , including carbon dioxide , to avert dangerous climate change . # Color Standards # There a color standard , made from dilutions of a Pt -Co solution , described by Dr. A. Hazen in American Chemical Journal , in 1892 , adopted in Standard Methods for the Examination of Water and Waste Water , made by APHA , sometimes referred as Pt-Co/Hazen/APHA Colour . # See also # Dr . Helen Rodriguez-Trias - First Hispanic president of the American Public Health Association and recipient of the Presidential Citizens Medal . # References # 
@@6142110 A health care provider is an individual or an institution that provides preventive , curative , promotional or rehabilitative health care services in a systematic way to individuals , families or communities . An individual health care provider ( also known as a health worker ) may be a health care professional within medicine , medical assistant or Assistant Medical Officer , midwifery-obstetrics , nursing , pharmacy , or allied health professions . Health care providers may also be a public/community health professional . Institutions ( also known as health facilities ) include hospitals , clinics , primary care centres , and other service delivery points . The practice of health professionals and operation of health care institutions is typically regulated by national or state/provincial authorities through appropriate regulatory bodies for purposes of quality assurance . Together , they form part of an overall health care system . # Medical facility # A medical facility is , in general , any location at which medicine is practiced regularly . Medical facilities range from small clinics and doctor 's offices to urgent care centers and large hospitals with elaborate emergency rooms and trauma centers . The number and quality of medical facilities in a country or region is one common measure of that area 's prosperity and quality of life . In many countries , medical facilities are regulated to some extent by law ; licensing by a regulatory agency is often required before a facility may open for business . Medical facilities may be owned and operated by for-profit businesses , non-profit organizations , governments , and in some cases by individuals , with proportions varying by country . # Practitioners and professionals # Health care practitioners include physicians , dentists , pharmacists ( including clinical pharmacists ) , physician assistants , nurses ( including advanced practice registered nurses ) , midwives ( obstetrics ) , dietitians , therapists , psychologists , chiropractors , clinical officers , social workers , phlebotomists , physical therapists , respiratory therapists , occupational therapists , audiologists , speech pathologists , optometrists , emergency medical technicians , paramedics , medical laboratory scientists , medical prosthetic technicians , radiographers and a wide variety of other human resources trained to provide some type of health care service . They often work in hospitals , health care centres , and other service delivery points , but also in academic training , research , and administration . Some provide care and treatment services for patients in private homes . Many countries have a large number of community health workers who work outside of formal health care institutions . Managers of health care services , health information technicians , and other assistive personnel and support workers are also considered a vital part of health care teams . Health care practitioners are commonly grouped into five key fields : #Medical ( including generalist practitioners and specialists ) ; #Nursing ( including various professional titles ) ; #Dentistry ; #Medical Assistant or Assistant Medical Officer #Health Professions , including occupational therapy , pharmacy , physical therapy , paramedicine , respiratory therapy , radiographer and many others health specialists . Within each field , practitioners are often classified according to skill level and skill specialization . Health professionals are highly skilled workers , in professions that usually require extensive knowledge including university-level study leading to the award of a first degree or higher qualification . This category includes physicians , physician assistants , dentists , registered medical assistants or registered assistant medical officer , registered nurses , pharmacists , physiotherapists , optometrists , and others . Allied health professionals , also referred to as health associate professionals in the International Standard Classification of Occupations , support implementation of health care , treatment and referral plans usually established by medical , nursing , and other health professionals , and usually require formal qualifications to practice their profession . In addition , unlicensed assistive personnel assist with providing health care services as permitted . Another way to categorize health care practitioners is according to the sub-field in which they practice , such as mental health care , pregnancy and childbirth care , surgical care , rehabilitation care , or public health . # Mental health practitioners # A mental health practitioner is a health worker who offers services for the purpose of improving an individual 's mental health or treating mental illness . These include psychiatrists , clinical psychologists , clinical social workers , psychiatric-mental health nurse practitioners , marriage and family therapists , as well as other health professionals and allied health professions . These health care providers often deal with the same illnesses , disorders , conditions , and issues ; however their scope of practice often differs . The most significant difference across categories of mental health practitioners is education and training . # Maternal and newborn health practitioners # A maternal and newborn health practitioner is a health worker who deals with the care of women and their children before , during and after pregnancy and childbirth . These include medical assistant or Assistant Medical Officer , obstetricians , midwives ( obstetrics ) , obstetrical nurses , nurse practitioners , clinical nurse specialists , and others . One of the main differences across these professions is the training and authority to provide surgical services and other life-saving interventions . In some developing countries , traditional birth attendants , or traditional midwives , are the primary source of pregnancy and childbirth care for many women and families , although they are not certified or licensed . # Geriatric care practitioners # A geriatric care practitioner plans and coordinates the care of the elderly and/or disabled to promote their health , improve their quality of life , and maintain their independence for as long as possible . They include geriatricians , adult-gerontology nurse practitioners , clinical nurse specialists , geriatric clinical pharmacists , geriatric nurses , geriatric care managers , geriatric aides , and others who focus on the health and psychological care needs of older adults . # Surgical practitioners # A surgical practitioner is a health worker who specializes in the planning and delivery of a patient 's perioperative care , including during the anaesthetic , surgical and recovery stages . They may include general and specialist surgeons , anesthesiologists , medical assistant or Assistant Medical Officer , nurse anesthetists , surgical nurses , clinical officers , operating department practitioners , anaesthetic technicians , surgical technologists , and others . # Rehabilitation care practitioners # A rehabilitation care practitioner is a health worker who provides care and treatment which aims to enhance and restore functional ability and quality of life to those with physical impairments or disabilities . These include physiatrists , rehabilitation nurses , clinical nurse specialists , nurse practitioners , physiotherapists , orthotists , prosthetists , occupational therapists , recreational therapists , audiologists , speech and language pathologists , respiratory therapists , rehabilitation counsellors , physiotherapy technicians , orthotic technicians , prosthetic technicians , personal care assistants , and others . # Eye care practitioners # Care and treatment for the eye and the adnexa may be delivered by ophthalmologists specializing in surgical/medical care , medical assistant or Assistant Medical Officer , or optometrists specializing in refractive management and medical/therapeutic care . # Oral health practitioners # A dental care practitioner is a health worker who provides care and treatment to promote and restore oral health . These include dentists and dental surgeons , dental assistants , dental auxiliaries , dental hygienists , dental nurses , dental technicians , dental therapists , and related professional titles . # Foot care practitioners # Care and treatment for the foot , ankle , and lower leg may be delivered by podiatrists , pedorthists , foot health practitioners , podiatric medical assistants , podiatric nurse and others . # Public health practitioners # A public health practitioner focuses on improving health among individuals , families and communities through the prevention and treatment of diseases and injuries , surveillance of cases , and promotion of healthy behaviors . This category includes community and preventive medicine specialists , medical assistants or Assistant Medical Officers , public health nurses , clinical nurse specialists , dietitians , environmental health officers , paramedics , epidemiologists , health inspectors , and others . # Traditional and complementary medicine practitioners # In many societies , practitioners of traditional medicine or alternative medicine are an important primary health care provider , either as integrated within or remaining outside of the formal health care system . These include practitioners in acupuncture , Ayurveda , herbalism , homeopathy , naturopathy , Siddha medicine , traditional Chinese medicine , traditional Korean medicine , and Unani. # Practice conditions and regulations # # Shortages of health professionals # Many jurisdictions report shortfalls in the number of trained health human resources to meet population health needs and/or service delivery targets , especially in medically underserved areas . For example , in the United States , the 2010 federal budget invested $330 million to increase the number of doctors , nurses , and dentists practicing in areas of the country experiencing shortages of health professionals . The Budget expands loan repayment programs for physicians , nurses , and dentists who agree to practice in medically underserved areas . This funding will enhance the capacity of nursing schools to increase the number of nurses . It will also allow states to increase access to oral health care through dental workforce development grants . The Budgets new resources will sustain the expansion of the health care workforce funded in the Recovery Act . In Canada , the 2011 federal budget announced a Canada Student Loan forgiveness programme to encourage and support new family physicians , nurse practitioners and nurses to practise in underserved rural or remote communities of the country , including communities that provide health services to First Nations and Inuit populations . In Uganda , the Ministry of Health reports that as many as 50% of staffing positions for health workers in rural and underserved areas remain vacant . As of early 2011 , the Ministry was conducting research and costing analyses to determine the most appropriate attraction and retention packages for medical officers , nursing officers , pharmacists , and laboratory technicians in the countrys rural areas . At the international level , the World Health Organization estimates a shortage of almost 4.3 million doctors , midwives , nurses , medical assistant or assistant medical officer and support workers worldwide to meet target coverage levels of essential primary health care interventions . The shortage is reported most severe in 57 of the poorest countries , especially in sub-Saharan Africa . # Health and stress among health care practitioners # Some studies suggest that workplace stress is pervasive in the health care industry because of inadequate staffing levels , long work hours , exposure to infectious diseases and hazardous substances leading to illness or death , and in some countries threat of malpractice litigation . According to a report from the United States ' National Institute for Occupational Safety and Health , health care workers have higher rates of substance abuse and suicide than other professions and elevated rates of depression and anxiety linked to job stress . Elevated levels of stress were also linked to high rates of burnout , absenteeism and diagnostic errors , and to reduced rates of patient satisfaction . In Canada , a national report ' ' Canada 's Health Care Providers ' ' also indicated higher rates of absenteeism due to illness or disability among health care workers compared to the rest of the working population , although those working in health care reported similar levels of good health and fewer reports of being injured at work . Female health care workers may face specific types of workplace-related health conditions and stress . According to the World Health Organization , women predominate in the formal health workforce in many countries , and are prone to musculoskeletal injury ( caused by physically demanding job tasks such as lifting and moving patients ) and burnout . Female health workers are exposed to hazardous drugs and chemicals in the workplace which may cause adverse reproductive outcomes such as spontaneous abortion and congenital malformations . In some contexts , female health workers are also subject to gender-based violence including from coworkers and patients . Violence in the workplace subjects almost every healthcare worker to higher risk of on-the-job injury . Drunk , confused , and hostile patients and visitors are a continual threat to providers attempting to treat patients . Frequently , assault and violence in a healthcare setting goes unreported and is wrongly assumed to be part of the job . In an ever changing work environment , health care providers face serious hazards on the job , including needlestick injuries , back injuries , violence , slips and falls , and stress . It is important for occupational health professionals within healthcare facilities to monitor occupational injuries and illnesses so that they can keep the workforce healthy . The is a secure electronic surveillance system developed by the National Institute for Occupational Safety and Health ( NIOSH ) to address health and safety risks among health care providers . Hospitals and other healthcare facilities can upload the occupational injury data they already collect to the secure database for analysis and benchmarking with other de-identified facilities from throughout the U.S. NIOSH works with OHSN participants in identifying and implementing timely and targeted interventions . OHSN modules currently focus on three high risk and preventable events that can lead to injuries or musculoskeletal disorders among healthcare providers : musculoskeletal injuries from patient handling activities ; slips , trips , and falls ; and workplace violence . OHSN enrollment is open to all healthcare facilities . # Regulation and registration of providers # Practicing without a license that is valid and current is typically illegal . In most jurisdictions , the provision of health care services is regulated by government , and individuals found to be providing medical , nursing or other professional services without the appropriate certification or licence may face sanctions including even criminal charges leading to prison . The number of professions subject to regulation , requisites for individuals to receive professional licensure , and nature of sanctions that can be imposed for failure to comply vary across jurisdictions . For instance , in the United States , under Michigan state laws , an individual is guilty of a felony if found to be practicing a health profession subject to regulation without a valid license or registration of their own , or exceeding what a limited license or registration allows . The state laws define the scope of practice for medicine , nursing , and a number of allied health professions . In Florida , practicing medicine without the appropriate license is a crime classified as a third degree felony , which may give imprisonment up to five years . Practicing a health care profession without a license which results in serious bodily injury classifies as a second degree felony , providing up to 15 years ' imprisonment . In the United Kingdom , healthcare professionals are regulated by the state ; the UK Health and Care Professions Council ( HCPC ) protects the ' title ' of each profession it regulates . For example , it is illegal for someone to call himself an Occupational Therapist or Radiographer if they are not on the register held by the HCPC. # Ratings # Health care provider ratings are ratings or evaluations of health care providers used to evaluate process of care , healthcare structures and/or outcomes of a healthcare services . This information is translated into report cards that are generated by quality organizations , nonprofit , consumer groups and media . This evaluation of quality can be based on : Measures of Hospital quality Measures of Health Plan Quality Measures of Physician Quality Measures of Quality for Other Health Care Providers Measures of Patient Experience # See also # Chronic care management Electronic superbill Geriatric care management Health care Health human resources Health insurance Health insurance cooperative Health policy Health system United States Department of Health and Human Services Catholic Church and health care # References # 
@@7367299 A health club ( also known as a fitness club , fitness center , and commonly referred to as a gym ) is a place which houses exercise equipment for the purpose of physical exercise . # Facilities and services # # Main workout area # Most health clubs have a main workout area , which primarily consists of free weights including dumbbells , barbells and exercise machines . This area often includes mirrors so that exercisers can monitor and maintain correct posture during their workout . A gym that predominantly or exclusively consists of free weights ( dumbbells and barbells ) , as opposed to exercise machines , is sometimes referred to as a , after the traditional color of weight plates . # Cardio area/Theatre # A cardio theater or cardio area includes many types of cardiovascular training-related equipment such as rowing machines , stationary exercise bikes , elliptical trainers and treadmills . These areas often include a number of audio-visual displays ( either integrated into the equipment , or placed on walls around the area itself ) in order to keep exercisers entertained during long cardio workout sessions. # Group exercise classes # Most newer health clubs offer group exercise classes that are conducted by certified fitness instructors . Many types of group exercise classes exist , but generally these include classes based on aerobics , cycling ( spin cycle ) , boxing or martial arts , high intensity training , step , regular and hot ( Bikram ) yoga , pilates , muscle training , and self-defense classes such as Krav Maga and Brazilian jiu-jitsu . Health clubs with swimming pools often offer aqua aerobics classes . The instructors often must gain certification in order to teach these classes and ensure participant safety . # Sports facilities # Some health clubs offer sports facilities such as a swimming pools , squash courts or boxing areas . In some cases , additional fees are charged for the use of these facilities . # Personal training # Most health clubs employ personal trainers who are accessible to members for *33;23;TOOLONG advice and consultation . Personal trainers can devise a customized fitness routine , sometimes including a nutrition plan , to help clients achieve their goals . They can also monitor and train with members . More often than not , access to personal trainers involves an additional hourly fee . # Other services # Newer health clubs generally include health-shops , snack bars , restaurants , child-care facilities , member lounges and cafes . It is not unusual for a sauna , steam shower , or wellness areas to be present . Health clubs generally charge a fee to allow visitors to use the equipment , courses , and other provided services . A fairly new trend is the advent of eco friendly health clubs which incorporate principles of green living in its fitness regimen . # Levels of services and offerings # Health clubs offer many services , and as a result the monthly membership prices can vary greatly . A recent study of American clubs found that the monthly cost of membership ranged from US$15 per month at basic chain clubs that offer limited amenities to over US$200 per month at spa-oriented clubs that cater to families and to those seeking social activities in addition to a workout . In addition , some clubs - such as many local YMCAs - offer per-use punchcards or one-time fees for those seeking to use the club on an as-needed basis . Costs can vary through the purchase of a higher-level membership , such as a Founders or a Life membership . Such memberships often have a high up-front cost but a lower monthly rate , making them potentially beneficial to those who use the club frequently and hold their memberships for years . # History # An early public gymnasium started in Paris ( France ) in 1847 . But Scott Roberts traces the history of health clubs for the general public to 1947 in Santa Monica , California . 
@@8587640 Health is a game mechanic used in tabletop role-playing games and video games to give value to characters , enemies , NPCs , and related objects . This value can be displayed as either Graphical ( a circle , ring , or rectangular bar ) and/or in numerical ( such as in numbers out of max health separated by the symbol / ) . # Hit points # Hit points , also known as health points ( or HP ) , damage points , heart points , life points , or just health ( among other synonyms ) , is a finite value used to determine how much damage ( usually in terms of physical injury ) a character can withstand . When a character is attacked , or is hurt from a hazard or fall , the total damage dealt ( which is also represented by a point value ) is subtracted from their current HP . Once their HP reaches 0 , the character will be unable to fight . In role-playing games , health is often abbreviated as HP . In some role-playing games such as ' ' Dungeons &amp; Dragons ' ' , a player character 's hit points are determined by character level . The hit points of monsters are decided by rolling Hit Dice . Characters with high constitution will have an advantage when hit points are assigned . A character whose hit points are reduced to zero is considered dead or incapacitated . Other games sometimes lack levels , hit points , or both . In certain editions of the game , player characters with 0 HP are not dead , but rather knocked unconscious . Within the range of -1 and -9 , they are considered to be mortally wounded and dying , and their HP will steadily drop until it is stabilized . At -10 , the character dies . Depending on the rules , a character who suffers 50+ points of damage from a single blow may die as a result of Death from Massive Damage . The player must then make a saving throw of the dice in hope of countering the damage . Failure to do so results in the characters dying , regardless of their remaining HP . In many role-playing video games , the objective is to deplete the hit points of enemies while maintaining the health of player characters . Hit points can typically be refilled by using a restorative item , staying the night at an inn , or utilizing healing magic . Generally , characters are killed or rendered unconscious as soon as their hit points reach 0 . # Concept # Hit points represent a method of determining the vitality of , or resistance to death or destruction , of a being or object ( some versions of ' ' Dungeons &amp; Dragons ' ' , for example , include hit point values for objects , weapons , armor , even doors and walls , allowing players to attack and destroy them . ) Rather than realistically model damage as it would exist in real world situations , hit points give an abstract idea of how much damage , in game terms , something can withstand until it is destroyed completely . An example would be the comparison of a serious , but non-lethal , wound . A person who has taken a serious sword wound might not be in danger of immediate death , but might lose the usage of a limb or some mobility as a result . In the same situation in most games , a character that suffers such an injury would lose hit points ; as long as they are still above zero , however , the character would not have diminished performance capacity . Contrarily , as a single assault from a weapon could kill a perfectly healthy person , a single attack against a healthy game character using a hit point system often does not result in death . Some games do penalize the player for his or her character taking damage . Several of ' ' The Legend of Zelda ' ' games , for instance , allow the main character to use a projectile attack , but only at full hit points . ' ' Paladin 's Quest ' ' has both magic powers and life energy using hit points as a resource , and thus a sufficiently damaged character may not be able to safely cast some spells . Generally , the usage of hit points avoids the complexities of having to model the effect of damage to various body or mechanism parts , although some games rely on this as part of the strategy inherent to combat . Many of the ' ' MechWarrior ' ' games give each body part of a mecha its own hit point allotment , and damaging or destroying individual parts has an adverse effect on the way the mech operates , despite not outright destroying it . The ' ' Fallout ' ' series of games allows targeting a specific body part , which results in not just damaging a foe 's hit points , but also possibly crippling a limb or even blinding the foe . Some games that do not usually employ this mechanic may do so in some circumstances ; the beholder and hydra of ' ' Dungeons &amp; Dragons ' ' have separate body parts , and destroying them individually plays into the strategy of fighting that foe . # History # ' ' Dungeons &amp; Dragons ' ' co-creator Dave Arneson described the origin of hit points in a 2002 interview . When Arneson was adapting the medieval wargame ' ' Chainmail ' ' to a fantasy setting , a process that with Gary Gygax would lead to the game ' ' Dungeons &amp; Dragons ' ' , he saw that the emphasis of the gameplay was moving from large armies to small groups of heroes and eventually to the identification of one player and one character that is so essential to role-playing as it was originally conceived . Players became attached to their heroes and did not want them to die every time they lost a die roll . Players were given multiple hit points which were then incrementally decreased . Arneson took the concept , along with armor class , from a set of a naval American Civil War game 's rules . # Graphical health bar # A ' ' health ' ' or ' ' life bar ' ' is used to display a character 's health in many video games . A typical life bar is a horizontal rectangle which begins full of color . If damage is taken or mistakes are made , the colored area gradually reduces and leaves behind a visible outline , typically from one end to another . Some also change color , typically from green to yellow to red as health is reduced . When the bar is completely emptied , the result is game over ( death , being knocked out , etc. ) or loss of a life . In 1984 , both the arcade game ' ' Dragon Buster ' ' and computer game ' ' Gemstone Warrior ' ' first used a bar to represent health . ' ' Punch Out ! ! ' ' was released earlier the same year and also has a health bar , and ' ' Star Trek Strategic Operations Simulator ' ' was released 2 years prior and also has a segmented life bar . There have since been many variations on the life bar : In ' ' Street Fighter ' ' and other fighting games , the bar does not instantly decrease when damage is taken . Instead , an area representing the damage is marked in red , and the health lost quickly drains away . This is useful in assessing the amount of damage caused by an attack . In most games , a health bar is indicated on the top left corner of the screen . Sometimes , whenever a boss is encountered , another health bar is displayed , along with the name of the boss . Some games use an incremental bar , composed of many smaller bars . Each attack will remove a certain number of these bars . This system is used in the ' ' Mega Man ' ' series . Some video games also feature a recharging health bar . In these games , the player character can not usually take as much damage as a player with a traditional life bar , but health regenerates over time ( usually initiating regeneration when the player avoids being damaged for a period of time ) . Notable examples of this are the ' ' Hydlide ' ' series , ' ' Ys ' ' series , ' ' Halo ' ' series , ' ' Call of Duty ' ' series , ' ' Destroy All Humans ! ' ' , ' ' Gears of War ' ' , ' ' Tom Clancy 's Rainbow Six : Vegas ' ' , ' ' Tom Clancy 's Splinter Cell : Double Agent ' ' , and ' ' Red Steel ' ' . Some games may increase the maximum health limit of the player character as they progress through the game like ' ' Paper Mario : Sticker Star ' ' and ' ' Metal Gear Solid ' ' . The video game ' ' Final Fantasy Mystic Quest ' ' includes an option to view health either as a fraction of current health versus maximum health , or as an image of dashes and blocks . Each yellow , or full block , represents a full set of dashes , and each empty , or red block , represents an empty set of dashes . The depicted dashes represent the health of the current , or highest un-emptied block , initially appearing as all yellow dashes , turning red as the current block is damaged . # Icon-based health # Icons are another method for measuring health . Some games such as ' ' Prince of Persia ' ' , ' ' DuckTales ' ' , and ' ' Mr. Nutz ' ' , which use a number of icons to represent health units ; every hit against the player character will always decrease health by one icon or unit at a time . In other games a hit may reduce health by one icon or unit , a fraction of one icon , or many icons at once , depending on how powerful the hit is , and the strength of the character 's defense of armor . In most of the games in the ' ' The Legend of Zelda ' ' series of video games , the player 's health is represented as small hearts . Weak attacks against the player will take only a fraction of a heart , usually one-quarter or one-half , and stronger attacks may take many whole hearts at once . Several games make use of similar heads-up displays . ' ' Super Mario Bros. 2 ' ' uses small red icons ( in 16-bit versions of the game , they are changed to hearts ) in the top left corner to designate how many hitpoints the player has remaining , and ' ' Bram Stoker 's Dracula ' ' uses small flasks of liquid . The game ' ' Minecraft ' ' uses hearts to display Health , like ' ' Legend of Zelda ' ' , but damage will not reduce quarters of a heart , rather , the minimum is half a Heart , but attacks can drain multiple hearts , depending on damage and player 's armor . Other games , such as ' ' Deus Ex ' ' , show a HUD of a human body , which is green to begin with . As the player takes damage , the respective region of the body turns yellow , orange , red , and eventually disappears altogether . For the head and torso , this is fatal . For arms , this causes a significant decrease in weapon accuracy or damage ( or a complete inability to use them ) , while such a damage for legs usually leads to a badly impaired movement . A similar system , but showing the player 's current vehicle rather than a human body , is used in some simulation games such as ' ' Rogue Squadron ' ' . # Other variations # # Recharging health # Some games use a system of ' ' recharging ' ' health ( or regeneration ) , where health points are regained over a short period of time ( usually minutes ) . This mechanic has its origins in Roguelike games of the 1980s . In the 2000s , the mechanic was popularized among first-person shooters by the ' ' Halo ' ' series , while action RPGs such as ' ' Fable ' ' have continued to utilize the mechanic . Other games require the use of healing spells , skills , or items ( such as potions , medicine , first aid kits , bandages , syringes , medical bags , herbs , and even food ) to regain health . Many game systems incorporate both slow regeneration and instant-effect healing skills and items . Games often have items that recharge all or some of a character 's health , but they may differ in that , some games allow the player character to collect and carry many items in an inventory and use them to recharge health at a later time when needed ; while in other games the player character can not carry items in such a way and items will recharge health immediately upon touching them or sometimes upon picking them up . If such health recharging items are carried , the player usually needs to manually select the item and use it before their health completely runs out . Some games however contain items that , when carried , automatically revive a character when their health reaches zero and restores them to either full or part health . Another common way of replenishing health in games is to have a number of fixed locations that characters can travel to , and where their health will be replenished either for free , or by paying some in game currency . These facilities can usually be used an unlimited number of times , and themes such as resting at an inn or character 's home or base , drinking from a fountain , visiting a hospital or other medical facility , or visiting a person or location that heals with magic have all been used across different games and genres . An increasingly common standard is a complete lack of any health-replenishing itemsthe wounded player is simply expected not to take damage by taking cover and waiting ( generally from 520 seconds ) as his or her character recovers ( as seen in ' ' Mass Effect ' ' and ' ' Mass Effect 2 ' ' ) . Some games ( such as ' ' Outlast ' ' ) do not feature a health meter , as the player judges his or her health and recovery from blood on the screen , heavy breathing , and other details . # Incremental health # In the ' ' Sonic the Hedgehog ' ' series , the player character collects rings , which are usually used as his or her health indicator . They are shown as numbers at the upper left side of the screen . Whenever the player character takes damage when he or she does not have a shield , all of the player 's rings scatter in many directions . If the player is fast enough , the player can reclaim some of the rings before they flicker and disappear . However , if the player character possesses a shield and takes a hit that the shield is not invulnerable against , the shield is lost and the player character will keep all of his or her rings . Almost all of the player characters can be killed instantly if they do not possess any rings or a shield when they take any damage . Sonic 's rings differ from most health mechanisms in that having multiple rings offers no extra protection ; however many rings a player possesses , all will be lost with one hit . However , some Sonic games such as ' ' Sonic Blast ' ' , ' ' Sonic the Hedgehog ' ' , ' ' Sonic and the Secret Rings ' ' , ' ' Shadow the Hedgehog ' ' and ' ' Sonic Unleashed ' ' have the player lose only a set number of rings per hit ( usually ten or twenty ) , meaning that having more rings provides better protection . ' ' Mass Effect 3 ' ' ( 2012 ) uses a combination of Incremental Health and Recharging health : Shepard 's health bar contains five segments , and although an individual segment will regenerate , loss of the entire segment is permanent . # Damage meter # In the ' ' Super Smash Bros. ' ' series , instead of health counter featured in most fighting games , percentage meters are used . A player 's meter is at 0% by the time they have respawned or begin the game , and can go as far as 999% . When attacking an opponent or being attacked by an opponent , the percentage meter rises based on the damage inflicted ; as the percentage meter increases , the character gradually becomes easier to knock away with strong attacks , possibly getting knocked out of the arena and , thus , losing either a life or a point , depending on the mode of play . In the Stamina mode , health percentage is used . When the characters fall off the stage , they are disqualified from the battle . # Health represented without Heads-Up Display # In order to immerse the player in the gaming experience , some developers do away with the health bar ( and other on-screen displays ) completely and try to present a character 's health in other ways , such as showing a character limping or displaying visible wounds when they are injured . ' ' Jurassic Park : Trespasser ' ' ( 1998 ) has no HUD and represents its player character 's ( Anne ) health as a heart-shaped tattoo on her breast which fills up with red as the damage increases . When she dies , the heart has a chain around it . In the early ' ' Resident Evil ' ' ( 1996present ) video games , health is shown both with the player character limping and pressing his/her wounds in pain , and with an EKG display in the inventory screen . Games such as ' ' Call of Duty 2 ' ' ( 2005 ) or ' ' Peter Jackson 's King Kong : The Official Game of the Movie ' ' ( 2005 ) have no life bar ; instead , the game uses the screen as health , and when the player gets hit , the screen flashes red , and in some games the vision also becomes blurred in this condition ( more damage indicated by a deeper red coloration ) . In some games , characters slouch over and breathe heavily as a result of low health when left idle ; blood stains or wounds may also appear on characters to show they are injured . Some third-person games such as ' ' RoboBlitz ' ' ( 2006 ) , ' ' Dead Space ' ' ( 2008 ) and ' ' Ghostbusters : The Video Game ' ' ( 2009 ) , ' ' Tom Clancy 's Splinter Cell : Conviction ' ' ( 2010 ) have health bars shown on the player model rather than in a HUD . They resemble ordinary health meters apart from being physically attached to the character 's equipment . ' ' Call of Cthulhu : Dark Corners of the Earth ' ' ( 2005 ) represents health through visual and auditory cues given by the character , as damage accumulates throughout his body ( gasping and limping from a broken leg , tunnel vision and ear-ringing from blood loss , etc . ) Each injury requires a specific treatment , such as sutures , a splint , or a bandage . Left untreated , injuries grow more severe until the character succumbs. 
@@8695082 : : ' ' This article is about policies , plans and strategies across the health care sector . For specific information on health insurance policies , see health insurance . ' ' Health policy can be defined as the decisions , plans , and actions that are undertaken to achieve specific health care goals within a society . According to the World Health Organization , an explicit health policy can achieve several things : it defines a vision for the future ; it outlines priorities and the expected roles of different groups ; and it builds consensus and informs people . There are many categories of health policies , including personal health care policy , pharmaceutical policy , and policies related to public health such as vaccination policy , tobacco control policy or breastfeeding promotion policy . They may cover topics of financing and delivery of health care , access to care , quality of care , and health equity . # Background # Health-related policy and its implementation is complex . Conceptual models can help show the flow from health-related policy development to health-related policy and program implementation and to health systems and health outcomes . Policy should be understood as more than a national law or health policy that supports a program or intervention . Operational policies are the rules , regulations , guidelines , and administrative norms that governments use to translate national laws and policies into programs and services . The policy process encompasses decisions made at a national or decentralized level ( including funding decisions ) that affect whether and how services are delivered . Thus , attention must be paid to policies at multiple levels of the health system and over time to ensure sustainable scale-up . A supportive policy environment will facilitate the scale-up of health interventions . There are many topics in the politics and evidence that can influence the decision of a government , private sector business or other group to adopt a specific policy . Evidence-based policy relies on the use of science and rigorous studies such as randomized controlled trials to identify programs and practices capable of improving policy relevant outcomes . Most political debates surround personal health care policies , especially those that seek to reform health care delivery , and can typically be categorized as either philosophical or economic . Philosophical debates center around questions about individual rights , ethics and government authority , while economic topics include how to maximize the efficiency of health care delivery and minimize costs . The modern concept of health care involves access to medical professionals from various fields as well as medical technology , such as medications and surgical equipment . It also involves access to the latest information and evidence from research , including medical research and health services research . In many countries it is left to the individual to gain access to health care goods and services by paying for them directly as out-of-pocket expenses , and to private sector players in the medical and pharmaceutical industries to develop research . Planning and production of health human resources is distributed among labour market participants . Other countries have an explicit policy to ensure and support access for all of its citizens , to fund health research , and to plan for adequate numbers , distribution and quality of health workers to meet health care goals . Many governments around the world have established universal health care , which takes the burden of health care expenses off of private businesses or individuals through pooling of financial risk . There are a variety of arguments for and against universal health care and related health policies . Health care is an important part of health systems and therefore it often accounts for one of the largest areas of spending for both governments and individuals all over the world . # Personal health care policy options # # Philosophy : right to health # Many countries and jurisdictions integrate a human rights philosophy in directing their health care policies . The World Health Organization reports that every country in the world is party to at least one human rights treaty that addresses health-related rights , including the right to health as well as other rights that relate to conditions necessary for good health . The United Nations ' Universal Declaration of Human Rights ( UDHR ) asserts that medical care is a right of all people :  ' ' UDHR Article 25 : ' ' Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family , including food , clothing , housing and medical care and necessary social services , and the right to security in the event of unemployment , illness , disability , widowhood , old age or other lack of livelihood in circumstances beyond his control . In some jurisdictions and among different faith-based organizations , health policies are influenced by the perceived obligation shaped by religious beliefs to care for those in less favorable circumstances , including the sick . Other jurisdictions and non-governmental organizations draw on the principles of humanism in defining their health policies , asserting the same perceived obligation and enshrined right to health . In recent years , the worldwide human rights organization Amnesty International has focused on health as a human right , addressing inadequate access to HIV drugs and women 's sexual and reproductive rights including wide disparities in maternal mortality within and across countries . Such increasing attention to health as a basic human right has been welcomed by the leading medical journal ' ' The Lancet ' ' . There remains considerable controversy regarding policies on who would be paying the costs of medical care for all people and under what circumstances . For example , government spending on health care is sometimes used as a global indicator of a government 's commitment to the health of its people . On the other hand , one school of thought emerging from the United States rejects the notion of health care financing through taxpayer funding as incompatible with the ( considered no less important ) right of the physician 's professional judgment , and the related concerns that government involvement in overseeing the health of its citizens could erode the right to privacy between doctors and patients . The argument furthers that universal health insurance denies the right of individual patients to dispose of their own income as per their own will . Another issue in the rights debate is governments ' use of legislation to control competition among private medical insurance providers against national social insurance systems , such as the case in Canada 's national health insurance program . Laissez-faire supporters argue that this erodes the cost-effectiveness of the health system , as even those who can afford to pay for private health care services drain resources from the public system . The issue here is whether investor-owned medical insurance companies or health maintenance organizations are in a better position to act in the best interests of their customers compared to government regulation and oversight . Another claim in the United States perceives government over-regulation of the health care and insurance industries as the effective end of charitable home visits from doctors among the poor and elderly . # Economics : health care financing # Many types of health policies exist focusing on the financing of health care services to spread the economic risks of ill health . These include publicly funded health care ( through taxation or insurance , also known as single-payer systems ) , mandatory or voluntary private health insurance , and complete capitalization of personal health care services through private companies , among others . The debate is ongoing on which type of health financing policy results in better or worse quality of health care services provided , and how to ensure allocated funds are used effectively , efficiently and equitably . There are many arguments on both sides of the issue of public versus private health financing policies : ' ' Claims that publicly funded health care improves the quality and efficiency of personal health care delivery : ' '  Government spending on health is essential for the accessibility and sustainability of health care services and programmes .  For those people who would otherwise go without care due to lack of financial means , any quality care is an improvement .  Since people perceive universal health care as ' ' free ' ' ( if there is no insurance premium or co-payment ) , they are more likely to seek preventive care which may reduce the disease burden and overall health care costs in the long run .  Single-payer systems reduce wastefulness by removing the middle man , i.e. private insurance companies , thus reducing the amount of bureaucracy . In particular , reducing the amount of paperwork that medical professionals have to deal with for insurance claims processing allows them to concentrate more on treating patients . ' ' Claims that privately funded health care leads to greater quality and efficiencies in personal health care : ' '  Perceptions that publicly funded health care is ' ' free ' ' can lead to overuse of medical services , and hence raise overall costs compared to private health financing .  Privately funded medicine leads to greater quality and efficiencies through increased access to and reduced waiting times for specialized health care services and technologies .  Limiting the allocation of public funds for personal health care does not curtail the ability of uninsured citizens to pay for their health care as out-of-pocket expenses . Public funds can be better rationalized to provide emergency care services regardless of insured status or ability to pay , such as with the Emergency Medical Treatment and Active Labor Act in the United States .  Privately funded and operated health care reduces the requirement for governments to increase taxes to cover health care costs , which may be compounded by the inefficiencies among government agencies due to their greater bureaucracy . # Other health policy options # Health policy options extend beyond the financing and delivery of personal health care , to domains such as medical research and health workforce planning , both domestically and internationally . # Medical research policy # Medical research can be both the basis for defining evidence-based health policy , and the subject of health policy itself , particularly in terms of its sources of funding . Those in favor of government policies for publicly funded medical research posit that removing profit as a motive will increase the rate of medical innovation . Those opposed argue that it will do the opposite , because removing the incentive of profit removes incentives to innovate and inhibits new technologies from being developed and utilized . The existence of sound medical research does not necessarily lead to evidence-based policymaking . For example , in South Africa , whose population sets the record for HIV infections , previous government policy limiting funding and access for AIDS treatments met with strong controversy given its basis on a refusal to accept scientific evidence on the means of transmission . A change of government eventually led to a change in policy , with new policies implemented for widespread access to HIV services . Another issue relates to intellectual property , as illustrated by the case of Brazil , where debates have arisen over government policy authorizing the domestic manufacture of antiretroviral drugs used in the treatment of HIV/AIDS in violation of drug patents . # Health workforce policy # Some countries and jurisdictions have an explicit policy or strategy to plan for adequate numbers , distribution and quality of health workers to meet health care goals , such as to address physician and nursing shortages . Elsewhere , health workforce planning is distributed among labour market participants as a laissez-faire approach to health policy . Evidence-based policies for health workforce development are typically based on findings from health services research . # Health in foreign policy # Many governments and agencies include a health dimension in their foreign policy in order to achieve global health goals . Promoting health in lower income countries has been seen as instrumental to achieve other goals on the global agenda , including :  Promoting global security linked to fears of global pandemics , the intentional spread of pathogens , and a potential increase in humanitarian conflicts , natural disasters , and emergencies ;  Promoting economic development including addressing the economic effect of poor health on development , of pandemic outbreaks on the global market place , and also the gain from the growing global market in health goods and services ;  Promoting social justice reinforcing health as a social value and human right , including supporting the United Nations ' Millennium Development Goals . # Global health policy # Global health policy encompasses the global governance structures that create the policies underlying public health throughout the world . In addressing global health , global health policy implies consideration of the health needs of the people of the whole planet above the concerns of particular nations . Distinguished from both international health policy ( agreements among sovereign states ) and comparative health policy ( analysis of health policy across states ) , global health policy institutions consist of the actors and norms that frame the global health response 
@@14335899 Doctor of Osteopathic Medicine ( D.O . or DO ) is a professional doctoral degree for physicians and surgeons offered by medical schools in the United States . Holders of the D.O . degree have attained the ability to become licensed as osteopathic physicians who have equivalent rights , privileges , and responsibilities as physicians with a Doctor of Medicine degree ( M.D. ) . D.O . physicians are licensed to practice the full scope of medicine and surgery in 65 countries , including all 50 states in the US , and make up 7 percent of the total U.S. physician population . In 2013 , there were 87,300 osteopathic physicians in the United States . Currently , there are 30 medical schools with 42 locations throughout the United States that offer the D.O . degree , and 141 medical schools that offer the M.D. degree . As of 2011 , 1 in 5 medical students in the United States were D.O . students . The curricula at osteopathic medical schools are very similar to those at M.D.-granting medical schools . Four years in total length , the first two years of medical school focus on the biomedical and clinical sciences , followed by two years of core clinical training in the clinical specialties . Upon leaving medical school , D.O . graduates may enter internship or residency training programs , which may be followed by fellowship training . Many D.O . graduates attend the same graduate medical education programs as their M.D. counterparts , and then take M.D. specialty board exams , while other D.O . graduates enter osteopathic programs and take D.O . specialty board examinations . One notable difference between D.O . and M.D. training is that D.O . training adds 300500 hours studying philosophically-based techniques for hands-on manipulation of the human musculoskeletal system . These techniques , known as osteopathic manipulative medicine ( OMM ) , have been criticized as pseudoscientific . # History # The practice of osteopathy began in the United States in 1874 . The term osteopathy was coined by physician and surgeon Andrew Taylor Still , MD , DO . Still named his new school of medicine osteopathy , reasoning that the bone , osteon , was the starting point from which he was to ascertain the cause of pathological conditions . Still founded the American School of Osteopathy ( now A.T . Still University of the Health Sciences ) in Kirksville , Missouri , for the teaching of osteopathy on 10 May 1892 . While the state of Missouri granted the right to award the MD degree , he remained dissatisfied with the limitations of conventional medicine and instead chose to retain the distinction of the DO degree . In 1898 the American Institute of Osteopathy started the ' ' Journal of Osteopathy ' ' and by that time four states recognized the profession . The osteopathic medical profession has evolved into two branches : non-physician manual medicine osteopaths who were educated and trained outside the United States and U.S. trained full scope of medical practice osteopathic physicians . The regulation of non-physician manual medicine osteopaths varies greatly between jurisdictions . In the United States , osteopathic physicians holding the D.O . degree have attained the same rights , privileges , and responsibilities as physicians with a Doctor of Medicine ( M.D. ) degree . These groups are so distinct that in practice they function as separate professions . As originally conceived by Andrew Still , the letters DO stood for Diplomate in Osteopathy and the title conferred by the degree was Doctor of Osteopathy . # Demographics # In 2013 , there were 87,300 osteopathic physicians in the United States , of which 73,074 were in active practice . The proportion of females in the profession has steadily increased since the 1980s . In 1985 , about 10 percent of D.O . physicians were female , compared with 34.6 percent in 2013 . Between 2008 and 2012 , 49 percent of new D.O . graduates were females . During the 2011-12 academic year , the osteopathic medical student body consisted of : 69 percent white/non-hispanic , 19 percent Asian or Pacific Islander , 3.5 percent hispanic , 3 percent African American , and 0.5 percent Native American or Alaskan . The remainder were listed as other or not entered . # Education , training and distinctiveness # Osteopathic medical school curricula are virtually identical to those at schools granting the M.D. degree ( Doctor of Medicine ) . Once admitted to an osteopathic medical school , it takes four years to graduate , and the schooling is divided into the pre-clinical and clinical years . The pre-clinical years , the first and second years , focus on the biomedical and clinical sciences . The clinical years , the third and fourth years , consist of core clinical training and sub-internships in the clinical specialties . Osteopathic medical school accreditation standards require training in internal medicine , obstetrics/gynecology , pediatrics , family practice , surgery , psychiatry , emergency medicine , radiology , preventive medicine and public health . According to Harrison 's Principles of Internal Medicine , the training , practice , credentialing , licensure , and reimbursement of osteopathic physicians is virtually indistinguishable from those of physicians with M.D. qualifications , with 4 years of osteopathic medical school followed by specialty and subspecialty training and board certification . However , D.O . schools provide an additional 300 500 hours in the study of hands-on manual medicine and the body 's musculoskeletal system , which is referred to as osteopathic manipulative medicine ( OMM ) . The D.O . physician Bryan E. Bledsoe , a professor of emergency medicine , has written disparagingly of this element of D.O . training . He characterized its foundations as pseudoscientific and asked why members of the osteopathic medical profession continue to teach an outdated and ineffective system of healthcare to undergraduate osteopathic medical students ? while other D.O . graduates enter osteopathic internships and residencies and take D.O . specialty board examinations . In 2003 Quackwatch published an article which stated that although most DOs offer competent care , the percentage involved in dubious practices appears to be higher than that of MDs ; in particular , Quackwatch characterized some types of cranial therapy as dubious . # Examinations # To be considered for entry into a D.O . program , an applicant must complete a national standardized exam called the Medical College Admissions Test ( MCAT ) . Some authors note the differences in the average MCAT scores and grade point average of students who matriculate at D.O . schools versus those who matriculate at M.D. schools within the United States . In 2011 , the average MCAT and GPA for students entering U.S.-based M.D. programs were 31.1 and 3.67 , respectively , and 27.1 and 3.51 for D.O . matriculants , although the gap has been getting smaller every year . D.O . medical schools are more likely to accept non-traditional students who are older and entering medicine as a second career , or coming from non-science majors . D.O . medical students are required to take the Comprehensive Osteopathic Medical Licensure Examination ( COMLEX-USA ) , which is sponsored by the National Board of Osteopathic Medical Examiners ( NBOME ) . The COMLEX-USA is series of three osteopathic medical licensing examinations . The first two steps of the COMLEX-USA are taken during medical school , and are prerequisites for osteopathic residency programs , which are available in almost every specialty of medicine and surgery . The step 3 portion of the COMLEX is taken during residency . In addition to the COMLEX-USA , D.O . medical students may choose to sit for the M.D. board examinations , which are called the United States Medical Licensing Examination ( USMLE ) . This is typically done if the student desires to enter an M.D. residency . However , this is not always required , as some M.D. residency programs do not require the USMLE from D.O . applicants . USMLE pass rates for D.O . and M.D. students in 2012 are as follows : Step 1 : 91% and 94% , Step 2 CK : 96% and 97% , and Step 2 CS : 87% and 97% , respectively ( this number may be misleading as only 46 D.O . students compared to 17,118 M.D. students were evaluated for Step 2 CS ) Step 3 : 100% and 95% ( this number may be misleading , as only 16 D.O . students compared to 19,056 M.D. students , were evaluated for Step 3 ) . # Licensing and board certification # To obtain a license to practice medicine in the United States , medical students must pass the Comprehensive Osteopathic Medical Licensing Examination ( COMLEX ) , the licensure exam administered by the National Board of Osteopathic Medical Examiners throughout their medical training . Students are given the option of also taking the United States Medical Licensing Examination ( USMLE ) to apply for some Accreditation Council for Graduate Medical Education ( ACGME ) residency programs . Those that have received or are in the process of earning an M.D. or D.O . degree are both eligible to sit for the USMLE . Because of their additional training , only holders of the D.O . are eligible to sit for the COMLEX . Upon completion of internship and residency requirements for their chosen medical specialty , and depending on whether the program attended as ACGME or AOA accredited , holders of the D.O . may elect to be board certified by either a specialty board ( through the American Medical Association 's American Board of Medical Specialties ) or an osteopathic specialty board ( through the American Osteopathic Association Bureau of Osteopathic Specialists certifying boards ) . In February 2014 , the American Osteopathic Association and the Accreditation Council for Graduate Medical Education agreed to unify allopathic and osteopathic Graduate medical education starting in 2020 . Depending on the state , medical licensure may be issued from a combined board ( D.O . and M.D. ) or a separate board of medical examiners . All of the 70 state medical boards are members of the Federation of State Medical Boards . # International variations # Currently , there are no osteopathic programs located outside of the United States that would qualify an individual to practice as an osteopathic physician in the United States . Foreign osteopathic degrees are not recognized by any state in the U.S. as being equivalent to American D.O . degrees . # International practice rights # The following is an International Licensure Summary for U.S.-trained Doctors of Osteopathic Medicine , as listed by the American Osteopathic Association : 
@@14780936 The National Health Service ( NHS ) is the publicly funded healthcare system for England . It is the largest and the oldest single-payer healthcare system in the world . Primarily funded through the general taxation system , the system provides healthcare to every legal resident in the United Kingdom , with most services free at the point of use . Free healthcare at the point of use comes from the core principles at the founding of the National Health Service by the United Kingdom Labour government in 1948 . In practice , free at the point of use normally means that anyone legitimately fully registered with the system ( i.e. in possession of an NHS number ) , including UK citizens and legal immigrants , can access the full breadth of critical and non-critical medical care without any out-of-pocket payment . Some specific NHS services do however require a financial contribution from the patient . Since 1948 , patients have been charged for some services such as eye tests , dental care , prescriptions , and aspects of long-term care . However , these charges are often free to vulnerable or low income groups , and when not free , often lower than equivalent services provided by a private health care provider . The NHS has further agreed a formal NHS constitution which sets out the legal rights and responsibilities of the NHS , its staff , and users of the service and makes additional non-binding pledges regarding many key aspects of its operations . In recent reform , the Health and Social Care Act 2012 came into effect in April 2013 , giving GP-led groups responsibility for commissioning most local NHS services . Starting April 2013 Primary Care Trusts ( PCTs ) are to be replaced by General Practitioner ( GP ) -led organisations called Clinical Commissioning Groups ( CCGs ) . Under the new system , a new ' ' NHS Commissioning Board ' ' , called NHS England , oversees the NHS from the Department of Health . The Act has also become associated with the perception of increased private provision of NHS services . In reality , the provision of NHS services by private companies long precedes this legislation , but there are concerns that the new role of the healthcare regulator ( ' Monitor ' ) could lead to increased use of private sector competition , balancing care options between private companies , charities , and NHS organisations . NHS Trusts are responding to the Nicholson challenge which involves making 20 billion in savings across the service by 2015 . The NHS provides the majority of healthcare in England , including primary care , in-patient care , long-term healthcare , ophthalmology , and dentistry . The National Health Service Act 1946 came into effect on 5 July 1948 . Private health care has continued parallel to the NHS , paid for largely by private insurance : it is used by about 8% of the population , generally as an add-on to NHS services . In the first decade of the 21st century , the private sector started to be increasingly used by the NHS to increase capacity . According to the BMA , a large proportion of the public opposed this move . The NHS is largely funded from general taxation with a small amount being contributed by National Insurance payments . The UK government department responsible for the NHS is the Department of Health , headed by the Secretary of State for Health . The Department of Health had a 110 billion in 2013-14 , most of this being spent on the NHS . # History # A national health service was one of the fundamental assumptions in the Beveridge Report which Arthur Greenwood , Labour 's Deputy Leader and wartime Cabinet Minister with responsibility for post-war reconstruction had successfully pressed the cabinet to commission from economist and social reformer William Beveridge . The government accepted this assumption in February 1943 , and after a White Paper in 1944 it fell to Clement Attlee 's Labour government to create the NHS as part of the cradle to grave welfare-state reforms in the aftermath of World War II . Aneurin Bevan , the newly appointed Minister of Health , was given the task of introducing the National Health Service . Healthcare prior to the war had been an unsatisfactory mix of private , municipal and charity schemes . Bevan now decided that the way forward was a national system rather than a system operated by regional authorities , to prevent inequalities between different regions . He proposed that each resident of the UK would be signed up to a specific General Practice ( GP ) as the point of entry into the system , and would have access to any kind of treatment they needed without having to raise the money to pay for it . Doctors were initially opposed to Bevan 's plan , primarily on the stated grounds that it reduced their level of independence . Bevan had to get them onside , as , without doctors , there would be no health service . Being a shrewd political operator , Bevan managed to push through the radical health care reform measure by dividing and cajoling the opposition , as well as by offering lucrative payment structures for consultants . On this subject he stated , I stuffed their mouths with gold . On 5 July 1948 , at the Park Hospital ( now known as Trafford General Hospital ) in Manchester , Bevan unveiled the National Health Service and stated , We now have the moral leadership of the world . After the publication by the ' ' British Medical Journal ' ' on 24 December 1949 of University of Cambridge paediatrician Douglas Gairdner 's landmark paper detailing the lack of medical benefit and the risks attached to non-therapeutic ( routine ) circumcision , the National Health Service decided that circumcision would not be performed unless there was a clear and present medical indication . The cost of the new NHS soon took its toll on government finances . On 21 April 1951 the Chancellor of the Exchequer , Hugh Gaitskell , proposed that there should be a one shilling ( 5p ) prescription charge and new charges for half the cost of dentures and spectacles . Bevan resigned from the Cabinet in protest . This led to a split in the party that contributed to the electoral defeat of the Labour government in 1951 . The one shilling prescription charge was introduced in 1952 together with a 1 flat rate fee for ordinary dental treatment . Prescription charges were abolished in 1965 , but re-introduced in June 1968 . Dr A. J. Cronin 's highly controversial novel ' ' The Citadel ' ' , published in 1937 , had fomented extensive dialogue about the severe inadequacies of health care . The author 's innovative ideas were not only essential to the conception of the NHS , but in fact , his best-selling novels are even said to have greatly contributed to the Labour Party 's victory in 1945 . On 13 November 2011 the government signed off on the 10-year contract to manage the debt-laden Hinchingbrooke Hospital in Huntingdon , Cambridgeshire by Circle Healthcare . It was the first time that an NHS hospital was to be taken over by a stock-market listed company . There have been documented failures of some parts of the National Health Service to provide adequate care at a basic level . These failures were associated with bureaucratic fumbling as local institutions attempted to meet conflicting demands with inadequate resources . article by Sarah Lyall in ' ' The New York Times ' ' 6 February 2013 , They were failed by a system which ignored the warning signs and put corporate interests and cost control ahead of patients and their safety , he added . There was a lack of care , compassion , humanity and leadership . The most basic standards of care were not observed , and fundamental rights to dignity were not respected . This notwithstanding , the NHS has received consistently strong approval and support from citizens . # Core principles # The principal NHS website states the following as core principles : The NHS was born out of a long-held ideal that good healthcare should be available to all , regardless of wealth . At its launch by the then minister of health , Aneurin Bevan , on 5 July 1948 , it had at its heart three core principles : That it meet the needs of everyone That it be free at the point of delivery That it be based on clinical need , not ability to pay These three principles have guided the development of the NHS over more than half a century and remain . However , in July 2000 , a full-scale modernisation programme was launched and new principles added . The main aims of the additional principles are that the NHS will : Provide a comprehensive range of services Shape its services around the needs and preferences of individual patients , their families and their carers Respond to the different needs of different populations Work continuously to improve the quality of services and to minimize errors Support and value its staff Use public funds for healthcare devoted solely to NHS patients Work with others to ensure a seamless service for patients Help to keep people healthy and work to reduce health inequalities Respect the confidentiality of individual patients and provide open access to information about services , treatment and performance # Structure # The English NHS is controlled by the UK government through the Department of Health ( DH ) , which takes political responsibility for the service . Resource allocation and oversight was delegated to NHS England , an arms-length body , by the Health and Social Care Act 2012 . NHS England commissions primary care services ( including GPs ) and some specialist services , and allocates funding to 211 geographically-based Clinical Commissioning Groups ( CCGS ) across England . The CCGs commission most services in their areas , including hospital and community-based healthcare . A number of types of organisation are commissioned to provide NHS services , including NHS trusts and private sector companies . Many NHS trusts have become NHS foundation trusts , giving them an independent legal status and greater financial freedoms . The following types of NHS trusts and foundation trusts provide NHS services in specific areas : NHS acute trusts administer hospitals , treatment centres and specialist care in around 1,600 NHS hospitals ( some trusts run between 2 and 8 different hospital sites ) NHS ambulance services trusts NHS care trusts , providing both health and social care services NHS mental health trusts , specialising in managing and treating mental illness , including by the use of involuntary commitment powers Some services are provided at a national level , including :  is the primary public-facing NHS website , providing comprehensive official information on services , treatments , conditions , healthy living and current health topics  NHS special health authorities provide various types of services Nearly all hospital doctors and nurses in England are employed by the NHS and work in NHS-run hospitals , with teams of more junior hospital doctors ( most of whom are in training ) being led by consultants , each of whom is trained to provide expert advice and treatment within a specific specialty . But most General Practitioners , dentists , optometrists ( opticians ) and other providers of local health care are almost all self-employed , and contract their services back to the NHS . They may operate in partnership with other professionals , own and operate their own surgeries and clinics , and employ their own staff , including other doctors etc . However , the NHS does sometimes provide centrally employed health care professionals and facilities in areas where there is insufficient provision by self-employed professionals . In 2009 , the NHS Hospital &amp; Community Health Service plus the General Practice service had a total workforce of a little under 1.18 million full-time equivalent of which 0.61 m were qualified clinical staff such as doctors ( 0.13 million ) , nurses ( 0.34 m ) , scientists , therapists and technical staff ( 0.13 m ) , and ambulance staff ( 0.02 m ) . It has been claimed that the NHS is the third or fifth largest workforce in the world , after the Chinese Army , Indian Railways and ( as argued by Jon Hibbs , the NHS 's head of news , in a press release from 22 March 2005 ) Wal-Mart and the United States Department of Defense . A recent analysis by the BBC placed the NHS fifth on the list of the world 's largest employers ( well above Indian Railways ) . The NHS also plays a unique role in the training of new doctors in England , with approximately 8000 places for student doctors each year , all of which are attached to an NHS University Hospital trust . After completing medical school , these new doctors must go on to complete a two-year foundation training programme to become fully registered with the General Medical Council . Most go on to complete their foundation training years in an NHS hospital although some may opt for alternative employers such as the armed forces . Most staff working for the NHS including non-clinical staff and GPs ( most of whom GP 's are self-employed ) are eligible to join the NHS Pension Scheme which , from 1 April 2008 , is an average-salary defined-benefit scheme . # Current reform proposals # The coalition government 's white paper on health reform , published on 12 July 2010 , sets out the most significant reorganisation of the NHS in its history . The white paper , ' ' Equity and excellence : liberating the NHS ' ' , has implications for all health organisations in the NHS and very significant changes for PCTs and strategic health authorities . It aims to shift power from the centre to GPs and patients , moving somewhere between 60 to 80 billion into the hands of groups of GPs to commission services . The new commissioning system is expected to be in place by April 2013 , by which time SHAs and PCTs will be abolished . Following widespread criticism of the plans , on 4 April 2011 , the Government announced a pause in the progress of the Health and Social Care Bill to allow the government to ' listen , reflect and improve ' the proposals . The bill became law on Tuesday 20 March 2012 . After more than 1,000 amendments in the House of Commons and the House of Lords , MPs cast their final vote for the bill , with a government majority of 88. # Funding # The money to pay for the NHS comes directly from taxation . The 2008/9 budget roughly equates to a contribution of 1,980 for every man , woman and child in the UK . When the NHS was launched in 1948 it had a budget of 437million ( roughly 9billion at todays value ) . In 2008/9 it received over 10 times that amount ( more than 100billion ) . This equates to an average rise in spending over the full 60-year period of about 4% a year once inflation has been taken into account . However , in recent years investment levels have been double that to fund a major modernisation programme . Some 60% of the NHS budget is used to pay staff . A further 20% pays for drugs and other supplies , with the remaining 20% split between buildings , equipment and training costs on the one hand and medical equipment , catering and cleaning on the other . Nearly 80% of the total budget is distributed by local trusts in line with the particular health priorities in their areas . The total budget of Department of Health in England in 2013/14 was 110bn . ) . The National Audit Office reports annually on the summarised consolidated accounts of the NHS . # The commissioning system # The principal fundholders in the NHS system are the NHS Primary Care Trusts ( PCTs ) , that commission healthcare from hospitals , GPs and others . PCTs disburse funds to them on an agreed tariff or contract basis , on guidelines set out by the Department of Health . The PCTs receive a budget from the Department of Health on a formula basis relating to population and specific local needs . They are required to break even - that is , they must not show a deficit on their budgets at the end of the financial year , although in recent years cost and demand pressures have made this objective impossible for some Trusts . Failure to meet financial objectives can result in the dismissal and replacement of a Trust 's Board of Directors , although such dismissals are enormously expensive for the NHS . # Free services and contributory services # # #Services free at the point of use# # The vast majority of NHS services are free at the point of use . This means that people generally do not pay anything for their doctor visits , nursing services , surgical procedures or appliances , consumables such as medications and bandages , plasters , medical tests , and investigations , x-rays , CT or MRI scans etc . Hospital inpatient and outpatient services are free , both medical and mental health services . Funding for these services is provided through general taxation and not a specific tax . Because the NHS is not funded by contributory insurance scheme in the ordinary sense and most patients pay nothing for their treatment there is thus no billing to the treated person nor to any insurer or sickness fund as is common in many other countries . This saves hugely on administration costs which might otherwise involve complex consumable tracking and usage procedures at the patient level and concomitant invoicing , reconciliation and bad debt processing . Eligibility for free NHS services is based on having permanent residence status ( a birthright for some or granted by the Home Office for those who have immigrated ) . The person must be registered with a general practitioner and have an NHS card and number . This will include overseas students with a visa to study at a recognized institution for 6 months or more , but not visitors on a tourist visa for example . Citizens of the EU holding a valid European Health Insurance Card and persons from certain other countries with which the UK has reciprocal arrangements concerning health care can likewise get emergency treatment without charge . In England , from 15 January 2007 , anyone who is working outside the UK as a missionary for an organisation with its principal place of business in the UK is fully exempt from NHS charges for services that would normally be provided free of charge to those resident in the UK . This is regardless of whether they derive a salary or wage from the organisation , or receive any type of funding or assistance from the organisation for the purposes of working overseas . This is in recognition of the fact that most missionaries would be unable to afford private health care and those working in developing countries should not effectively be penalised for their contribution to development and other work . Those who are not ordinarily resident who do not fall into the above category ( including British citizens who may have paid National Insurance contributions in the past ) are liable to charges for services . There are some other categories of people who are exempt from the residence requirements such as specific government workers and those in the armed forces stationed overseas . # #Prescription charges# # the prescription charge for medicines was 7.85 ( which contrasts with Scotland , Wales and Northern Ireland where they are free ) . People over sixty , children under sixteen ( or under nineteen if in full-time education ) , patients with certain medical conditions , and those with low incomes , are exempt from paying . Those who require repeated prescriptions may purchase a single-charge pre-payment certificate which allows unlimited prescriptions during its period of validity . The charge is the same regardless of the actual cost of the medicine , but higher charges apply to medical appliances . For more details of prescription charges , see Prescription drugs . The high and rising costs of some medicines , especially some types of cancer treatment , means that prescriptions can present a heavy burden to the PCTs , whose limited budgets include responsibility for the difference between medicine costs and the fixed prescription charge . This has led to disputes whether some expensive drugs ( e.g. Herceptin ) should be prescribed by the NHS . # #NHS dentistry# # Main article NHS dentistry Where available , NHS dentistry charges were : 18 for an examination ; 49 for a filling or extraction ; and 214 for more complex procedures such as crowns , dentures or bridges . Less than 50% of the turnover of dentists comes from work contracted from the NHS . # #NHS Optical Services# # From 1 April 2007 the NHS Sight Test Fee ( in England ) was 19.32 , and there were 13.1 million NHS sight tests carried out in the UK . For those who qualify through need , the sight test is free , and a voucher system is employed to pay for or reduce the cost of lenses . There is a free spectacles frame and most opticians keep a selection of low-cost items . For those who already receive certain means-tested benefits , or who otherwise qualify , participating opticians use tables to find the amount of the subsidy . Where vouchers do not cover the cost of the selected product , they reduce the cost at their face value . Although these voucher values are the maximum amounts that opticians can recover from the NHS , they might well make additional marketing offers of their own . See the external site for a full NHS listing that includes varifocals , contact lenses , and essential coatings. # #Injury cost recovery scheme# # Under older legislation ( mainly the Road Traffic Act 1930 ) a hospital treating the victims of a road traffic accident was entitled to limited compensation ( under the 1930 Act before any amendment , up to 25 per person treated ) from the insurers of driver(s) of the vehicle(s) involved , but were not compelled to do so and often did not do so ; the charge was in turn covered by the then legally required element of those drivers ' motor vehicle insurance ( commonly known as ' ' Road Traffic Act insurance ' ' when a driver held only that amount of insurance ) . As the initial bill was sent to the driver rather than to his/her insurer , even when a charge was imposed it was often not passed on to the liable insurer ; it was common for no further action to be taken in such cases as there was no practical financial incentive ( and often a financial disincentive due to potential legal costs ) for individual hospitals to do so . The Road Traffic ( NHS Charges ) Act 1999 introduced a standard national scheme for recovery of costs using a tariff based on a single charge for out-patient treatment or a daily charge for in-patient treatment ; these charges again ultimately fell upon insurers . This scheme did not however fully cover the costs of treatment in serious cases . Since January 2007 , the NHS has a duty to claim back the cost of treatment , and for ambulance services , for those who have been paid personal injury compensation . In the last year of the scheme immediately preceding 2007 , over 128 million was reclaimed . # #Car park charges# # Car parking charges are a minor source of revenue for the NHS , with most hospitals deriving about 0.25% of their budget from them . The level of fees is controlled individually by each trust . In 2006 car park fees contributed 78 million towards hospital budgets . Patient groups are opposed to such charges . ( This contrasts with Scotland where car park charges were mostly scrapped from the beginning of 2009 and with Wales where car park charges were scrapped at the end of 2011. ) # #Charitable funds# # There are over 300 official NHS charities in England and Wales . Collectively , they hold assets in excess of 2bn and have an annual income in excess of 300m . Some NHS charities have their own independent board of trustees whilst in other cases the relevant NHS Trust acts as a corporate Trustee . Charitable funds are typically used for medical research , larger items of medical equipment , aesthetic and environmental improvements , or services which increase patient comfort . In addition to official NHS charities , many other charities raise funds which are spent through the NHS , particularly in connection with medical research and capital appeals . Regional lotteries were also common for fundraising , and in 1988 , a National Health Service Lottery was approved by the government , before being found to be illegal . The idea continued to become the National Lottery . # Financial outlook # As each division of the NHS is required to break even at the end of each financial year , the service should in theory never be in deficit . However in recent years overspends have meant that , on a ' going-concern ' ( normal trading ) basis , these conditions have been consistently , and increasingly , breached . Former Secretary of State for Health Patricia Hewitt consistently asserted that the NHS would be in balance at the end of the financial year 2007-8 ; however , a study by Professor Nick Bosanquet for the Reform think tank predicts a true annual deficit of nearly 7bn in 2010. # NHS policies and programmes # # Changes under the Thatcher government # The 1980s saw the introduction of modern management processes ( ' ' General Management ' ' ) in the NHS to replace the previous system of consensus management . This was outlined in the Griffiths Report of 1983 . *8;36575;!-- This recommended the appointment of general managers in the NHS with whom responsibility should lie . The report also recommended that clinicians be better involved in management . Financial pressures continued to place strain on the NHS . In 1987 , an additional 101 million was provided by the government to the NHS . In 1988 Prime Minister Margaret Thatcher announced a review of the NHS . From this review in 1989 two white papers ' ' Working for Patients ' ' and ' ' Caring for People ' ' were produced . These outlined the introduction of what was termed the internal market , which was to shape the structure and organisation of health services for most of the next decade . In England , the National Health Service and Community Care Act 1990 defined this internal market , whereby health authorities ceased to run hospitals but purchased care from their own or other authorities ' hospitals . Certain GPs became fund holders and were able to purchase care for their patients . The providers became independent trusts , which encouraged competition but also increased local differences . Increasing competition may have been statistically associated with poor patient outcomes . # Changes under the Blair government # These innovations , especially the fund holder option , were condemned at the time by the Labour Party . Opposition to what was claimed to be the Conservative intention to privatise the NHS became a major feature of Labour 's election campaigns . Labour came to power in 1997 with the promise to remove the internal market and abolish fundholding . However in his second term Blair renounced this direction . He pursued measures to strengthen the internal market as part of his plan to modernise the NHS . A number of factors drove these reforms . They include the rising costs of medical technology and medicines , the desire to improve standards and patient choice , an ageing population , and a desire to contain government expenditure . ( Since the National Health Services in Wales , Scotland and Northern Ireland are not controlled by the UK government , these reforms have increased the differences between the National Health Services in different parts of the United Kingdom . See NHS Wales and NHS Scotland for descriptions of their developments ) . Reforms included ( amongst other actions ) the laying down of detailed service standards , strict financial budgeting , revised job specifications , reintroduction of fundholding ( under the description practice-based commissioning ) , closure of surplus facilities and emphasis on rigorous clinical and corporate governance . Some new services were developed to help manage demand , including NHS Direct . The Agenda for Change agreement aimed to provide harmonised pay and career progression . These changes have , however , given rise to controversy within the medical professions , the news media and the public . The British Medical Association in 2009 in a document on Independent Sector Treatment Centres urged the Government to restore the NHS to a service based on public provision , not private ownership ; co-operation , not competition ; integration , not fragmentation ; public service , not private profits . The Blair Government , whilst leaving services free at point of use , encouraged outsourcing of medical services and support to the private sector . Under the Private Finance Initiative , an increasing number of hospitals were built ( or rebuilt ) by private sector consortia ; hospitals may have both medical services such as independent Sector Treatment Centres ( ISTCs ) and non-medical services such as catering provided under long-term contracts by the private sector . A study by a consultancy company which works for the Department of Health shows that every 200 million spent on privately financed hospitals will result in the loss of 1000 doctors and nurses . The first PFI hospitals contain some 28 per cent fewer beds than the ones they replaced . The NHS was also required to take on pro-active socially directive policies , for example , in respect of smoking and obesity. # Internet information service # In the 1980s and 90s , NHS IT spent money on several failed IT projects . The Wessex project , in the 1980s , attempted to standardise IT systems across a regional health authority . The London Ambulance Service was to be a computer-aided dispatch system . Read codes was an attempt to develop a new electronic language of health . The NHS Information Authority ( NHSIA ) was established by an Act of Parliament in 1999 with the goal to bring together four NHS IT and Information bodies ( NHS Telecoms , Family Health Service ( FHS ) , NHS Centre for Coding and Classification ( CCC ) and NHS Information Management Group ( IMG ) to work together to deliver IT infrastructure and information solutions to the NHS in England . A 2002 plan was for NHSIA to implement four national IT projects : Basic infrastructure , Electronic records , Electronic prescribing , and Electronic booking , modeled after the large NHS Direct tele-nurse and healthcare website program . The NHSIA functions were divided into other organizations by April 2005 . In 2002 , the NHS National Programme for IT ( NPfIT ) was announced by the Department of Health . Despite problems with internal IT programmes , the NHS has broken new ground in providing health information to the public via the internet . In June 2007 was relaunched under the banner as a comprehensive health information service for the public . In a break with the norm for government sites , www.nhs.uk allows users to add public comments giving their views on individual hospitals and to add comments to the articles it carries . It also publishes blogs on a range of health topics written by patients , carers and clinicians and enables users to compare hospitals for treatment via a scorecard . In April 2009 it became the first official site to publish hospital death rates ( Hospital Standardised Mortality Rates ) for the whole of England . Its Behind the Headlines daily health news analysis service , which critically appraises media stories and the science behind them , was declared Best Innovation in Medical Communication in the prestigious BMJ Group Awards 2009. 11 of the NHS hospitals in the West London Cancer Network have been linked using the IOCOM Grid System . The NHS has reported that the Grid has helped increase collaboration and meeting attendance and even improved clinical decisions . # Health screening for over 40s # From 1 April 2008 , everyone over 40 years old will be offered health checks for heart disease , stroke , diabetes and kidney disease under new government plans . However , doctors currently reserve judgment on the effectiveness of the policy . # Public satisfaction and criticism # An independent survey conducted in 2004 found that users of the NHS often expressed very high levels of satisfaction about their personal experience of the medical services . Of hospital inpatients , 92% said they were satisfied with their treatment ; 87% of GP users were satisfied with their GP ; 87% of hospital outpatients were satisfied with the service they received ; and 70% of Accident and Emergency department users reported being satisfied . When asked whether they agreed with the question My local NHS is providing me with a good service 67% of those surveyed agreed with it , and 51% agreed with the statement The NHS is providing a good service . The reason for this disparity between personal experience and overall perceptions is not clear , however researchers at King 's College London found high profile media spectacles may function as part a wider ' blame business ' , in which the media , lawyers and regulators have vested interests . It is also apparent from the satisfaction survey that most people believe that the national press is generally critical of the service ( 64% reporting it as being critical compared to just 13% saying the national press is favourable ) , and also that the national press is the least reliable source of information ( 50% reporting it to be not very or not at all reliable , compared to 36% believing the press was reliable ) . Newspapers were reported as being less favourable and also less reliable than the broadcast media . The most reliable sources of information were considered to be leaflets from GPs and information from friends ( both 77% reported as reliable ) and medical professionals ( 75% considered reliable ) . Some examples of criticism include : #Some extremely expensive treatments may be available in some areas but not in others , the so-called postcode lottery . #The National Programme for IT which was designed to provide the infrastructure for electronic prescribing , booking appointments and elective surgery , and a national care records service . The programme ran into delays and overspends before it was finally abandoned . #In 2008 there was a decreasing availability of NHS dentistry following a new government contract and a trend towards dentists accepting private patients only , with 1 in 10 dentists having left the NHS totally . However , the number of NHS dental patients is now increasing . #There have been a number of high-profile scandals within the NHS . Most recently there have been scandals at acute hospitals such as at Alder Hey and at the Bristol Royal Infirmary . Stafford Hospital is currently under investigation for poor conditions and inadequacies that statistical analysis has shown caused excess deaths . #A 14 October 2008 article in The Daily Telegraph stated , An NHS trust has spent more than 12,000 on private treatment for hospital staff because its own waiting times are too long . #In January 2010 , the NHS was accused of allocating 4 million annually on homeopathic medicines , which are unsupported by scientific research . #The absence of identity/residence checks on patients at clinics and hospitals allows people who ordinarily reside overseas to travel to the UK for the purpose of obtaining free treatment , at the expense of the UK taxpayer . A report published in 2007 estimates that the NHS bill for treatment of so-called health tourists was 30m , 0.03% of the total cost . NHS mental health services is one area that tends to receive regular criticism from service users and the public , for sometimes opposing reasons . # Quality of healthcare , and accreditation # There are various regulatory bodies in the UK , both government-based ( e.g. Department of Health , General Medical Council , Nursing and Midwifery Council ) and non-governmental-based ( e.g. Royal Colleges ) . Some of these organisations have a high worldwide standing . With respect to assessing , maintaining and improving the quality of healthcare , in common with the United States and many other developed countries , the UK government has separated the roles of suppliers of healthcare and assessors of the quality of its delivery . Quality is assessed by independent bodies such as the Healthcare Commission according to standards set by the Department of Health and the National Institute for Health and Clinical Excellence . Responsibility for assessing quality transferred to the Care Quality Commission in April 2009 . Independent accreditation groups exist within the UK , such as the public sector Trent Accreditation Scheme and the private sector CHKS . The National Institute for Health Research is a government body that coordinates and funds research for the NHS in England . A recent comparative analysis of health care systems put the NHS second in a study of seven rich countries . The report put the UK health systems above those of Germany , Canada and the US ; the NHS was deemed the most efficient among those health systems studied . 
@@16453539 In medicine , an acute disease is a disease with a rapid onset and/or a short course . Acute may be used to distinguish a disease from a chronic ( medicine ) # Terminology # The term acute may often be confused by the general public to mean severe The term acute is also included in the definition of several diseases , such as severe acute respiratory syndrome , acute leukemia , acute myocardial infarction , and acute hepatitis . This is often to distinguish diseases from their chronic forms , such as chronic leukemia , or to highlight the sudden onset of the disease , such as acute myocardial infarct . Associated terms may include :  ' ' Peracute ' ' , meaning very acute or violent .  ' ' Acute on chronic ' ' , referring to an acute exacerbation of a chronic condition .  ' ' Acute on chronic inflammation ' ' , a term sometimes used in pathology sometimes used to describe a pattern of inflammation which is a mixture of chronic and acute inflammation . It may be seen in asthma , rheumatoid arthritis , chronic peptic ulcer , chronic periodontitis , tuberculosis , tonsillitis and other conditions .  ' ' Subacute ' ' , a poorly defined state between acute and chronic , for example subacute endocarditis , or subacute sclerosing panencephalitis.  ' ' Chronic ' ' , referring to a long-term condition . # Acute care # Acute care is the early and specialist management of adult patients suffering from a wide range of medical conditions requiring urgent or emergency care usually within 48 hours of admission or referral from other specialties . Acute hospitals are those intended for short-term medical and/or surgical treatment and care . The related medical speciality is acute medicine . 
@@16462572 The four publicly funded healthcare systems in the countries of the United Kingdom , may be referred to as the National Health Service ( NHS ) . The systems are primarily funded through central taxation . They provide a comprehensive range of health services , the vast majority of which are free at the point of use for people legally resident in the United Kingdom . The four systems are mostly independent from each other although some functions might be routinely performed on behalf of the UK Department of Health or for one of the other three systems ( e.g. Northern Ireland has no high security mental hospitals and thus depends on using hospitals in Great Britain , routinely Carstairs State Mental Hospital in Scotland for male patients and Rampton Secure Hospital in England for female patients ) ; otherwise , they operate under different management , rules , and political authority . The individual systems are :  National Health Service ( England )  Health and Social Care in Northern Ireland  NHS Scotland  NHS Wales All services are often referred to as the NHS , although only the English NHS is officially called the National Health Service . All of the services were founded in 1948 , based on legislation passed in 1946 , 1947 and 1948 . NHS Wales was part of the same structure as England until powers over the NHS in Wales were transferred to the Secretary of State for Wales in 1969 , and responsibility for NHS Wales was passed to the Welsh Government under devolution in 1999. # History # The Labour Government elected in 1945 had made manifesto commitments to implement the recommendations of the Beveridge Report of 1942 . The report 's recommendation to create comprehensive health and rehabilitation services for prevention and cure of disease was implemented across the United Kingdom on 5th July 1948 . The services were initially funded through general taxation and National Insurance as part of the introduction of a wider Welfare State . They were initially free at the point of use , although some prescription charges were soon introduced in response to economic difficulties . These charges are still in place with the English NHS , but not in the other three systems . In the UK Parliament at Westminster , the new health services were established through two Acts : The National Health Service Act 1946 , creating the National Health Service in England and Wales  The National Health Service ( Scotland ) Act 1947 , creating the National Health Service in Scotland From 1969 the National Health Service in Wales became a separate entity under the Secretary of State for Wales . In the Parliament of Northern Ireland at Stormont :  Health Services Act ( Northern Ireland ) 1948 , creating a Health Service in Northern Ireland . # Recent # Following devolution in the United Kingdom from 1998 onward , control over the non-English services ( other than those ' ' reserved ' ' to the UK Parliament ) passed to the devolved national governments , with the UK Government retaining control over the English NHS . The English NHS underwent a major reorganization in the years after 2010 in the run-up to and passing of the Health and Social Care Act 2012. # Structure # Each system operates independently , and is politically accountable to the relevant government : the Scottish Government , Welsh Government , the Northern Ireland Executive , and the UK Government which is responsible for England 's NHS . Despite their separate funding and administration , there is no discrimination when a resident of one country of the United Kingdom requires treatment in another , although a patient will often be returned to their home area when they are fit to be moved . The financial and administrative consequences are dealt with by the organisations involved and no personal involvement by the patient is required . Treatment of people not resident in the United Kingdom is subject to mostly uniform arrangements made by or delegated to the UK Department of Health rather than any individual health service . Foreign nationals always receive treatment free at the time of use for emergencies . Foreign nationals also receive free treatment if they have been legally resident in the UK for 12 months , have recently arrived to take up permanent residence , are claiming asylum or have other legal resident status . Citizens of European Economic Area nations , as well as those from countries with which the UK has a reciprocal arrangements , are also entitled to free treatment by using the European Health Insurance Card . Foreign nationals may be subject to an interview to establish their nationality and residence status , which must be resolved before non-emergency treatment can commence . Patients who do not qualify for free treatment are asked to pay in advance , or to sign a written undertaking to pay . Treatment for injuries caused in a road traffic accident has been chargeable since the 1930s , but such charges were not generally enforced until the came into force to direct the charges to the insurers of the vehicles involved . This necessarily involves patients in the charging process even though they are not personally billed for treatment . # Funding # Each National Health Service is mainly funded ultimately from general taxation ( with a much smaller amount from National Insurance contributions ) . Other , less significant sources of income include charging overseas visitors and their insurers for the cost of NHS treatment , charges to patients for prescriptions and dental treatment , hospital car parking , patient telephone services , etc . NHS Trusts can earn income through treating patients privately ; in England Trusts generate 0.6% of core revenues this way , much less in the rest of the UK . Expenditure for 2012/13 is planned to be :  108.9 billion for National Health Service ( England )  3.9bn for Health and Social Care in Northern Ireland  9.38bn for NHS Scotland  5.3bn for NHS Wales The UK Parliament sets the overall budget available to the NHS in England . It also allocates a block grant to each devolved national government to spend on local needs . Each government may choose how much of its block grant to spend on its health care system . 
@@18914017 ICDO= Alzheimer 's disease ( AD ) , also known in medical literature as Alzheimer disease , is the most common form of dementia . There is no cure for the disease , which worsens as it progresses , and eventually leads to death . It was first described by German psychiatrist and neuropathologist Alois Alzheimer in 1906 and was named after him . Most often , AD is diagnosed in people over 65 years of age , although the less-prevalent early-onset Alzheimer 's can occur much earlier . In 2006 , there were people worldwide with AD . Alzheimer 's is predicted to affect 1 in 85 people globally by 2050 . Although Alzheimer 's disease develops differently for every individual , there are many common symptoms . Early symptoms are often mistakenly thought to be ' age-related ' concerns , or manifestations of stress . In the early stages , the most common symptom is difficulty in remembering recent events , known as short term memory loss . When AD is suspected , the diagnosis is usually confirmed with tests that evaluate behaviour and thinking abilities , often followed by a brain scan if available , however , examination of brain tissue is required for a definitive diagnosis . As the disease advances , symptoms can include confusion , irritability , aggression , mood swings , trouble with language , and long-term memory loss . As the person 's condition declines they often withdraw from family and society . Gradually , bodily functions are lost , ultimately leading to death . Since the disease is different for each individual , predicting how it will affect the person is difficult . AD develops for an unknown and variable amount of time before becoming fully apparent , and it can progress undiagnosed for years . On average , the life expectancy following diagnosis is approximately seven years . Fewer than 3% of individuals live more than 14 years after diagnosis . AD is classified as a neurodegenerative disorder . The cause and progression of the disease are not well understood ; it is associated with plaques and tangles in the brain . Current treatments only help with the symptoms of the disease . There are no available treatments that stop or reverse the progression of the disease . as of Because AD can not be cured and is degenerative , the affected person increasingly relies on others for assistance . The role of the main caregiver is often taken by the spouse or a close relative . Alzheimer 's disease is known for placing a great burden on caregivers ; the pressures can be wide-ranging , involving social , psychological , physical , and economic elements of the caregiver 's life . In developed countries , AD is one of the most costly diseases to society . # Characteristics # , which claims Alzheimers Association guidance as a source Misplacing items sometimes Forgetting that memory lapses happened ; Early stage Alzheimer 's Absent-mindedness Slight changes seen by close loved ones Some confusion in situations outside the familiar ; Middle stage Alzheimer 's Deeper difficulty remembering recently learned information Speech impairment ; Late stage Alzheimer 's More aggressive or passive Debilitating cognitive deficit The disease course is divided into four stages , with progressive patterns of cognitive and functional impairments . # Pre-dementia # The first symptoms are often mistakenly attributed to ageing or stress . Detailed neuropsychological testing can reveal mild cognitive difficulties up to eight years before a person fulfils the clinical criteria for diagnosis of AD . These early symptoms can affect the most complex daily living activities . The most noticeable deficit is memory loss , which shows up as difficulty in remembering recently learned facts and inability to acquire new information . Subtle problems with the executive functions of attentiveness , planning , flexibility , and abstract thinking , or impairments in semantic memory ( memory of meanings , and concept relationships ) can also be symptomatic of the early stages of AD . Apathy can be observed at this stage , and remains the most persistent neuropsychiatric symptom throughout the course of the disease . Depressive symptoms , irritability and reduced awareness of subtle memory difficulties also occur commonly . The preclinical stage of the disease has also been termed mild cognitive impairment , but whether this term corresponds to a different diagnostic stage or identifies the first step of AD is a matter of dispute . # Early # In people with AD the increasing impairment of learning and memory eventually leads to a definitive diagnosis . In a small portion of them , difficulties with language , executive functions , perception ( agnosia ) , or execution of movements ( apraxia ) are more prominent than memory problems . AD does not affect all memory capacities equally . Older memories of the person 's life ( episodic memory ) , facts learned ( semantic memory ) , and implicit memory ( the memory of the body on how to do things , such as using a fork to eat ) are affected to a lesser degree than new facts or memories . Language problems are mainly characterised by a shrinking vocabulary and decreased word fluency , which lead to a general impoverishment of oral and written language . In this stage , the person with Alzheimer 's is usually capable of communicating basic ideas adequately . While performing fine motor tasks such as writing , drawing or dressing , certain movement co-ordination and planning difficulties ( apraxia ) may be present but they are commonly unnoticed . As the disease progresses , people with AD can often continue to perform many tasks independently , but may need assistance or supervision with the most cognitively demanding activities . # Moderate # Progressive deterioration eventually hinders independence , with subjects being unable to perform most common activities of daily living . Speech difficulties become evident due to an inability to recall vocabulary , which leads to frequent incorrect word substitutions ( paraphasias ) . Reading and writing skills are also progressively lost . Complex motor sequences become less coordinated as time passes and AD progresses , so the risk of falling increases . During this phase , memory problems worsen , and the person may fail to recognise close relatives . Long-term memory , which was previously intact , becomes impaired . Behavioural and neuropsychiatric changes become more prevalent . Common manifestations are wandering , irritability and labile affect , leading to crying , outbursts of unpremeditated aggression , or resistance to caregiving . Sundowning can also appear . Approximately 30% of people with AD develop illusionary misidentifications and other delusional symptoms . Subjects also lose insight of their disease process and limitations ( anosognosia ) . These symptoms create stress for relatives and caretakers , which can be reduced by moving the person from home care to other long-term care facilities . # Advanced # During the final stage of AD , the person is completely dependent upon caregivers . Language is reduced to simple phrases or even single words , eventually leading to complete loss of speech . Despite the loss of verbal language abilities , people can often understand and return emotional signals . Although aggressiveness can still be present , extreme apathy and exhaustion are much more common symptoms . Persons with Alzheimer 's disease will ultimately not be able to perform even the simplest tasks without any assistance . Muscle mass and mobility deteriorate to the point where they are bedridden , and they lose the ability to feed themselves . AD is a terminal illness , with the cause of death typically being an external factor , such as infection of pressure ulcers or pneumonia , not the disease itself . # Cause # The cause for most Alzheimer 's cases is still mostly unknown except for 1% to 5% of cases where genetic differences have been identified . Several competing hypotheses exist trying to explain the cause of the disease : # Genetics # Around 0.1% of the cases are familial forms of autosomal ( not sex-linked ) dominant inheritance , which usually have an onset before age 65 . This form of the disease is known as early onset familial Alzheimer 's disease . Most of autosomal dominant familial AD can be attributed to mutations in one of three genes : those encoding amyloid precursor protein ( APP ) and presenilins 1 and 2 . Most mutations in the APP and presenilin genes increase the production of a small protein called A <sub> </sub> 42 , which is the main component of senile plaques . Some of the mutations merely alter the ratio between A42 and the other major formse.g. , A40without increasing A42 levels . This suggests that presenilin mutations can cause disease even if they lower the total amount of A <sub> </sub> produced and may point to other roles of presenilin or a role for alterations in the function of APP and/or its fragments other than A <sub> </sub> . There exist variants of the APP gene which are protective . Most cases of Alzheimer 's disease do not exhibit autosomal-dominant inheritance and are termed sporadic AD , in which environmental and genetic differences may act as risk factors . The best known genetic risk factor is the inheritance of the 4 allele of the apolipoprotein E ( APOE ) . Between 40 and 80% of people with AD possess at least one APOE4 allele . The APOE4 allele increases the risk of the disease by three times in heterozygotes and by 15 times in homozygotes . Like many human diseases , environmental effects and genetic modifiers result in incomplete penetrance . For example , certain Nigerian populations do not show the relationship between dose of APOE4 and incidence or age-of-onset for Alzheimer 's disease seen in other human populations . Early attempts to screen up to 400 candidate genes for association with late-onset sporadic AD ( LOAD ) resulted in a low yield , More recent genome-wide association studies ( GWAS ) have found 19 areas in genes that appear to affect the risk . These genes include : CASS4 , CELF1 , FERMT2 , HLA-DRB5 , INPP5D , MEF2C , NME8 , PTK2B , SORL1 , ZCWPW1 , SlC24A4 , CLU , PICALM , CR1 , BIN1 , MS4A , ABCA7 , EPHA1 , and CD2AP . Mutations in the TREM2 gene have been associated with a 3 to 5 times higher risk of developing Alzheimer 's disease . A suggested mechanism of action is that when TREM2 is mutated , white blood cells in the brain are no longer able to control the amount of beta amyloid present . # Cholinergic hypothesis # The oldest , on which most currently available drug therapies are based , is the ' ' cholinergic hypothesis ' ' , which proposes that AD is caused by reduced synthesis of the neurotransmitter acetylcholine . The cholinergic hypothesis has not maintained widespread support , largely because medications intended to treat acetylcholine deficiency have not been very effective . Other cholinergic effects have also been proposed , for example , initiation of large-scale aggregation of amyloid , leading to generalised neuroinflammation. # Amyloid hypothesis # In 1991 , the ' ' amyloid hypothesis ' ' postulated that extracellular beta-amyloid ( A <sub> </sub> ) deposits are the fundamental cause of the disease . Support for this postulate comes from the location of the gene for the amyloid precursor protein ( APP ) on chromosome 21 , together with the fact that people with trisomy 21 ( Down Syndrome ) who have an extra gene copy almost universally exhibit AD by 40 years of age . Also , a specific isoform of apolipoprotein , APOE4 , is a major genetic risk factor for AD . Whilst apolipoproteins enhance the breakdown of beta amyloid , some isoforms are not very effective at this task ( such as APOE4 ) , leading to excess amyloid buildup in the brain . Further evidence comes from the finding that transgenic mice that express a mutant form of the human APP gene develop fibrillar amyloid plaques and Alzheimer's-like brain pathology with spatial learning deficits . An experimental vaccine was found to clear the amyloid plaques in early human trials , but it did not have any significant effect on dementia . Researchers have been led to suspect non-plaque A <sub> </sub> oligomers ( aggregates of many monomers ) as the primary pathogenic form of A <sub> </sub> . These toxic oligomers , also referred to as amyloid-derived diffusible ligands ( ADDLs ) , bind to a surface receptor on neurons and change the structure of the synapse , thereby disrupting neuronal communication . One receptor for A <sub> </sub> oligomers may be the prion protein , the same protein that has been linked to mad cow disease and the related human condition , CreutzfeldtJakob disease , thus potentially linking the underlying mechanism of these neurodegenerative disorders with that of Alzheimer 's disease . In 2009 , this theory was updated , suggesting that a close relative of the beta-amyloid protein , and not necessarily the beta-amyloid itself , may be a major culprit in the disease . The theory holds that an amyloid-related mechanism that prunes neuronal connections in the brain in the fast-growth phase of early life may be triggered by ageing-related processes in later life to cause the neuronal withering of Alzheimer 's disease . N-APP , a fragment of APP from the peptide 's N-terminus , is adjacent to beta-amyloid and is cleaved from APP by one of the same enzymes . N-APP triggers the self-destruct pathway by binding to a neuronal receptor called death receptor 6 ( DR6 , also known as TNFRSF21 ) . DR6 is highly expressed in the human brain regions most affected by Alzheimer 's , so it is possible that the N-APP/DR6 pathway might be hijacked in the ageing brain to cause damage . In this model , beta-amyloid plays a complementary role , by depressing synaptic function . # Tau hypothesis # The ' ' tau hypothesis ' ' is the idea that tau protein abnormalities initiate the disease cascade . In this model , hyperphosphorylated tau begins to pair with other threads of tau . Eventually , they form neurofibrillary tangles inside nerve cell bodies . When this occurs , the microtubules disintegrate , collapsing the neuron 's transport system . This may result first in malfunctions in biochemical communication between neurons and later in the death of the cells . # Other hypotheses # Herpes simplex virus type 1 has been proposed to play a causative role in people carrying the susceptible versions of the apoE gene . The cellular homeostasis of ionic copper , iron , and zinc is disrupted in AD , though it remains unclear whether this is produced by or causes the changes in proteins . These ions affect ' ' and ' ' are affected by tau , APP , and APOE . Some studies have shown an increased risk of developing AD with environmental factors such as the intake of metals , particularly aluminium . The quality of some of these studies has been criticised , and other studies have concluded that there is no relationship between these environmental factors and the development of AD . Some have hypothesized that dietary copper may play a causal role . While some studies suggest that extremely low frequency electromagnetic fields may increase the risk for Alzheimer 's disease , reviewers found that further epidemiological and laboratory investigations of this hypothesis are needed . Smoking is a significant AD risk factor . Systemic markers of the innate immune system are risk factors for late-onset AD . Another hypothesis asserts that the disease may be caused by age-related myelin breakdown in the brain . Iron released during myelin breakdown is hypothesised to cause further damage . Homeostatic myelin repair processes contribute to the development of proteinaceous deposits such as beta-amyloid and tau . Oxidative stress and dys-homeostasis of biometal ( biology ) metabolism may be significant in the formation of the pathology . AD individuals show 70% loss of locus coeruleus cells that provide norepinephrine ( in addition to its neurotransmitter role ) that locally diffuses from varicosities as an endogenous anti-inflammatory agent in the microenvironment around the neurons , glial cells , and blood vessels in the neocortex and hippocampus . It has been shown that norepinephrine stimulates mouse microglia to suppress A <sub> </sub> -induced production of cytokines and their phagocytosis of A <sub> </sub> . This suggests that degeneration of the locus ceruleus might be responsible for increased A <sub> </sub> deposition in AD brains . There is tentative evidence that exposure to air pollution may be a contributing factor to the development of Alzheimer 's disease . # Pathophysiology # # Neuropathology # Alzheimer 's disease is characterised by loss of neurons and synapses in the cerebral cortex and certain subcortical regions . This loss results in gross atrophy of the affected regions , including degeneration in the temporal lobe and parietal lobe , and parts of the frontal cortex and cingulate gyrus . Degeneration is also present in brainstem nuclei like the locus coeruleus . Studies using MRI and PET have documented reductions in the size of specific brain regions in people with AD as they progressed from mild cognitive impairment to Alzheimer 's disease , and in comparison with similar images from healthy older adults . Both amyloid plaques and neurofibrillary tangles are clearly visible by microscopy in brains of those afflicted by AD . Plaques are dense , mostly insoluble deposits of beta-amyloid peptide and cellular material outside and around neurons . Tangles ( neurofibrillary tangles ) are aggregates of the microtubule-associated protein tau which has become hyperphosphorylated and accumulate inside the cells themselves . Although many older individuals develop some plaques and tangles as a consequence of ageing , the brains of people with AD have a greater number of them in specific brain regions such as the temporal lobe . Lewy bodies are not rare in the brains of people with AD. # Biochemistry # Alzheimer 's disease has been identified as a protein misfolding disease ( proteopathy ) , caused by plaque accumulation of abnormally folded beta amyloid and tau amyloid proteins in the brain . Plaques are made up of small peptides , 3943 amino acids in length , called beta-amyloid ( A <sub> </sub> ) . Beta-amyloid is a fragment from a larger protein called amyloid precursor protein ( APP ) , a transmembrane protein that penetrates through the neuron 's membrane . APP is critical to neuron growth , survival and post-injury repair . In Alzheimer 's disease , an unknown process causes APP to be divided into smaller fragments by enzymes through proteolysis . One of these fragments gives rise to fibrils of beta-amyloid , which form clumps that deposit outside neurons in dense formations known as senile plaques . AD is also considered a tauopathy due to abnormal aggregation of the tau protein . Every neuron has a cytoskeleton , an internal support structure partly made up of structures called microtubules . These microtubules act like tracks , guiding nutrients and molecules from the body of the cell to the ends of the axon and back . A protein called ' ' tau ' ' stabilises the microtubules when phosphorylated , and is therefore called a microtubule-associated protein . In AD , tau undergoes chemical changes , becoming hyperphosphorylated ; it then begins to pair with other threads , creating neurofibrillary tangles and disintegrating the neuron 's transport system . # Disease mechanism # Exactly how disturbances of production and aggregation of the beta-amyloid peptide gives rise to the pathology of AD is not known . The amyloid hypothesis traditionally points to the accumulation of beta-amyloid peptides as the central event triggering neuron degeneration . Accumulation of aggregated amyloid fibrils , which are believed to be the toxic form of the protein responsible for disrupting the cell 's calcium ion homeostasis , induces programmed cell death ( apoptosis ) . It is also known that A <sub> </sub> selectively builds up in the mitochondria in the cells of Alzheimer's-affected brains , and it also inhibits certain enzyme functions and the utilisation of glucose by neurons . Various inflammatory processes and cytokines may also have a role in the pathology of Alzheimer 's disease . Inflammation is a general marker of tissue damage in any disease , and may be either secondary to tissue damage in AD or a marker of an immunological response . Alterations in the distribution of different neurotrophic factors and in the expression of their receptors such as the brain-derived neurotrophic factor ( BDNF ) have been described in AD. # Diagnosis # Alzheimer 's disease is usually diagnosed based on the person 's history , history from relatives , and observations of the person 's behaviours . The presence of characteristic neurological and neuropsychological features and the absence of alternative conditions is supportive . Advanced medical imaging with computed tomography ( CT ) or magnetic resonance imaging ( MRI ) , and with single-photon emission computed tomography ( SPECT ) or positron emission tomography ( PET ) can be used to help exclude other cerebral pathology or subtypes of dementia . Moreover , it may predict conversion from prodromal stages ( mild cognitive impairment ) to Alzheimer 's disease . Assessment of intellectual functioning including memory testing can further characterise the state of the disease . Medical organisations have created diagnostic criteria to ease and standardise the diagnostic process for practising physicians . The diagnosis can be confirmed with very high accuracy post-mortem when brain material is available and can be examined histologically. # Criteria # The National Institute of Neurological and Communicative Disorders and Stroke ( NINCDS ) and the Alzheimer 's Disease and Related Disorders Association ( ADRDA , now known as the Alzheimer 's Association ) established the most commonly used NINCDS-ADRDA Alzheimer 's Criteria for diagnosis in 1984 , extensively updated in 2007 . These criteria require that the presence of cognitive impairment , and a suspected dementia syndrome , be confirmed by neuropsychological testing for a clinical diagnosis of possible or probable AD . A histopathologic confirmation including a microscopic examination of brain tissue is required for a definitive diagnosis . Good statistical reliability and validity have been shown between the diagnostic criteria and definitive histopathological confirmation . Eight cognitive domains are most commonly impaired in ADmemory , language , perceptual skills , attention , constructive abilities , orientation , problem solving and functional abilities . These domains are equivalent to the NINCDS-ADRDA Alzheimer 's Criteria as listed in the ' ' Diagnostic and Statistical Manual of Mental Disorders ' ' ( DSM-IV-TR ) published by the American Psychiatric Association . # Techniques # Neuropsychological tests such as the minimental state examination ( MMSE ) are widely used to evaluate the cognitive impairments needed for diagnosis . More comprehensive test arrays are necessary for high reliability of results , particularly in the earliest stages of the disease . Neurological examination in early AD will usually provide normal results , except for obvious cognitive impairment , which may not differ from that resulting from other diseases processes , including other causes of dementia . Further neurological examinations are crucial in the differential diagnosis of AD and other diseases . Interviews with family members are also utilised in the assessment of the disease . Caregivers can supply important information on the daily living abilities , as well as on the decrease , over time , of the person 's mental function . A caregiver 's viewpoint is particularly important , since a person with AD is commonly unaware of his own deficits . Many times , families also have difficulties in the detection of initial dementia symptoms and may not communicate accurate information to a physician . Supplemental testing provides extra information on some features of the disease or is used to rule out other diagnoses . Blood tests can identify other causes for dementia than AD causes which may , in rare cases , be reversible . It is common to perform thyroid function tests , assess B12 , rule out syphilis , rule out metabolic problems ( including tests for kidney function , electrolyte levels and for diabetes ) , assess levels of heavy metals ( e.g. lead , mercury ) and anaemia . ( See differential diagnosis for Dementia ) . ( It is also necessary to rule out delirium ) . Psychological tests for depression are employed , since depression can either be concurrent with AD ( see Depression of Alzheimer disease ) , an early sign of cognitive impairment , or even the cause . # Early diagnosis # Emphasis in Alzheimer 's research has been placed on diagnosing the condition before symptoms begin . A number of biochemical tests have been developed to allow for early detection . One such test involves the analysis of cerebrospinal fluid for beta-amyloid or tau proteins , both total tau protein and phosphorylated tau <sub> 181P </sub> protein concentrations . Searching for these proteins using a spinal tap can predict the onset of Alzheimer 's with a sensitivity of between 94% and 100% . When used in conjunction with existing neuroimaging techniques , doctors can identify people with significant memory loss who are already developing the disease . # Prevention # At present , there is no definitive evidence to support that any particular measure is effective in preventing AD . Global studies of measures to prevent or delay the onset of AD have often produced inconsistent results . Epidemiological studies have proposed relationships between certain modifiable factors , such as diet , cardiovascular risk , pharmaceutical products , or intellectual activities among others , and a population 's likelihood of developing AD . Only further research , including clinical trials , will reveal whether these factors can help to prevent AD. # Medication # Although cardiovascular risk factors , such as hypercholesterolaemia , hypertension , diabetes , and smoking , are associated with a higher risk of onset and course of AD , statins , which are cholesterol lowering drugs , have not been effective in preventing or improving the course of the disease . Long-term usage of non-steroidal anti-inflammatory drugs ( NSAIDs ) is associated with a reduced likelihood of developing AD . Human postmortem studies , in animal models , or in vitro investigations also support the notion that NSAIDs can reduce inflammation related to amyloid plaques . However , trials investigating their use as palliative treatment have failed to show positive results , apparently because the brain NSAID concentration after an oral NSAID dose is exceedingly small . No prevention trial has been completed . Hormone replacement therapy , although previously used , may increase the risk of dementia . # Lifestyle # People who engage in intellectual activities such as reading , playing board games , completing crossword puzzles , playing musical instruments , or regular social interaction show a reduced risk for Alzheimer 's disease . This is compatible with the cognitive reserve theory , which states that some life experiences result in more efficient neural functioning providing the individual a cognitive reserve that delays the onset of dementia manifestations . Education delays the onset of AD syndrome , but is not related to earlier death after diagnosis . Learning a second language even later in life seems to delay getting Alzheimer disease . Physical activity is also associated with a reduced risk of AD. # Diet # People who eat a mediterranean diet have a lower risk of AD , and it may improve outcomes in those with the disease . Those who eat a diet high in saturated fats and simple carbohydrates have a higher risk . The mediterranean diet 's beneficial cardiovascular effect has been proposed as the mechanism of action . There is limited evidence that light to moderate use of alcohol , particularly red wine , is associated with lower risk of AD . There is tentative evidence that caffeine may be protective . A number of foods high in flavonoids such as cocoa , red wine , and tea may decrease the risk of AD . Reviews on the use of vitamins and minerals have not found enough consistent evidence to recommend them . This includes vitamin A , C , E , selenium , zinc , and folic acid with or without vitamin B <sub> 12 </sub> . Additionally vitamin E is associated with health risks . Trials examining folic acid ( B9 ) and other B vitamins failed to show any significant association with cognitive decline . In those already affected with AD adding docosahexaenoic acid , an Omega 3 fatty acid , to the diet has not been found to slow decline . Curcumin as of 2010 has not shown benefit in people even though there is tentative evidence in animals . There is inconsistent and unconvincing evidence that ginkgo has any positive effect on cognitive impairment and dementia . As of 2008 there is no concrete evidence that cannabinoids are effective in improving the symptoms of AD or dementia . Some research in its early stages however looks promising . # Management # There is no cure for Alzheimer 's disease ; available treatments offer relatively small symptomatic benefit but remain palliative in nature . Current treatments can be divided into pharmaceutical , psychosocial and caregiving. # Medications # Five medications are currently used to treat the cognitive problems of AD : four are acetylcholinesterase inhibitors ( tacrine , rivastigmine , galantamine and donepezil ) and the other ( memantine ) is an NMDA receptor antagonist . The benefit from their use is small . No medication has been clearly shown to delay or halt the progression of the disease . Reduction in the activity of the cholinergic neurons is a well-known feature of Alzheimer 's disease . Acetylcholinesterase inhibitors are employed to reduce the rate at which acetylcholine ( ACh ) is broken down , thereby increasing the concentration of ACh in the brain and combating the loss of ACh caused by the death of cholinergic neurons . There is evidence for the efficacy of these medications in mild to moderate Alzheimer 's disease , and some evidence for their use in the advanced stage . Only donepezil is approved for treatment of advanced AD dementia . The use of these drugs in mild cognitive impairment has not shown any effect in a delay of the onset of AD . The most common side effects are nausea and vomiting , both of which are linked to cholinergic excess . These side effects arise in approximately 1020% of users and are mild to moderate in severity . Less common secondary effects include muscle cramps , decreased heart rate ( bradycardia ) , decreased appetite and weight , and increased gastric acid production . Glutamate is a useful excitatory neurotransmitter of the nervous system , although excessive amounts in the brain can lead to cell death through a process called excitotoxicity which consists of the overstimulation of glutamate receptors . Excitotoxicity occurs not only in Alzheimer 's disease , but also in other neurological diseases such as Parkinson 's disease and multiple sclerosis . Memantine ( brand names : Ebixa , Maruxa , Memanxa and Namenda ) is a noncompetitive NMDA receptor antagonist first used as an anti-influenza agent . It acts on the glutamatergic system by blocking NMDA receptors and inhibiting their overstimulation by glutamate . Memantine has been shown to be moderately efficacious in the treatment of moderate to severe Alzheimer 's disease . Its effects in the initial stages of AD are unknown . Reported adverse events with memantine are infrequent and mild , including hallucinations , confusion , dizziness , headache and fatigue . The combination of memantine and donepezil has been shown to be of statistically significant but clinically marginal effectiveness . Antipsychotic drugs are modestly useful in reducing aggression and psychosis in Alzheimer 's disease with behavioural problems , but are associated with serious adverse effects , such as stroke , movement difficulties or cognitive decline , that do not permit their routine use . When used in the long-term , they have been shown to associate with increased mortality . Huperzine A while promising , requires further evidence before it use can be recommended . # Psychosocial intervention # Psychosocial interventions are used as an adjunct to pharmaceutical treatment and can be classified within behaviour- , emotion- , cognition- or stimulation-oriented approaches . Research on efficacy is unavailable and rarely specific to AD , focusing instead on dementia in general . Behavioural interventions attempt to identify and reduce the antecedents and consequences of problem behaviours . This approach has not shown success in improving overall functioning , but can help to reduce some specific problem behaviours , such as incontinence . There is a lack of high quality data on the effectiveness of these techniques in other behaviour problems such as wandering . Emotion-oriented interventions include reminiscence therapy , validation therapy , supportive psychotherapy , sensory integration , also called snoezelen , and simulated presence therapy . Supportive psychotherapy has received little or no formal scientific study , but some clinicians find it useful in helping mildly impaired people adjust to their illness . Reminiscence therapy ( RT ) involves the discussion of past experiences individually or in group , many times with the aid of photographs , household items , music and sound recordings , or other familiar items from the past . Although there are few quality studies on the effectiveness of RT , it may be beneficial for cognition and mood . Simulated presence therapy ( SPT ) is based on attachment theories and involves playing a recording with voices of the closest relatives of the person with Alzheimer 's disease . There is partial evidence indicating that SPT may reduce challenging behaviours . Finally , validation therapy is based on acceptance of the reality and personal truth of another 's experience , while sensory integration is based on exercises aimed to stimulate senses . There is no evidence to support the usefulness of these therapies . The aim of cognition-oriented treatments , which include reality orientation and cognitive retraining , is the reduction of cognitive deficits . Reality orientation consists in the presentation of information about time , place or person to ease the understanding of the person about its surroundings and his or her place in them . On the other hand cognitive retraining tries to improve impaired capacities by exercitation of mental abilities . Both have shown some efficacy improving cognitive capacities , although in some studies these effects were transient and negative effects , such as frustration , have also been reported . Stimulation-oriented treatments include art , music and pet therapies , exercise , and any other kind of recreational activities . Stimulation has modest support for improving behaviour , mood , and , to a lesser extent , function . Nevertheless , as important as these effects are , the main support for the use of stimulation therapies is the change in the person 's routine . # Caregiving # Since Alzheimer 's has no cure and it gradually renders people incapable of tending for their own needs , caregiving essentially is the treatment and must be carefully managed over the course of the disease . During the early and moderate stages , modifications to the living environment and lifestyle can increase patient safety and reduce caretaker burden . Examples of such modifications are the adherence to simplified routines , the placing of safety locks , the labelling of household items to cue the person with the disease or the use of modified daily life objects . Patients may also become incapable of feeding themselves , so they require food in smaller pieces or pureed . When swallowing difficulties arise , the use of feeding tubes may be required . In such cases , the medical efficacy and ethics of continuing feeding is an important consideration of the caregivers and family members . The use of physical restraints is rarely indicated in any stage of the disease , although there are situations when they are necessary to prevent harm to the person with AD or their caregivers . As the disease progresses , different medical issues can appear , such as oral and dental disease , pressure ulcers , malnutrition , hygiene problems , or respiratory , skin , or eye infections . Careful management can prevent them , while professional treatment is needed when they do arise . During the final stages of the disease , treatment is centred on relieving discomfort until death . A small recent study in the US concluded that people whose caregivers had a realistic understanding of the prognosis and clinical complications of late dementia were less likely to receive aggressive treatment near the end of life . # Feeding tubes # There is strong evidence that feeding tubes do not help people with advanced Alzheimer 's dementia gain weight , regain strength or function , prevent aspiration pneumonias , or improve quality of life . # Prognosis # The early stages of Alzheimer 's disease are difficult to diagnose . A definitive diagnosis is usually made once cognitive impairment compromises daily living activities , although the person may still be living independently . The symptoms will progress from mild cognitive problems , such as memory loss through increasing stages of cognitive and non-cognitive disturbances , eliminating any possibility of independent living , especially in the late stages of the disease . Life expectancy of the population with the disease is reduced . The mean life expectancy following diagnosis is approximately seven years . Fewer than 3% of people live more than fourteen years . Disease features significantly associated with reduced survival are an increased severity of cognitive impairment , decreased functional level , history of falls , and disturbances in the neurological examination . Other coincident diseases such as heart problems , diabetes or history of alcohol abuse are also related with shortened survival . While the earlier the age at onset the higher the total survival years , life expectancy is particularly reduced when compared to the healthy population among those who are younger . Men have a less favourable survival prognosis than women . The disease is the underlying cause of death in 70% of all cases . Pneumonia and dehydration are the most frequent immediate causes of death , while cancer is a less frequent cause of death than in the general population . # Epidemiology # Two main measures are used in epidemiological studies : incidence and prevalence . Incidence is the number of new cases per unit of persontime at risk ( usually number of new cases per thousand personyears ) ; while prevalence is the total number of cases of the disease in the population at any given time . Regarding incidence , cohort longitudinal studies ( studies where a disease-free population is followed over the years ) provide rates between 10 and 15 per thousand personyears for all dementias and 58 for AD , which means that half of new dementia cases each year are AD . Advancing age is a primary risk factor for the disease and incidence rates are not equal for all ages : every five years after the age of 65 , the risk of acquiring the disease approximately doubles , increasing from 3 to as much as 69 per thousand person years . There are also sex differences in the incidence rates , women having a higher risk of developing AD particularly in the population older than 85 . The risk of dying from Alzheimers disease is twenty-six percent higher among the non-Hispanic white population than among the non-Hispanic black population , whereas the Hispanic population has a thirty percent lower risk than the non-Hispanic white population . Prevalence of AD in populations is dependent upon different factors including incidence and survival . Since the incidence of AD increases with age , it is particularly important to include the mean age of the population of interest . In the United States , Alzheimer prevalence was estimated to be 1.6% in 2000 both overall and in the 6574 age group , with the rate increasing to 19% in the 7584 group and to 42% in the greater than 84 group . Prevalence rates in less developed regions are lower . The World Health Organization estimated that in 2005 , 0.379% of people worldwide had dementia , and that the prevalence would increase to 0.441% in 2015 and to 0.556% in 2030 . Other studies have reached similar conclusions . Another study estimated that in 2006 , 0.40% of the world population ( range 0.170.89% ; absolute number , range ) were afflicted by AD , and that the prevalence rate would triple and the absolute number would quadruple by 2050. # History # The ancient Greek and Roman philosophers and physicians associated old age with increasing dementia . It was not until 1901 that German psychiatrist Alois Alzheimer identified the first case of what became known as Alzheimer 's disease in a fifty-year-old woman he called Auguste D. He followed her case until she died in 1906 , when he first reported publicly on it . During the next five years , eleven similar cases were reported in the medical literature , some of them already using the term Alzheimer 's disease . The disease was first described as a distinctive disease by Emil Kraepelin after suppressing some of the clinical ( delusions and hallucinations ) and pathological features ( arteriosclerotic changes ) contained in the original report of Auguste D. He included ' ' Alzheimer 's disease ' ' , also named ' ' presenile ' ' dementia by Kraepelin , as a subtype of ' ' senile dementia ' ' in the eighth edition of his ' ' Textbook of Psychiatry ' ' , published on 1910 . For most of the 20th century , the diagnosis of Alzheimer 's disease was reserved for individuals between the ages of 45 and 65 who developed symptoms of dementia . The terminology changed after 1977 when a conference on AD concluded that the clinical and pathological manifestations of presenile and senile dementia were almost identical , although the authors also added that this did not rule out the possibility that they had different causes . This eventually led to the diagnosis of ' ' Alzheimer 's disease ' ' independently of age . The term ' ' senile dementia of the Alzheimer type ' ' ( SDAT ) was used for a time to describe the condition in those over 65 , with classical Alzheimer 's disease being used for those younger . Eventually , the term Alzheimer 's disease was formally adopted in medical nomenclature to describe individuals of all ages with a characteristic common symptom pattern , disease course , and neuropathology. # Society and culture # # Social costs # Dementia , and specifically Alzheimer 's disease , may be among the most costly diseases for society in Europe and the United States , while their cost in other countries such as Argentina , or South Korea , is also high and rising . These costs will probably increase with the ageing of society , becoming an important social problem . AD-associated costs include direct medical costs such as nursing home care , direct nonmedical costs such as in-home day care , and indirect costs such as lost productivity of both patient and caregiver . Numbers vary between studies but dementia costs worldwide have been calculated around $160 billion , while costs of Alzheimer 's disease in the United States may be $100 billion each year . The greatest origin of costs for society is the long-term care by health care professionals and particularly institutionalisation , which corresponds to 2/3 of the total costs for society . The cost of living at home is also very high , especially when informal costs for the family , such as caregiving time and caregiver 's lost earnings , are taken into account . Costs increase with dementia severity and the presence of behavioural disturbances , and are related to the increased caregiving time required for the provision of physical care . Therefore any treatment that slows cognitive decline , delays institutionalisation or reduces caregivers ' hours will have economic benefits . Economic evaluations of current treatments have shown positive results . # Caregiving burden # The role of the main caregiver is often taken by the spouse or a close relative . Alzheimer 's disease is known for placing a great burden on caregivers which includes social , psychological , physical or economic aspects . Home care is usually preferred by people with AD and their families . This option also delays or eliminates the need for more professional and costly levels of care . Nevertheless two-thirds of nursing home residents have dementias . Dementia caregivers are subject to high rates of physical and mental disorders . Factors associated with greater psychosocial problems of the primary caregivers include having an affected person at home , the carer being a spouse , demanding behaviours of the cared person such as depression , behavioural disturbances , hallucinations , sleep problems or walking disruptions and social isolation . Regarding economic problems , family caregivers often give up time from work to spend 47 hours per week on average with the person with AD , while the costs of caring for them are high . Direct and indirect costs of caring for an Alzheimer 's patient average between $18,000 and $77,500 per year in the United States , depending on the study . Cognitive behavioural therapy and the teaching of coping strategies either individually or in group have demonstrated their efficacy in improving caregivers ' psychological health . # Notable cases # As Alzheimer 's disease is highly prevalent , many notable people have developed it . Well-known examples are former United States President Ronald Reagan and Irish writer Iris Murdoch , both of whom were the subjects of scientific articles examining how their cognitive capacities deteriorated with the disease . the former Prime Ministers Harold Wilson ( United Kingdom ) and Adolfo Surez ( Spain ) , the novelist Terry Pratchett , the author Harnett Kane was stricken in his middle fifties and unable to write for the last seventeen years of his life , Indian politician George Fernandes , and the 2009 Nobel Prize in Physics recipient Charles K. Kao . AD has also been portrayed in films such as : ' ' Iris ' ' ( 2001 ) , based on John Bayley 's memoir of his wife Iris Murdoch ; ' ' The Notebook ' ' ( 2004 ) , based on Nicholas Sparks ' 1996 novel of the same name ; ' ' A Moment to Remember ' ' ( 2004 ) ; ' ' Thanmathra ' ' ( 2005 ) ; ' ' Memories of Tomorrow ( Ashita no Kioku ) ' ' ( 2006 ) , based on Hiroshi Ogiwara 's novel of the same name ; ' ' Away from Her ' ' ( 2006 ) , based on Alice Munro 's short story The Bear Came over the Mountain . Documentaries on Alzheimer 's disease include ' ' Malcolm and Barbara : A Love Story ' ' ( 1999 ) and ' ' Malcolm and Barbara : Love 's Farewell ' ' ( 2007 ) , both featuring Malcolm Pointon. # Research directions # , the safety and efficacy of more than 400 pharmaceutical treatments had been or were being investigated in 1012 clinical trials worldwide , and approximately a quarter of these compounds are in Phase III trials , the last step prior to review by regulatory agencies . One area of clinical research is focused on treating the underlying disease pathology . Reduction of beta-amyloid levels is a common target of compounds ( such as apomorphine ) under investigation . Immunotherapy or vaccination for the amyloid protein is one treatment modality under study . Unlike preventative vaccination , the putative therapy would be used to treat people already diagnosed . It is based upon the concept of training the immune system to recognise , attack , and reverse deposition of amyloid , thereby altering the course of the disease . An example of such a vaccine under investigation was ACC-001 , although the trials were suspended in 2008 . Another similar agent is bapineuzumab , an antibody designed as identical to the naturally induced anti-amyloid antibody . Other approaches are neuroprotective agents , such as AL-108 , and metal-protein interaction attenuation agents , such as PBT2 . A TNF receptor fusion protein , etanercept has showed encouraging results . In 2008 , two separate clinical trials showed positive results in modifying the course of disease in mild to moderate AD with methylthioninium chloride ( trade name ' ' rember ' ' ) , a drug that inhibits tau aggregation , and dimebon , an antihistamine . The consecutive phase-III trial of dimebon failed to show positive effects in the primary and secondary endpoints . The common herpes simplex virus HSV-1 has been found to colocate with amyloid plaques . This suggested the possibility that AD could be treated or prevented with antiviral medication . Preliminary research on the effects of meditation on retrieving memory and cognitive functions have been encouraging . Limitations of this research can be addressed in future studies with more detailed analyses . An FDA panel voted unanimously to recommend approval of florbetapir , which is currently used in an investigational study . The imaging agent can help to detect Alzheimer 's brain plaques , but will require additional clinical research before it can be made available commercially . Manned spaceflight may harm the brain of astronauts and accelerate the onset of ' ' Alzheimer 's disease ' ' . # Imaging # In a person already having dementia , single photon emission computed tomography ( SPECT ) appears to be superior in differentiating Alzheimer 's disease from other possible causes , compared with the usual attempts employing mental testing and medical history analysis . Advances have led to the proposal of new diagnostic criteria . PiB PET remains investigational , but a similar PET scanning radiopharmaceutical called florbetapir , containing the longer-lasting radionuclide fluorine-18 , has recently been tested as a diagnostic tool in Alzheimer 's disease , and given FDA approval for this use . Amyloid imaging is likely to be used in conjunction with other markers rather than as an alternative . Volumetric MRI can detect changes in the size of brain regions . Measuring those regions that atrophy during the progress of Alzheimer 's disease is showing promise as a diagnostic indicator . It may prove less expensive than other imaging methods currently under study . 
@@19019270 ICDO = Sexually transmitted diseases ( STD ) , also referred to as sexually transmitted infections ( STI ) and venereal diseases ( VD ) , are illnesses that have a significant probability of transmission between humans by means of sexual behavior , including vaginal intercourse , anal sex and oral sex . Some STIs can also be contracted by using IV drug needles after their use by an infected person , as well as through any incident involving the contact of a wound with contaminated blood or through childbirth or breastfeeding . Sexually transmitted infections have been well known for hundreds of years , and venereology is the branch of medicine that studies these diseases . While in the past , these illnesses have mostly been referred to as STDs or VD , the term ' ' sexually transmitted infections ' ' ( ' ' STIs ' ' ) has been preferred by many up-to-date medical sources , as it has a broader range of meaning ; a person may be ' ' infected ' ' , and may potentially infect others , without having a ' ' disease ' ' . There are 19 million new cases of sexually transmitted infections every year in the United States , and , in 2005 , the World Health Organization estimated that 448 million people aged 1549 were being infected a year with curable STIs ( such as syphilis , gonorrhea and chlamydia ) . # Classification # Until the 1990s , STIs were commonly known as ' ' venereal diseases ' ' , the word venereal being derived from the Latin word venereus , and meaning relating to sexual intercourse or desire , ultimately derived from Venus , the Roman goddess of love . ' ' Social disease ' ' was a phrase used as a euphemism . ' ' Sexually transmitted infection ' ' is a broader term than ' ' sexually transmitted disease . ' ' An infection is a colonization by a parasitic species , which may not cause any adverse effects . In a disease , the infection leads to impaired or abnormal function . In either case , the condition may not exhibit signs or symptoms . Increased understanding of infections like HPV , which infects a significant portion of sexually active individuals but cause disease in only a few has led to increased use of the term ' ' STI . ' ' Public health officials originally introduced the term ' ' sexually transmitted infection ' ' , which clinicians are increasingly using alongside the term ' ' sexually transmitted disease ' ' in order to distinguish it from the former . ' ' STD ' ' may refer only to infections that are causing diseases , or it may be used more loosely as a synonym for ' ' STI . ' ' Most of the time , people do not know that they are infected with an STI until they are tested or start showing symptoms of disease . Moreover , the term ' ' sexually transmissible disease ' ' is sometimes used since it is less restrictive in consideration of other factors or means of transmission . For instance , meningitis is transmissible by means of sexual contact but is not labeled an STI because sexual contact is not the primary vector for the pathogens that cause meningitis . This discrepancy is addressed by the probability of infection by means ' ' other than sexual contact ' ' . In general , an STI is an infection that has a negligible probability of transmission by means other than sexual contact , but has a realistic means of transmission by sexual contact ( more sophisticated meansblood transfusion , sharing of hypodermic needlesare not taken into account ) . Thus , one may presume that , if a person is infected with an STI , e.g. , chlamydia , gonorrhea , genital herpes , HPV it was transmitted to him/her by means of sexual contact . The diseases on this list are most commonly transmitted solely by sexual activity . Many infectious diseases , including the common cold , influenza , pneumonia , and most others that are transmitted person-to-person can also be transmitted during sexual contact , if one person is infected , due to the close contact involved . However , even though these diseases may be transmitted during sex , they are not considered STIs. # Signs and symptoms # Not all STIs are symptomatic , and symptoms may not appear immediately after infection . In some instances a disease can be carried with no symptoms , which leaves a greater risk of passing the disease on to others . Depending on the disease , some untreated STIs can lead to infertility , chronic pain or even death . # Cause # # Transmission # The risks and transmission probabilities of sexually transmitted diseases are summarized by act in the table : # Bacterial #  Chancroid ( ' ' Haemophilus ducreyi ' ' )  Chlamydia ( ' ' Chlamydia trachomatis ' ' )  Gonorrhea ( ' ' Neisseria gonorrhoeae ' ' ) , colloquially known as the clap  Granuloma inguinale or ( ' ' Klebsiella granulomatis ' ' )  Syphilis ( ' ' Treponema pallidum ' ' ) # Fungal # Candidiasis ( yeast infection ) # Viral # Viral hepatitis ( Hepatitis B virus ) saliva , venereal fluids . *6;112934;br ( Note : Hepatitis A and Hepatitis E are transmitted via the fecal-oral route ; Hepatitis C is rarely sexually transmittable , *8;112942;!-- *8;112952;!-- and the route of transmission of Hepatitis D ( only if infected with B ) is uncertain , but may include sexual transmission . ) Herpes simplex ( Herpes simplex virus 1 , 2 ) skin and mucosal , transmissible with or without visible blisters HIV ( ' ' Human Immunodeficiency Virus ' ' ) venereal fluids , semen , breast milk , blood HPV ( ' ' Human Papillomavirus ' ' ) skin and mucosal contact . ' High risk ' types of HPV cause almost all cervical cancers , as well as some anal , penile , and vulvar cancer . Some other types of HPV cause genital warts . Molluscum contagiosum ( molluscum contagiosum virus MCV ) close contact # Parasites # Crab louse , colloquially known as crabs or pubic lice ( ' ' Pthirus pubis ' ' ) Scabies ( ' ' Sarcoptes scabiei ' ' ) # Protozoal # Trichomoniasis ( ' ' Trichomonas vaginalis ' ' ) , colloquially known as trich # Main types # Sexually transmitted infections include : Chlamydia is a sexually transmitted infection caused by the bacterium ' ' Chlamydia trachomatis ' ' . In women , symptoms may include abnormal vaginal discharge , burning during urination , and bleeding in between periods , although most women do not experience any symptoms . Symptoms in men include pain when urinating , and abnormal discharge from their penis . If left untreated in both men and women , Chlamydia can infect the urinary tract and potentially lead to pelvic inflammatory disease ( PID ) . PID can cause serious problems during pregnancy and even has the potential to cause infertility . It can cause a woman to have a potentially deadly ectopic pregnancy , in which the child is born outside of the uterus . However , Chlamydia can be cured with antibiotics . The two most common forms of herpes are caused by infection with herpes simplex virus ( HSV ) . HSV-1 is acquired orally and causes cold sores . HSV-2 is acquired during sexual contact and affects the genitals . Some people are asymptomatic or have very mild symptoms . Those that do experience symptoms usually notice them 2 to 20 days after exposure which last 2 to 4 weeks . Symptoms can include small fluid-filled blisters , headaches , backaches , itching or tingling sensations in the genital or anal area , pain during urination , Flu like symptoms , swollen glands , or fever . Herpes is spread through skin contact with a person infected with the virus . The virus affects the areas where it entered the body . This can occur through kissing , vaginal intercourse , oral sex or anal sex . The virus is most infectious during times when there are visible symptoms , however those who are asymptomatic can still spread the virus through skin contact . The primary attack is the most severe because the body does not have any antibodies built up . After the primary attack , one might have recurring attacks that are milder or might not even have future attacks . There is no cure for the disease but there are antiviral medications that treat its symptoms and lower the risk of transmission ( Valtrex ) . Although HSV-1 is typically the oral version of the virus , and HSV-2 is typically the genital version of the virus , a person with HSV-1 orally CAN transmit that virus to their partner genitally . The virus , either type , will settle into a nerve bundle either at the top of the spine , producing the oral outbreak , or a second nerve bundle at the base of the spine , producing the genital outbreak . The human papillomavirus ( HPV ) is the most common STI in the United States . There are more than 40 different strands of HPV and many do not cause any health problems . In 90% of cases the bodys immune system clears the infection naturally within 2 years . Some cases may not be cleared and can lead to genital warts ( bumps around the genitals that can be small or large , raised or flat , or shaped like cauliflower ) or cervical cancer and other HPV related cancers . Symptoms might not show up until advanced stages . It is important for women to get pap smears in order to check for and treat cancers . There are also two vaccines available for women ( Cervarix and Gardasil ) that protect against the types of HPV that cause cervical cancer . HPV can be passed through genital-to-genital contact as well as during oral sex . It is important to remember that the infected partner might not have any symptoms . Gonorrhea is caused by bacterium that lives on moist mucous membranes in the urethra , vagina , rectum , mouth , throat , and eyes . The infection can spread through contact with the penis , vagina , mouth or anus . Symptoms of Gonorrhea usually appear 2 to 5 days after contact with an infected partner however , some men might not notice symptoms for up to a month . Symptoms in men include burning and pain while urinating , increased urinary frequency , discharge from the penis ( white , green , or yellow in color ) , red or swollen urethra , swollen or tender testicles , or sore throat . Symptoms in women may include vaginal discharge , burning or itching while urinating , painful sexual intercourse , severe pain in lower abdomen ( if infection spreads to fallopian tubes ) , or fever ( if infection spreads to fallopian tubes ) , however many women do not show any symptoms . There are some antibiotic resistant strains for Gonorrhea but most cases can be cured with antibiotics . Syphilis is an STI caused by a bacterium . If acquired , syphilis needs to be treated adequately , otherwise it can cause long-term complications and death . Clinical manifestations of syphilis include the ulceration of the uro-genital tract , mouth or rectum ; if left untreated the symptoms worsen . In recent years , the prevalence of syphilis has declined in Western Europe , but it has increased in Eastern Europe ( former Soviet states ) . A high incidence of syphilis can be found in places such as Cameroon , Cambodia , Papua New Guinea . Trichomoniasis is a common STI that is caused by infection with a protozoan parasite called ' ' Trichomonas vaginalis ' ' . Trichomoniasis affects both women and men , but symptoms are more common in women . Most patients are treated with an antibiotic called metronidazole , which is very effective . HIV ( human immunodeficiency virus ) damages the body 's immune system which interferes with fighting off disease-causing agents . The virus kills CD4 cells , which are white blood cells that help fight off various infections . HIV is carried in body fluids , and is spread by sexual activity . It can also be spread by contact with infected blood , breast feeding , childbirth , and from mother to child during pregnancy . When HIV is at its most advanced stage , an individual is said to have AIDS ( acquired immunodeficiency syndrome ) . There are different stages of the progression of and HIV infection . The stages include primary infection , asymptomatic infection , symptomatic infection , and AIDS . In the primary infection stage , an individual will have flu like symptoms ( headache , fatigue , fever , muscle aches ) for about 2 weeks . In the asymptomatic stage , symptoms usually disappear , and the patient can remain asymptomatic for years . When HIV progresses to the symptomatic stage , the immune system is weakened , and has a low cell count of CD4+ T Cells . When the HIV infection becomes life-threatening , it is called AIDS . People with AIDS fall prey to opportunistic infections and die as a result . When the disease was first discovered in the 1980s , those who had AIDS were not likely to live longer than a few years . There are now antiretroviral drugs ( ARVs ) available to treat HIV infections . There is no known cure for HIV or AIDS but the drugs help suppress the virus . By suppressing the amount of virus in the body , people can lead longer and healthier lives . Even though their virus levels may be low they can still spread the virus to others . # Unscreened # There are many species of bacteria , protozoa , fungi , and viruses , many which remain undocumented or poorly studied with regards to sexual transmission . Despite that the above include what are generally known as STIs , sexually transmission of microbes is far from limited to the above list . Since the sexual route of transmission is not considered common , and/or the microbe itself is not implicated in a major research study on disease , the following pathogens are simply not screened for in sexual health clinics . Some of these microbes are known to be sexually transmittable . Microbes known to be sexually transmissible ( but not generally considered STDs/STIs ) include :  Ebola- transmissible 2 months after recovery .  Marburg virus - Virus in semen for 7 weeks after clinical recovery .  HTLV ( both types 1 and 2 ) - Sexually transmissible , consumption of breast milk breastfeeding , and once mistaken as a HIV , risk of leukemia. # Pathophysiology # Many STIs are ( more easily ) transmitted through the mucous membranes of the penis , vulva , rectum , urinary tract and ( less oftendepending on type of infection ) the mouth , throat , respiratory tract and eyes . The visible membrane covering the head of the penis is a mucous membrane , though it produces no mucus ( similar to the lips of the mouth ) . Mucous membranes differ from skin in that they allow certain pathogens into the body . The amount of contact with infective sources which causes infection varies with each pathogen but in all cases a disease may result from even light contact from fluid carriers like venereal fluids onto a mucous membrane . This is one reason that the probability of transmitting many infections is far higher from sex than by more casual means of transmission , such as non-sexual contacttouching , hugging , shaking handsbut it is not the only reason . Although mucous membranes exist in the mouth as in the genitals , many STIs seem to be easier to transmit through oral sex than through deep kissing . According to a safe sex chart , many infections that are easily transmitted from the mouth to the genitals or from the genitals to the mouth are much harder to transmit from one mouth to another . With HIV , genital fluids happen to contain much more of the pathogen than saliva . Some infections labeled as STIs can be transmitted by direct skin contact . Herpes simplex and HPV are both examples . KSHV , on the other hand , may be transmitted by deep-kissing but also when saliva is used as a sexual lubricant . Depending on the STI , a person may still be able to spread the infection if no signs of disease are present . For example , a person is much more likely to spread herpes infection when blisters are present than when they are absent . However , a person can spread HIV infection at any time , even if he/she has not developed symptoms of AIDS . ' ' All ' ' sexual behaviors that involve contact with the bodily fluids of another person should be considered to contain some risk of transmission of sexually transmitted diseases . Most attention has focused on controlling HIV , which causes AIDS , but each STI presents a different situation . As may be noted from the name , sexually transmitted diseases are ' ' transmitted ' ' from one person to another by certain sexual activities rather than being actually ' ' caused by ' ' those sexual activities . Bacteria , fungi , protozoa or viruses are still the causative agents . It is not possible to catch any sexually transmitted disease from a sexual activity with a person who is not carrying a disease ; conversely , a person who has an STI got it from contact ( sexual or otherwise ) with someone who had it , or his/her bodily fluids . Some STIs such as HIV can be transmitted from mother to child either during pregnancy or breastfeeding . Although the likelihood of transmitting various diseases by various sexual activities varies a great deal , in general , all sexual activities between two ( or more ) people should be considered as being a two-way route for the transmission of STIs , i.e. , giving or receiving are both risky although receiving carries a higher risk . Healthcare professionals suggest safer sex , such as the use of condoms , as the most reliable way of decreasing the risk of contracting sexually transmitted diseases during sexual activity , but safer sex should by no means be considered an absolute safeguard . The transfer of and exposure to bodily fluids , such as blood transfusions and other blood products , sharing injection needles , needle-stick injuries ( when medical staff are inadvertently jabbed or pricked with needles during medical procedures ) , sharing tattoo needles , and childbirth are other avenues of transmission . These different means put certain groups , such as medical workers , and haemophiliacs and drug users , particularly at risk . Recent epidemiological studies have investigated the networks that are defined by sexual relationships between individuals , and discovered that the properties of sexual networks are crucial to the spread of sexually transmitted diseases . In particular , assortative mixing between people with large numbers of sexual partners seems to be an important factor . It is possible to be an asymptomatic carrier of sexually transmitted diseases . In particular , sexually transmitted diseases in women often cause the serious condition of pelvic inflammatory disease . # Prevention # Prevention is key in addressing incurable STIs , such as HIV and herpes . Sexual health clinics promote the use of condoms and provide outreach for at-risk communities . The most effective way to prevent sexual transmission of STIs is to avoid contact of body parts or fluids which can lead to transfer with an infected partner . Not all sexual activities involve contact : cybersex , phonesex or masturbation from a distance are methods of avoiding contact . Proper use of condoms reduces contact and risk . Although a condom is effective in limiting exposure , some disease transmission may occur even with a condom . Both partners should get tested for STIs before initiating sexual contact , or before resuming contact if a partner engaged in contact with someone else . Many infections are not detectable immediately after exposure , so enough time must be allowed between possible exposures and testing for the tests to be accurate . Certain STIs , particularly certain persistent viruses like HPV , may be impossible to detect with current medical procedures . Many diseases that establish permanent infections can so occupy the immune system that other diseases become more easily transmitted . The innate immune system led by defensins against HIV can prevent transmission of HIV when viral counts are very low , but if busy with other viruses or overwhelmed , HIV can establish itself . Certain viral STI 's also greatly increase the risk of death for HIV infected patients . # Vaccines # Vaccines are available that protect against some viral STIs , such as Hepatitis A , Hepatitis B , and some types of HPV . Vaccination before initiation of sexual contact is advised to assure maximal protection . # Condoms # Condoms and female condoms only provide protection when used properly as a barrier , and only to and from the area that it covers . ' ' Uncovered areas are still susceptible to many STDs ' ' . In the case of HIV , sexual transmission routes almost always involve the penis , as HIV can not spread through unbroken skin , thus ' ' properly shielding the insertive penis with a properly worn condom from the vagina or anus effectively stops HIV transmission ' ' . An infected fluid to broken skin borne direct transmission of HIV would not be considered sexually transmitted , but can still theoretically occur during sexual contact , this can be avoided simply by not engaging in sexual contact when having open bleeding wounds . Other STIs , even viral infections , can be prevented with the use of latex , polyurethane or polyisoprene condoms as a barrier . Some microorganisms and viruses are small enough to pass through the pores in natural skin condoms , but are still too large to pass through latex or synthetic condoms . Proper usage entails : Not putting the condom on too tight at the end , and leaving 1.5 cm ( 3/4 inch ) room at the tip for ejaculation . Putting the condom on snug can and often does lead to failure . Wearing a condom too loose can defeat the barrier . Avoiding inverting , spilling a condom once worn , whether it has ejaculate in it or not . Avoiding the use of oil based lubricants ( or anything with oil in it ) with latex condoms , as oil can eat holes into them . Using flavored condoms for oral sex only , as the sugar in the flavoring can lead to yeast infections if used to penetrate . Not following the first five guidelines above perpetuates the common misconception that condoms are not tested or designed properly . In order to best protect oneself and the partner from STIs , the old condom and its contents should be assumed to be infectious . Therefore the old condom must be properly disposed of . A new condom should be used for each act of intercourse , as multiple usage increases the chance of breakage , defeating the effectiveness as a barrier . # Nonoxynol-9 # Researchers had hoped that nonoxynol-9 , a vaginal microbicide would help decrease STI risk . Trials , however , have found it ineffective and it may put women at a higher risk of HIV infection . # Screening # Sexually active women under the age of 25 and those over 25 with risk should be screened for chlamydia and gonorrhea yearly . After being treated for gonorrhea all people should be re tested for the disease after three months . Nucleic acid amplification tests are the recommended method of diagnosis for gonorrhea and chlamydia . This can be done on either urine in both men and women , vaginal or cervical swabs in women , or urethral swabs in men . # Diagnosis # Testing may be for a single infection , or consist of a number of tests for a range of STIs , including tests for syphilis , trichomonas , gonorrhea , chlamydia , herpes , hepatitis and HIV tests . No procedure tests for all infectious agents . STI tests may be used for a number of reasons :  as a diagnostic test to determine the cause of symptoms or illness  as a screening test to detect asymptomatic or presymptomatic infections  as a check that prospective sexual partners are free of disease before they engage in sex without safer sex precautions ( for example , when starting a long term mutually monogamous sexual relationship , in fluid bonding , or for procreation ) .  as a check prior to or during pregnancy , to prevent harm to the baby  as a check after birth , to check that the baby has not caught an STI from the mother  to prevent the use of infected donated blood or organs  as part of the process of contact tracing from a known infected individual  as part of mass epidemiological surveillance Early identification and treatment results in less chance to spread disease , and for some conditions may improve the outcomes of treatment . There is often a window period after initial infection during which an STI test will be negative . During this period the infection may be transmissible . The duration of this period varies depending on the infection and the test . Diagnosis may also be delayed by reluctance of the infected person to seek a medical professional . One report indicated that people turn to the Internet rather than to a medical professional for information on STIs to a higher degree than for other sexual problems . # Management # High-risk exposure such as that which occurs in rape cases may be treated preventatively using antibiotic combinations such as azithromycin , cefixime , and metronidazole . An option for treating partners of patients ( index cases ) diagnosed with chlamydia or gonorrhea is patient-delivered partner therapy , which is the clinical practice of treating the sex partners of index cases by providing prescriptions or medications to the patient to take to his/her partner without the health care provider first examining the partner . # Epidemiology # STD incidence rates remain high in most of the world , despite diagnostic and therapeutic advances that can rapidly render patients with many STDs noninfectious and cure most . In many cultures , changing sexual morals and oral contraceptive use have eliminated traditional sexual restraints , especially for women , and both physicians and patients have difficulty dealing openly and candidly with sexual issues . Additionally , development and spread of drug-resistant bacteria ( e.g. , penicillin-resistant gonococci ) makes some STDs harder to cure . The effect of travel is most dramatically illustrated by the rapid spread of the AIDS virus ( HIV-1 ) from Africa to Europe and the Americas in the late 1970s . In 1996 , the World Health Organization estimated that more than 1 million people were being infected daily . About 60% of these infections occur in young people *133788;112962;25 ( Camp , 1930 ) Stocker , 2010 </small>  ' ' S. gregorii ' ' <small> ( Camp , 1930 ) Long &amp; Murry , 1995 </small>  ' ' S. lithodendrorum ' ' <small> ( Camp , 1930 ) Stocker , 2010 </small> ' ' Smilosuchus ' ' ( meaning chisel crocodile ) is an extinct genus of leptosuchomorph phytosaurid from the Late Triassic of North America . The type species was first described in 1995 as a replacement generic name for ' ' Leptosuchus gregorii ' ' . Because of the large rostral crest it possessed , it was considered to be distinct enough from other species of ' ' Leptosuchus ' ' ( all of which had smaller and more restricted crests ) to be within its own genus . Some studies seem to suggest that ' ' Smilosuchus ' ' is congeneric with ' ' Leptosuchus ' ' , as the enlarged crest could have been independently developed in ' ' Leptosuchus ' ' . However , newer studies support the idea that ' ' Smilosuchus ' ' is distinct from the type species of ' ' Leptosuchus ' ' , ' ' Leptosuchus crosbiensis ' ' . Phylogenetic analyses suggest that ' ' Smilosuchus ' ' is more closely related to pseudopalatines than to ' ' Leptosuchus ' ' species . # Phylogeny # Below is a cladogram from Stocker ( 2012 ) : 4=clade 2=clade # List of synonyms # Synonyms of ' ' S. adamanensis ' ' : <br/> ' ' Machaeroprosopus adamanensis ' ' <small> Camp , 1930 </small> <br/> ' ' Rutiodon adamanensis ' ' <small> ( Gregory , 1962 ) </small> <br/> ' ' Leptosuchus adamanensis ' ' <small> ( Long &amp; Murry , 1995 ) </small> Synonyms of ' ' S. gregorii ' ' : <br/> ' ' Machaeroprosopus gregorii ' ' <small> Camp , 1930 </small> <br/> ' ' Phytosaurus gregorii ' ' <small> ( Gregory , 1962 ) </small> <br/> ' ' Nicrosaurus gregorii ' ' <small> ( Gregory , 1962 ) </small> <br/> ' ' Rutiodon gregorii ' ' <small> ( Ballew 1989 ) </small> <br/> ' ' Leptosuchus gregorii ' ' <small> ( Irmis , 2005 ) </small> Synonyms of ' ' S. lithodendrorum ' ' : <br/> ' ' Machaeroprosopus lithodendrorum ' ' <small> Camp , 1930 </small> <br/> ' ' Rutiodon adamanensis ' ' <small> ( Gregory , 1962 ) </small> 
@@19468046 Autoimmune diseases arise from an abnormal immune response of the body against substances and tissues normally present in the body ( autoimmunity ) . This may be restricted to certain organs ( e.g. in autoimmune thyroiditis ) or involve a particular tissue in different places ( e.g. Goodpasture 's disease which may affect the basement membrane in both the lung and the kidney ) . The treatment of autoimmune diseases is typically with immunosuppression -- medication that decreases the immune response . A large number of autoimmune diseases are recognized . A major understanding of the underlying pathophysiology of autoimmune diseases has been the application of genome wide association scans that have identified a striking degree of genetic sharing among the autoimmune diseases . # Criteria # For a disease to be regarded as an autoimmune disease it needs to answer to ' ' Witebsky 's postulates ' ' ( first formulated by Ernst Witebsky and colleagues in 1957 and modified in 1994 ) :  Direct evidence from transfer of pathogenic antibody or pathogenic T cells  Indirect evidence based on reproduction of the autoimmune disease in experimental animals  Circumstantial evidence from clinical clues  Genetic architecture clustering with other autoimmune diseases # Effects # It has been estimated that autoimmune diseases are among the ten leading causes of death among women in all age groups up to 65 years . A substantial minority of the population suffers from these diseases , which are often chronic , debilitating , and life-threatening . There are more than eighty illnesses caused by autoimmunity. # Classification # It is possible to classify autoimmune diseases by corresponding type of hypersensitivity : type II , type III , or type IV . ( No type of autoimmune disease mimics type I hypersensitivity . ) There is continuing debate about when a disease should be considered autoimmune , leading to different criteria such as Witebsky 's postulates. # Development of therapies # In both autoimmune and inflammatory diseases , the condition arises through aberrant reactions of the human adaptive or innate immune systems . In autoimmunity , the patients immune system is activated against the body 's own proteins . In chronic inflammatory diseases , neutrophils and other leukocytes are constitutively recruited by cytokines and chemokines , leading to tissue damage . Mitigation of inflammation by activation of anti-inflammatory genes and the suppression of inflammatory genes in immune cells is a promising therapeutic approach . 
@@20254750 Syncope ( ) , the medical term for fainting or passing out , is defined as a transient loss of consciousness and postural tone , characterized by rapid onset , short duration , and spontaneous recovery , due to global cerebral hypoperfusion ( low blood flow to the brain ) that most often results from hypotension ( low blood pressure ) . This definition of syncope differs from others by including the cause of unconsciousness , i.e. transient global cerebral hypoperfusion . Without that addition , the definition of syncope would include disorders such as epileptic seizures , concussion or cerebrovascular accident . Syncope is distinguished from coma , which can include persistent states of unconsciousness . This confusion still occurs in some literature . Many forms of syncope are preceded by a prodromal state that often includes dizziness and loss of vision ( blackout ) ( temporary ) , loss of hearing ( temporary ) , loss of pain and feeling ( temporary ) , nausea and abdominal discomfort , weakness , sweating , a feeling of heat , palpitations and other phenomena , which , if they do not progress to loss of consciousness and postural tone are often denoted presyncope . There are three broad categories of syncope : cardiogenic , reflex ( i.e. neurally mediated ) and orthostatic hypotension , which underlie most forms of syncope . Cardiogenic forms are more likely to produce serious morbidity or mortality and require prompt or even immediate treatment . Although cardiogenic syncope is much more common in older patients , an effort to rule out arrhythmic , obstructive , ischemic , or cardiomyopathic causes of syncope and circulatory inadequacy is mandatory in each patient . Variants of reflex syncope often have characteristic histories , including precipitants and time course . These become evident through skilled history-taking . Thus , the clinical history is the foremost tool used in the differential diagnosis of syncope . Physical examination , and electrocardiogram are part of the initial evaluation of syncope and other more specific tools such as implantable loop recorders may be necessary in clinically uncertain cases . Syncope is extraordinarily common , occurring for the most part in two age ranges : the teenage years and older age . Estimates of lifetime incidence of at least one syncopal episode include 40 to 50 percent of the general populace . Syncope comprises 1 to 3 percent of all attendances to emergency departments and 1 to 6 percent of all hospital admissions. # Etymology # The term is derived from the Late Latin ' ' syncope ' ' , from Ancient Greek ( ' ' sunkop ' ' ) , from ( ' ' sin ' ' , together , thoroughly ) and ( ' ' koptein ' ' , strike , cut off ) . # Differential diagnosis # # Central nervous system ischaemia # The central ischaemic response is triggered by an inadequate supply of oxygenated blood in the brain . The respiratory system may contribute to oxygen levels through hyperventilation , though a sudden ischaemic episode may also proceed faster than the respiratory system can respond . These processes cause the typical symptoms of fainting : pale skin , rapid breathing , nausea and weakness of the limbs , particularly of the legs . If the ischaemia is intense or prolonged , limb weakness progresses to collapse . An individual with very little skin pigmentation may appear to have all color drained from his or her face at the onset of an episode . This effect combined with the following collapse can make a strong and dramatic impression on bystanders . The weakness of the legs causes most sufferers to sit or lie down if there is time to do so . This may avert a complete collapse , but whether the sufferer sits down or falls down , the result of an ischaemic episode is a posture in which less blood pressure is required to achieve adequate blood flow . It is unclear whether this is a mechanism evolved in response to the circulatory difficulties of human bipedalism or merely a serendipitous result of a pre-existing circulatory response . # #Vertebro-basilar arterial disease# # Arterial disease in the upper spinal cord , or lower brain , causes syncope if there is a reduction in blood supply , which may occur with extending the neck or after drugs to lower blood pressure . # Vasovagal # Vasovagal ( situational ) syncope , one of the most common types , may occur in scary , embarrassing or uneasy situations , or during blood drawing , coughing ( cough syncope ) , urination ( micturition syncope ) or defecation ( defecation syncope ) . Vasovagal syncope can be considered in two forms : Isolated episodes of loss of consciousness , unheralded by any warning symptoms for more than a few moments . These tend to occur in the adolescent age group , and may be associated with fasting , exercise , abdominal straining , or circumstances promoting vaso-dilation ( e.g. , heat , alcohol ) . The subject is invariably upright . The tilt-table test , if performed , is generally negative . Recurrent syncope with complex associated symptoms . This is so-called neurally mediated syncope ( NMS ) . It is associated with any of the following : preceding or succeeding sleepiness , preceding visual disturbance ( spots before the eyes ) , sweating , light-headedness . The subject is usually but not always upright . The tilt-table test , if performed , is generally positive . A pattern of background factors contributes to the attacks . There is typically an unsuspected relatively low blood volume , for instance , from taking a low-salt diet in the absence of any salt-retaining tendency . Heat causes vaso-dilation and worsens the effect of the relatively insufficient blood volume . That sets the scene , but the next stage is the adrenergic response . If there is underlying fear or anxiety ( e.g. , social circumstances ) , or acute fear ( e.g. , acute threat , needle phobia ) , the vaso-motor centre demands an increased pumping action by the heart ( flight or fight response ) . This is set in motion via the adrenergic ( sympathetic ) outflow from the brain , but the heart is unable to meet requirement because of the low blood volume , or decreased return . The high ( ineffective ) sympathetic activity is always modulated by vagal outflow , in these cases leading to excessive slowing of heart rate . The abnormality lies in this excessive vagal response . The tilt-table test typically evokes the attack . Much of this pathway was discovered in animal experiments by Bezold ( Vienna ) in the 1860s . In animals , it may represent a defence mechanism when confronted by danger ( playing possum ) . This reflex occurs in only some people and may be similar to that described in other animals . The mechanism described here suggests that a practical way to prevent attacks might seem *29;123402;TOOLONG to block the adrenergic signal with a beta-blocker . A simpler plan might be to explain the mechanism , discuss causes of fear , and optimise salt as well as water intake . Psychological factors also have been found to mediate syncope . It is important for general practitioners and the psychologist in their primary care team to work closely together , and to help patients identify how they might be avoiding activities of daily living due to anticipatory anxiety in relation to a possible faint and the feared physical damage it may cause . Fainting in response to a blood stimulus , needle or a dead body are common and patients can quickly develop safety behaviours to avoid any recurrences of a fainting response . See link for a good description of psychological interventions and theories . An evolutionary psychology view is that some forms of fainting are non-verbal signals that developed in response to increased inter-group aggression during the paleolithic . A non-combatant who has fainted signals that she or he is not a threat . This would explain the association between fainting and stimuli such as bloodletting and injuries seen in blood-injection-injury type phobias such as trypanophobia as well as the gender differences . # #Deglutition ( Swallowing ) syncope# # Syncope may occur during deglutition . Manisty et al . note : Deglutition syncope is characterised by loss of consciousness on swallowing ; it has been associated not only with ingestion of solid food , but also with carbonated and ice-cold beverages , and even belching . # Cardiac # # #Cardiac arrhythmias# # Most common cause of cardiac syncope . Two major groups of arrhythmias are bradycardia and tachycardia . Bradycardia can be caused by heart blocks . Tachycardias include SVT ( supraventricular tachycardia ) and VT ( ventricular tachycardia ) . SVT does not cause syncope except in Wolff-Parkinson-White syndrome . Ventricular tachycardia originate in the ventricles . VT causes syncope and can result in sudden death . Ventricular tachycardia , which describes a heart rate of over 100 beats per minute with at least three irregular heartbeats as a sequence of consecutive premature beats , can degenerate into ventricular fibrillation , which requires DC cardioversion . Typically , tachycardic generated syncope is caused by a cessation of beats following a tachycardic episode . This condition , called tachycardia-bradycardia syndrome , is usually caused by sinoatrial node dysfunction or block or atrioventricular block . # #Obstructive cardiac lesion# # Aortic stenosis and mitral stenosis are the most common examples . Aortic stenosis presents with repeated episodes of syncope . A pulmonary embolism can cause obstructed blood vessels . High blood pressure in the arteries supplying the lungs ( pulmonary artery hypertension ) can occur during pulmonary embolism . Rarely , cardiac tumors such as atrial myxomas can also lead to syncope. # #Structural cardiopulmonary disease# # These are relatively infrequent causes of faints . The most common cause in this category is fainting associated with an acute myocardial infarction or ischemic event . The faint in this case is primarily caused by an abnormal nervous system reaction similar to the reflex faints . In general , faints caused by structural disease of the heart or blood vessels are particularly important to recognize , as they are warning of potentially life-threatening conditions . Among other conditions prone to trigger syncope ( by either hemodynamic compromise or by a neural reflex mechanism , or both ) , some of the most important are hypertrophic cardiomyopathy , acute aortic dissection , pericardial tamponade , pulmonary embolism , aortic stenosis , and pulmonary hypertension. # #Other cardiac causes# # Sick sinus syndrome , a sinus node dysfunction , causing alternating bradycardia and tachycardia . Often there is a long pause asystole between heartbeat . Adams-Stokes syndrome is a cardiac syncope that occurs with seizures caused by complete or incomplete heart block . Symptoms include deep and fast respiration , weak and slow pulse and respiratory pauses that may last for 60 seconds . Aortic dissection ( a tear in the aorta ) and cardiomyopathy can also result in syncope . Various medications , such as -blockers , may cause bradycardia induced syncope. # Blood pressure # ' ' Orthostatic ( postural ) hypotensive faint ' ' s are as common or perhaps even more common than vasovagal syncope . Orthostatic faints are most often associated with movement from lying or sitting to a standing position . Apparently healthy individuals may experience minor symptoms ( lightheadedness , greying-out ) as they stand up if blood pressure is slow to respond to the stress of upright posture . If the blood pressure is not adequately maintained during standing , faints may develop . However , the resulting transient orthostatic hypotension does not necessarily signal any serious underlying disease . The most susceptible individuals are elderly frail individuals , or persons who are dehydrated from hot environments or inadequate fluid intake . More serious orthostatic hypotension is often the result of certain commonly prescribed medications such as diuretics , -adrenergic blockers , other anti-hypertensives ( including vasodilators ) , and nitroglycerin . In a small percentage of cases , the cause of orthostatic hypotensive faints is structural damage to the autonomic nervous system due to systemic diseases ( e.g. , amyloidosis or diabetes ) or in neurological diseases ( e.g. , Parkinson 's disease ) . # Other causes # Factors that influence fainting are fasting long hours , taking in too little food and fluids , low blood pressure , hypoglycemia , high g-force , emotional distress , and lack of sleep . Orthostatic hypotension caused by standing up too quickly or being in a very hot room can also cause fainting . The classic example of a combination of these is seen in the frequent fainting by medical students in the operating theatre during observation of surgery . More serious causes of fainting include cardiac ( heart-related ) conditions such as an abnormal heart rhythm ( an arrhythmia ) , wherein the heart beats too slowly , too rapidly , or too irregularly to pump enough blood to the brain . Some arrhythmias can be life-threatening . Other important cardio-vascular conditions that can be manifested by syncope include subclavian steal syndrome and aortic stenosis . Fainting can also occur following the severe fits of coughing associated with pertussis or whooping cough . # Diagnostic approach # For people with uncomplicated syncope ( without seizures and a normal neurological exam ) computed tomography or MRI is not indicated . Likewise , using carotid ultrasonography on the premise of identifying carotid artery disease as a cause of syncope also is not indicated . Although sometimes investigated as a cause of syncope , carotid artery problems are unlikely to cause that condition . A hemoglobin count may indicate anemia or blood loss . However , this has been useful in only about 5% of patients evaluated for fainting . An electrocardiogram ( ECG ) records the electrical activity of the heart . It is estimated that from 20%-50% of patients have an abnormal ECG . However , while an ECG may identify conditions such as atrial fibrillation , heart block , or a new or old heart attack , it typically does not provide a definite diagnosis for the underlying cause for fainting . Sometimes , a Holter monitor may be used . This is a portable ECG device that can record the wearer 's heart rhythms during daily activities over an extended period of time . Since fainting usually does not occur upon command , a Holter monitor can provide a better understanding of the heart 's activity during fainting episodes . The Tilt table test is performed to elicit orthostatic syncope secondary to autonomic dysfunction ( neurogenic ) . For patients with more than two episodes of syncope and no diagnosis on routine testing , an insertable cardiac monitor might be used . It lasts 2836 months . Smaller than a pack of gum , it is inserted just beneath the skin in the upper chest area . The procedure typically takes 15 to 20 minutes . Once inserted , the device continuously monitors the rate and rhythm of the heart . Upon waking from a fainting spell , the patient places a hand held pager size device called an Activator over the implanted device and simply presses a button . This information is stored and retrieved by their physician and some devices can be monitored remotely . # San Francisco syncope rule # The San Francisco syncope rule was developed to isolate people who have higher risk for a serious cause of syncope . High risk is anyone who has : congestive heart failure , hematocrit *4533;123433;30%, Source : </small> 
@@21010263 Name = Sickle-cell disease Image = Sickle cell 01. jpg Caption = Figure ( A ) shows normal red blood cells flowing freely through veins . The inset shows a cross section of a normal red blood cell with normal haemoglobin . Figure B shows abnormal , sickled red blood cells log jamming , sticking and accumulating at the branching point in a vein . The inset image shows a cross-section of a sickle cell with long polymerized HbS strands stretching and distorting the cell shape . DiseasesDB = 12069 ICD10 = ICD9 = OMIM = 603903 MedlinePlus = 000527 eMedicineSubj = med eMedicineTopic = 2126 eMedicinemult = MeshName = Sickle+Cell+anemia MeshNumber = C15.378.071.141.150.150 GeneReviewsID = sickle GeneReviewsName= Sickle-cell disease Sickle-cell disease ( SCD ) , or sickle-cell anaemia ( SCA ) or drepanocytosis , is a hereditary blood disorder , characterized by red blood cells that assume an abnormal , rigid , sickle shape . Sickling decreases the cells ' flexibility and results in a risk of various life-threatening complications . This sickling occurs because of a mutation in the haemoglobin gene . Individuals with one copy of the mutant gene produce a mixture of both normal and abnormal haemoglobin . This is an example of codominance . Life expectancy is shortened . In 1994 , in the US , the average life expectancy of persons with this condition was estimated to be 42 years in males and 48 years in females , but today , thanks to better management of the disease , patients can live into their 70s or beyond . Sickle-cell disease occurs more commonly among people whose ancestors lived in tropical and sub-tropical sub-Saharan regions where malaria is or was common . Where malaria is common , carrying a single sickle-cell allele ( sickle cell trait ) confers a selective advantagein other words , being a heterozygote is advantageous . Specifically , humans with one of the two alleles of sickle-cell disease show less severe symptoms when infected with malaria . Sickle-cell anaemia is a form of sickle-cell disease in which there is homozygosity for the mutation that causes HbS . Sickle-cell anaemia is also referred to as HbSS , SS disease , haemoglobin S or permutations of those names . In heterozygous people , that is , those who have only one sickle gene and one normal adult haemoglobin gene , the condition is referred to as HbAS or sickle cell trait . Other , rarer forms of sickle-cell disease are compound heterozygous states in which the person has only one copy of the mutation that causes HbS and one copy of another abnormal haemoglobin allele . They include sickle-haemoglobin C disease ( HbSC ) , sickle beta-plus-thalassaemia ( HbS/ <sup> + </sup> ) and sickle beta-zero-thalassaemia ( HbS/ <sup> 0 </sup> ) . The term ' ' disease ' ' is applied because the inherited abnormality causes a pathological condition that can lead to death and severe complications . Not all inherited variants of haemoglobin are detrimental , a concept known as genetic polymorphism . # Signs and symptoms # Sickle-cell disease may lead to various acute and chronic complications , several of which have a high mortality rate . # Sickle cell crisis # The terms sickle cell crisis or sickling crisis may be used to describe several independent acute conditions occurring in patients with sickle cell disease . Sickle cell disease results in anemia and crises that could be of many types including the vaso-occlusive crisis , aplastic crisis , sequestration crisis , haemolytic crisis and others . Most episodes of sickle cell crises last between five and seven days . Although infection , dehydration , and acidosis ( all of which favor sickling ) can act as triggers , in most instances no predisposing cause is identified . # Vaso-occlusive crisis # The vaso-occlusive crisis is caused by sickle-shaped red blood cells that obstruct capillaries and restrict blood flow to an organ resulting in ischaemia , pain , necrosis and often organ damage . The frequency , severity , and duration of these crises vary considerably . Painful crises are treated with hydration , analgesics , and blood transfusion ; pain management requires opioid administration at regular intervals until the crisis has settled . For milder crises , a subgroup of patients manage on NSAIDs ( such as diclofenac or naproxen ) . For more severe crises , most patients require inpatient management for intravenous opioids ; patient-controlled analgesia ( PCA ) devices are commonly used in this setting . Vaso-occlusive crisis involving organs such as the penis or lungs are considered an emergency and treated with red-blood cell transfusions . Diphenhydramine is sometimes effective for the itching associated with the opioid use . Incentive spirometry , a technique to encourage deep breathing to minimise the development of atelectasis , is recommended . # #Splenic sequestration crisis# # Because of its narrow vessels and function in clearing defective red blood cells , the spleen is frequently affected . It is usually infarcted before the end of childhood in individuals suffering from sickle-cell anemia . This autosplenectomy increases the risk of infection from encapsulated organisms ; preventive antibiotics and vaccinations are recommended for those with such asplenia . Splenic sequestration crises are acute , painful enlargements of the spleen , caused by intrasplenic trapping of red cells and resulting in a precipitous fall in hemoglobin levels with the potential for hypovolemic shock . Sequestration crises are considered an emergency . If not treated , patients may die within 12 hours due to circulatory failure . Management is supportive , sometimes with blood transfusion . These crises are transient , they continue for 34 hours and may last for one day . # Acute chest syndrome ACS # Acute chest syndrome ( ACS ) is defined by new pulmonary infiltrate with a manifestation of pulmonary symptoms like tachypnea and dyspnea . It is the second most common complication and it accounts for about 25% of death in patients with SCD , majority of cases present with vaso occlusive crises then they develop ACS . Nevertheless , in Dessap et al. , 2007 study they reported that about 80% of patients has vaso occlusive crises during ACS. # Aplastic crisis # Aplastic crises are acute worsenings of the patient 's baseline anaemia , producing pallor , tachycardia , and fatigue . This crisis is normally triggered by parvovirus B19 , which directly affects production of red blood cells by invading the red cell precursors and multiplying in them and destroying them . Parvovirus infection nearly completely prevents red blood cell production for two to three days . In normal individuals , this is of little consequence , but the shortened red cell life of sickle-cell patients results in an abrupt , life-threatening situation . Reticulocyte counts drop dramatically during the disease ( causing reticulocytopenia ) , and the rapid turnover of red cells leads to the drop in haemoglobin . This crisis takes 4 days to one week to disappear . Most patients can be managed supportively ; some need blood transfusion. # Haemolytic crisis # Haemolytic crises are acute accelerated drops in haemoglobin level . The red blood cells break down at a faster rate . This is particularly common in patients with co-existent G6PD deficiency . Management is supportive , sometimes with blood transfusions. # Other # One of the earliest clinical manifestations is dactylitis , presenting as early as six months of age , and may occur in children with sickle trait . The crisis can last up to a month . Another recognised type of sickle crisis is the acute chest syndrome , a condition characterised by fever , chest pain , difficulty breathing , and pulmonary infiltrate on a chest X-ray . Given that pneumonia and sickling in the lung can both produce these symptoms , the patient is treated for both conditions . It can be triggered by painful crisis , respiratory infection , bone-marrow embolisation , or possibly by atelectasis , opiate administration , or surgery . # Complications # Sickle-cell anaemia can lead to various complications , including :  Increased risk of severe bacterial infections due to loss of functioning spleen tissue ( and comparable to the risk of infections after having the spleen removed surgically ) . These infections are typically caused by encapsulated organisms such as ' ' Streptococcus pneumoniae ' ' and ' ' Haemophilus influenzae ' ' . Daily penicillin prophylaxis is the most commonly used treatment during childhood , with some haematologists continuing treatment indefinitely . Patients benefit today from routine vaccination for ' ' S. pneumoniae ' ' .  Stroke , which can result from a progressive narrowing of blood vessels , preventing oxygen from reaching the brain . Cerebral infarction occurs in children and cerebral haemorrhage in adults .  Silent stroke is a stroke that causes no immediate symptoms but is associated with damage to the brain . Silent stroke is probably five times as common as symptomatic stroke . Approximately 1015% of children with sickle cell disease suffer strokes , with silent strokes predominating in the younger patients .  Cholelithiasis ( gallstones ) and cholecystitis , which may result from excessive bilirubin production and precipitation due to prolonged haemolysis.  Avascular necrosis ( aseptic bone necrosis ) of the hip and other major joints , which may occur as a result of ischaemia.  Decreased immune reactions due to hyposplenism ( malfunctioning of the spleen ) .  Priapism and infarction of the penis .  Osteomyelitis ( bacterial bone infection ) ; the most common cause of osteomyelitis in sickle cell disease is ' ' Salmonella ' ' ( especially the non-typical serotypes Salmonella typhimurium , Salmonella enteritidis , Salmonella choleraesuis and Salmonella paratyphi B ) , followed by ' ' Staphylococcus aureus ' ' and Gram-negative enteric bacilli perhaps because intravascular sickling of the bowel leads to patchy ischaemic infarction.  Opioid tolerance , which can occur as a normal , physiologic response to the therapeutic use of opiates . Addiction to opiates occurs no more commonly among individuals with sickle-cell disease than among other individuals treated with opiates for other reasons .  Acute papillary necrosis in the kidneys.  Leg ulcers.  In eyes , background retinopathy , proliferative retinopathy , vitreous haemorrhages and retinal detachments , resulting in blindness . Regular annual eye checks are recommended .  During pregnancy , intrauterine growth retardation , spontaneous abortion , and pre-eclampsia.  Chronic pain : Even in the absence of acute vaso-occlusive pain , many patients have chronic pain that is not reported .  Pulmonary hypertension ( increased pressure on the pulmonary artery ) , leading to strain on the right ventricle and a risk of heart failure ; typical symptoms are shortness of breath , decreased exercise tolerance and episodes of syncope.  Chronic renal failure due to Sickle cell nephropathymanifests itself with hypertension ( high blood pressure ) , proteinuria ( protein loss in the urine ) , haematuria ( loss of red blood cells in urine ) and worsened anaemia . If it progresses to end-stage renal failure , it carries a poor prognosis . # Heterozygotes # The heterozygous form ( sickle cell trait ) is almost always asymptomatic , and the only usual significant manifestation is the renal concentrating defect presenting with isosthenuria. # Pathophysiology # Sickle-cell anaemia is caused by a point mutation in the -globin chain of haemoglobin , causing the hydrophilic amino acid glutamic acid to be replaced with the hydrophobic amino acid valine at the sixth position . The -globin gene is found on chromosome 11 . The association of two wild-type -globin subunits with two mutant -globin subunits forms haemoglobin S ( HbS ) . Under low-oxygen conditions ( being at high altitude , for example ) , the absence of a polar amino acid at position six of the -globin chain promotes the non-covalent polymerisation ( aggregation ) of haemoglobin , which distorts red blood cells into a sickle shape and decreases their elasticity . The loss of red blood cell elasticity is central to the pathophysiology of sickle-cell disease . Normal red blood cells are quite elastic , which allows the cells to deform to pass through capillaries . In sickle-cell disease , low-oxygen tension promotes red blood cell sickling and repeated episodes of sickling damage the cell membrane and decrease the cell 's elasticity . These cells fail to return to normal shape when normal oxygen tension is restored . As a consequence , these rigid blood cells are unable to deform as they pass through narrow capillaries , leading to vessel occlusion and ischaemia . The actual anaemia of the illness is caused by haemolysis , the destruction of the red cells , because of their misshape . Although the bone marrow attempts to compensate by creating new red cells , it does not match the rate of destruction . Healthy red blood cells typically live 90120 days , but sickle cells only survive 1020 days . # Genetics # Normally , humans have Haemoglobin A , which consists of two alpha and two beta chains , Haemoglobin A2 , which consists of two alpha and two delta chains and Haemoglobin F , consisting of two alpha and two gamma chains in their bodies . Of these , Haemoglobin A makes up around 96-97% of the normal haemoglobin in humans . Sickle-cell gene mutation probably arose spontaneously in different geographic areas , as suggested by restriction endonuclease analysis . These variants are known as Cameroon , Senegal , Benin , Bantu and Saudi-Asian . Their clinical importance springs from the fact that some of them are associated with higher HbF levels , e.g. , Senegal and Saudi-Asian variants , and tend to have milder disease . In people heterozygous for HgbS ( carriers of sickling haemoglobin ) , the polymerisation problems are minor , because the normal allele is able to produce over 50% of the haemoglobin . In people homozygous for HgbS , the presence of long-chain polymers of HbS distort the shape of the red blood cell from a smooth doughnut-like shape to ragged and full of spikes , making it fragile and susceptible to breaking within capillaries . Carriers have symptoms only if they are deprived of oxygen ( for example , while climbing a mountain ) or while severely dehydrated . The sickle-cell disease occurs when the sixth amino acid , glutamic acid , is replaced by valine to change its structure and function ; as such , sickle cell anemia is also known as E6V . Valine is hydrophobic , causing the haemoglobin to collapse in on itself occasionally . The structure is not changed otherwise . When enough haemoglobin collapses in on itself the red blood cells become sickle-shaped . The gene defect is a known mutation of a single nucleotide ( see single-nucleotide polymorphism - SNP ) ( A to T ) of the -globin gene , which results in glutamic acid being substituted by valine at position 6 . Haemoglobin S with this mutation is referred to as HbS , as opposed to the normal adult HbA . The genetic disorder is due to the mutation of a single nucleotide , from a CTC to CAC codon on the coding strand , which is transcribed from the template strand into a GUG codon . This is normally a benign mutation , causing ' ' no ' ' apparent effects on the secondary , tertiary , or quaternary structure of haemoglobin in conditions of normal oxygen concentration . What it does allow for , under conditions of low oxygen concentration , is the polymerization of the HbS itself . The deoxy form of haemoglobin exposes a hydrophobic patch on the protein between the E and F helices . The hydrophobic residues of the valine at position 6 of the beta chain in haemoglobin are able to associate with the hydrophobic patch , causing haemoglobin S molecules to aggregate and form fibrous precipitates . The allele responsible for sickle-cell anaemia can be found on the short arm of chromosome 11 . A person that receives the defective gene from both father and mother develops the disease ; a person that receives one defective and one healthy allele remains healthy , but can pass on the disease and is known as a carrier . If two parents who are carriers have a child , there is a 1-in-4 chance of their child developing the disease and a 1-in-2 chance of their child being just a carrier . Heterozygotes are still able to contract malaria , but their symptoms are generally less severe . Due to the adaptive advantage of the heterozygote , the disease is still prevalent , especially among people with recent ancestry in malaria-stricken areas , such as Africa , the Mediterranean , India and the Middle East . Malaria was historically endemic to southern Europe , but it was declared eradicated in the mid-20th century , with the exception of rare sporadic cases . The malaria parasite has a complex life cycle and spends part of it in red blood cells . In a carrier , the presence of the malaria parasite causes the red blood cells with defective haemoglobin to rupture prematurely , making the plasmodium unable to reproduce . Further , the polymerization of Hb affects the ability of the parasite to digest Hb in the first place . Therefore , in areas where malaria is a problem , people 's chances of survival actually increase if they carry sickle-cell trait ( selection for the heterozygote ) . In the USA , where there is no endemic malaria , the prevalence of sickle-cell anaemia among blacks is lower ( about 0.25% ) than in West Africa ( about 4.0% ) and is falling . Without endemic malaria , the sickle cell mutation is purely disadvantageous and will tend to be selected out of the affected population via natural selection . However , the African American community of the USA is known to be the result of significant admixture between several African and non-African ethnic groups , and also represents the descendants of survivors of the slavery and the slave trade . Thus , a lower degree of endogamy and , particularly , abnormally high health-selective pressure through slavery may be the most plausible explanations for the lower prevalence of sickle-cell anaemia ( and , possibly , other genetic diseases ) among African-Americans compared to Sub-Saharan Africans . Another factor limiting the spread of sickle-cell genes in North America is the absence of cultural proclivities to polygamy , which allows affected males to continue to seek unaffected children with multiple partners . # Inheritance # Sickle-cell conditions have an autosomal recessive pattern of inheritance from parents . The types of haemoglobin a person makes in the red blood cells depend on what haemoglobin genes are inherited from her or his parents . If one parent has sickle-cell anaemia ( SS ) and the other has sickle-cell trait then there is a 50% chance of a child 's having sickle-cell disease and a 50% chance of a child 's having sickle-cell trait . When both parents have sickle-cell trait a child has a 25% chance of sickle-cell disease , 25% will not carry any sickle cell alleles , and 50% will have the heterozygous condition , as shown in the diagram . # Diagnosis # In HbSS , the full blood count reveals haemoglobin levels in the range of 68 g/dL with a high reticulocyte count ( as the bone marrow compensates for the destruction of sickle cells by producing more red blood cells ) . In other forms of sickle-cell disease , Hb levels tend to be higher . A blood film may show features of hyposplenism ( target cells and Howell-Jolly bodies ) . Sickling of the red blood cells , on a blood film , can be induced by the addition of sodium metabisulfite . The presence of sickle haemoglobin can also be demonstrated with the sickle solubility test . A mixture of haemoglobin S ( Hb S ) in a reducing solution ( such as sodium dithionite ) gives a turbid appearance , whereas normal Hb gives a clear solution . Abnormal haemoglobin forms can be detected on haemoglobin electrophoresis , a form of gel electrophoresis on which the various types of haemoglobin move at varying speeds . Sickle-cell haemoglobin ( HgbS ) and haemoglobin C with sickling ( HgbSC ) the two most common formscan be identified from there . The diagnosis can be confirmed with high-performance liquid chromatography ( HPLC ) . Genetic testing is rarely performed , as other investigations are highly specific for HbS and HbC . An acute sickle-cell crisis is often precipitated by infection . Therefore , a urinalysis to detect an occult urinary tract infection , and chest X-ray to look for occult pneumonia should be routinely performed . People who are known carriers of the disease often undergo genetic counseling before they have a child . A test to see if an unborn child has the disease takes either a blood sample from the fetus or a sample of amniotic fluid . Since taking a blood sample from a fetus has greater risks , the latter test is usually used . Neonatal screening provides not only a method of early detection for individuals with sickle cell disease , but also allows for identification of the groups of people that carry the sickle cell trait . After the mutation responsible for this disease was discovered in 1979 , the U.S. Air Force required black applicants to test for the mutation . It dismissed 143 applicants because they were carriers , even though none of them had the condition . It eventually withdrew the requirement , but only after a trainee filed a lawsuit . # Management # # Folic acid and penicillin # Children born with sickle-cell disease will undergo close observation by the pediatrician and will require management by a haematologist to assure they remain healthy . These patients will take a 1 mg dose of folic acid daily for life . From birth to five years of age , they will also have to take penicillin daily due to the immature immune system that makes them more prone to early childhood illnesses . # Malaria chemoprophylaxis # The protective effect of sickle cell trait does not apply to people with sickle cell disease ; in fact , they are uniquely vulnerable to malaria , since the most common cause of painful crises in malarial countries is infection with malaria . It has therefore been recommended that people with sickle cell disease living in malarial countries should receive anti-malarial chemoprophylaxis for life . # Vaso-occlusive crises # Most people with sickle-cell disease have intensely painful episodes called vaso-occlusive crises . The frequency , severity , and duration of these crises , however , vary tremendously . Painful crises are treated symptomatically with analgesics ; pain management requires opioid administration at regular intervals until the crisis has settled . For milder crises , a subgroup of patients manage on NSAIDs ( such as diclofenac or naproxen ) . For more severe crises , most patients require inpatient management for intravenous opioids ; patient-controlled analgesia ( PCA ) devices are commonly used in this setting . Diphenhydramine is also an effective agent that is frequently prescribed by doctors in order to help control any itching associated with the use of opioids. # Acute chest crisis # Management is similar to vaso-occlusive crisis , with the addition of antibiotics ( usually a quinolone or macrolide , since cell wall-deficient atypical bacteria are thought to contribute to the syndrome ) , oxygen supplementation for hypoxia , and close observation . Should the pulmonary infiltrate worsen or the oxygen requirements increase , simple blood transfusion or exchange transfusion is indicated . The latter involves the exchange of a significant portion of the patients red cell mass for normal red cells , which decreases the percent of haemoglobin S in the patient 's blood . # Hydroxyurea # The first approved drug for the causative treatment of sickle-cell anaemia , hydroxyurea , was shown to decrease the number and severity of attacks in a study in 1995 ( Charache ' ' et al . ' ' ) and shown to possibly increase survival time in a study in 2003 ( Steinberg ' ' et al . ' ' ) . This is achieved , in part , by reactivating fetal haemoglobin production in place of the haemoglobin S that causes sickle-cell anaemia . Hydroxyurea had previously been used as a chemotherapy agent , and there is some concern that long-term use may be harmful , but this risk has been shown to be either absent or very small and it is likely that the benefits outweigh the risks . # Transfusion therapy # Blood transfusions are often used in the management of sickle cell disease in acute cases and to prevent complications by decreasing the number of red blood cells ( RBC ) that can sickle by adding normal red blood cells . In children prophylactic chronic red blood cell ( RBC ) transfusion therapy has been shown to be efficacious to a certain extent in reducing the risk of first stroke or silent stroke when transcranial Doppler ( TCD ) ultrasonography shows abnormal increased cerebral blood flow velocities . In those who have sustained a prior stroke event it also reduces the risk of recurrent stroke and additional silent strokes . # Bone marrow transplants # Bone marrow transplants have proven to be effective in children . Bone marrow transplants are the only known cure for SCD . However , bone marrow transplants are difficult to obtain because of the specific HLA typing necessary . Ideally , a twin family member ( syngeneic ) or close relative ( allogeneic ) would donate the bone marrow necessary for transplantation . # Prognosis # About 90% of patients survive to age 20 , and close to 50% survive beyond the fifth decade . In 2001 , according to one study , the estimated mean survival for sickle cell patients was 53 years old for men and 58 years old for women with homozygous SCD. # Epidemiology # The highest frequency of sickle cell disease is found in tropical regions , particularly sub-Saharan Africa , India and the Middle-East . Migration of substantial populations from these high prevalence areas to low prevalence countries in Europe has dramatically increased in recent decades and in some European countries sickle cell disease has now overtaken more familiar genetic conditions such as haemophilia and cystic fibrosis . In 2010 , there were about 29,000 deaths attributed to sickle cell disease globally . # Africa # Three quarters of sickle-cell cases occur in Africa . A recent WHO report estimated that around 2% of newborns in Nigeria were affected by sickle cell anaemia , giving a total of 150,000 affected children born every year in Nigeria alone . The carrier frequency ranges between 10% and 40% across equatorial Africa , decreasing to 12% on the north African coast and *34246;101108;1% An editorial in the ' ' Asia Times ' ' noted that Sin did not steal only from the rich , or give away a large part of his takings . Instead , he stole as opportunity allowed , and was also accused of other crimes such as rape . Sin 's escape and evasions were also compared to the plot of the American television series Prison Break , which became popular in Korea . Sin 's story was embarrassing to South Korean police not only because of their long failure to capture him , but also because he alleged wide misconduct by police officers . He reported having personally bribed police , and accused officers of raping his girlfriend . According to the Associated Press , about 50 officers were disciplined for failing to capture Sin , and 20 were implicated in his accusations of corruption . Sin 's image also benefited from the juxtaposition with contemporary government corruption scandals , such as the case of the governor of Gyeonggi Province , Lim Chang-yuel ( ) , who was arrested for bribery on the same day as Sin was captured . While corrupt officials were wealthy people enriching themselves at the expense of the poor , Sin was seen as a working-class hero , stealing from the rich and sharing with the needy . His popularity made him a fashion icon , and in particular , the colorful Missoni T-shirt worn by Sin when he was captured became a popular fashion item in Korea . 
@@21438755 ICDO = Foot-and-mouth disease or hoof-and-mouth disease ( ' ' Aphthae epizooticae ' ' ) is an infectious and sometimes fatal viral disease that affects cloven-hoofed animals , including domestic and wild bovids . The virus causes a high fever for two or three days , followed by blisters inside the mouth and on the feet that may rupture and cause lameness . Foot-and-mouth disease ( FMD ) has severe implications for animal farming , since it is highly infectious and can be spread by infected animals through aerosols , through contact with contaminated farming equipment , vehicles , clothing , or feed , and by domestic and wild predators . Its containment demands considerable efforts in vaccination , strict monitoring , trade restrictions , and quarantines , and occasionally the killing of animals . Susceptible animals include cattle , water buffalo , sheep , goats , pigs , antelope , deer , and bison . It has also been known to infect hedgehogs and elephants ; llamas , and alpacas may develop mild symptoms , but are resistant to the disease and do not pass it on to others of the same species . In laboratory experiments , mice , rats , and chickens have been successfully infected by artificial means , but they are not believed to contract the disease under natural conditions . Humans are very rarely infected . The virus responsible for the disease is a picornavirus , the prototypic member of the genus ' ' Aphthovirus ' ' . Infection occurs when the virus particle is taken into a cell of the host . The cell is then forced to manufacture thousands of copies of the virus , and eventually bursts , releasing the new particles in the blood . The virus is genetically highly variable , which limits the effectiveness of vaccination. # History # The cause of FMD was first shown to be viral in 1897 by Friedrich Loeffler . He passed the blood of an infected animal through a Chamberland filter and found the collected fluid could still cause the disease in healthy animals . FMD occurs throughout much of the world , and whilst some countries have been free of FMD for some time , its wide host range and rapid spread represent cause for international concern . After World War II , the disease was widely distributed throughout the world . In 1996 , endemic areas included Asia , Africa , and parts of South America ; as of August 2007 , Chile is disease-free , and Uruguay and Argentina have not had an outbreak since 2001 . In May 2014 , the FAO informed that Bolivia , Colombia , Ecuador and Peru were just one step away from eradication ; North America and Australia have been free of FMD for many years . New Zealand has never had a case of foot-and-mouth disease . Most European countries have been recognized as disease-free , and countries belonging to the European Union have stopped FMD vaccination . However , in 2001 , a serious outbreak of FMD in Britain resulted in the slaughter of many animals , the postponing of the general election for a month , and the cancellation of many sporting events and leisure activities , such as the Isle of Man TT . Due to strict government policies on sale of livestock , disinfection of all persons leaving and entering farms , and the cancellation of large events likely to be attended by farmers , a potentially economically disastrous epizootic was avoided in the Republic of Ireland , with just one case recorded in Proleek , Co . Louth . In August 2007 , FMD was found at two farms in Surrey , England . All livestock were culled and a quarantine erected over the area . Two other suspected outbreaks have occurred since , although these seem now not to be related to FMD . The only reported cases in 2010 were a false alarm from GIS Alex Baker , as proven false by the Florida Farm and Agricultural Department , and confirmed quarantine/slaughter of cattle and pigs has been reported from Miyazaki Prefecture in Japan in June after three cows tested positive . A total of some 270,000 cattle have been ordered slaughtered following the disease 's outbreak . # Clinical signs # The incubation period for foot-and-mouth disease virus has a range between two and 12 days . The disease is characterized by high fever that declines rapidly after two or three days , blisters inside the mouth that lead to excessive secretion of stringy or foamy saliva and to drooling , and blisters on the feet that may rupture and cause lameness . Adult animals may suffer weight loss from which they do not recover for several months , as well as swelling in the testicles of mature males , and in cows , milk production can decline significantly . Though most animals eventually recover from FMD , the disease can lead to myocarditis ( inflammation of the heart muscle ) and death , especially in newborn animals . Some infected animals remain asymptomatic , but they nonetheless carry FMD and can transmit it to others . # Evolution # Of the seven serotypes of this virus , A , C , O , Asia 1 , and SAT3 appear to be distinct lineages ; SAT 1 and SAT 2 are unresolved clades . The mutation rate of the protein-encoding sequences of strains isolated between 1932 and 2007 has been estimated to be 1.46 10 <sup> 3 </sup> substitutions/site/year , a rate similar to that of other RNA viruses . The most recent common ancestor appears to have evolved about 481 years ago ( early 16th century ) . This ancestor then diverged into two clades which have given rise to the extant circulating Euro-Asiatic and South African . This event occurred around 1800 . Skyline plot analysis shows a population expansion in the early 20th century , which was then followed by a rapid decline in population size in the late 20th century . At least seven genotypes of serotype Asia 1 are known . # Transmission # The FMD virus can be transmitted in a number of ways , including close-contact animal-to-animal spread , long-distance aerosol spread and fomites , or inanimate objects , typically fodder and motor vehicles . The clothes and skin of animal handlers , such as farmers , standing water , and uncooked food scraps and feed supplements containing infected animal products can harbor the virus , as well . Cows can also catch FMD from the semen of infected bulls . Control measures include quarantine and destruction of infected livestock , and export bans for meat and other animal products to countries not infected with the disease . Just as humans may spread the disease by carrying the virus on their clothes and bodies , animals that are not susceptible to the disease may still aid in spreading it . This was the case in Canada in 1952 , when an outbreak flared up again after dogs had carried off bones from dead animals . Wolves are thought to play a similar role in the former Soviet Union . # Foot-and-mouth disease infecting humans # Humans can be infected with foot-and-mouth disease through contact with infected animals , but this is extremely rare . Some cases were caused by laboratory accidents . Because the virus that causes FMD is sensitive to stomach acid , it can not spread to humans via consumption of infected meat , except in the mouth before the meat is swallowed . In the UK , the last confirmed human case occurred in 1966 , and only a few other cases have been recorded in countries of continental Europe , Africa , and South America . Symptoms of FMD in humans include malaise , fever , vomiting , red ulcerative lesions ( surface-eroding damaged spots ) of the oral tissues , and sometimes vesicular lesions ( small blisters ) of the skin . According to a newspaper report , FMD killed two children in England in 1884 , supposedly due to infected milk . Another viral disease with similar symptoms , hand , foot and mouth disease , occurs more frequently in humans , especially in young children ; the cause , Coxsackie A virus , is different from FMDV . Coxsackie viruses belong to the ' ' Enteroviruses ' ' within the Picornaviridae . Because FMD rarely infects humans , but spreads rapidly among animals , it is a much greater threat to the agriculture industry than to human health . Farmers around the world can lose huge amounts of money during a foot-and-mouth epizootic , when large numbers of animals are destroyed , and revenues from milk and meat production go down . # Vaccination # Like other viruses , the FMD virus continually evolves and mutates , thus one of the difficulties in vaccinating against it is the huge variation between , and even within , serotypes . There is no cross-protection between serotypes ( a vaccine for one serotype will not protect against any others ) and in addition , two strains within a given serotype may have nucleotide sequences that differ by as much as 30% for a given gene . This means FMD vaccines must be highly specific to the strain involved . Vaccination only provides temporary immunity that lasts from months to years . Currently , the World Organisation for Animal Health recognizes countries to be in one of three disease states with regards to FMD : FMD present with or without vaccination , FMD-free with vaccination , and FMD-free without vaccination . Countries designated FMD-free without vaccination have the greatest access to export markets , so many developed nations , including Canada , the United States , and the UK , work hard to maintain their current status . Some countries such as Brazil and Argentina which have large beef exporting industries , practise vaccination in some areas but have other vaccination-free zones . Reasons cited for restricting export from countries using FMD vaccines include , probably most importantly , routine blood tests relying on antibodies can not distinguish between an infected and a vaccinated animal , which severely hampers screening of animals used in export products , risking a spread of FMD to importing countries . A widespread preventive vaccination would also conceal the existence of the virus in a country . From there , it could potentially spread to countries without vaccine programs . Lastly , an animal infected shortly after being vaccinated can harbor and spread FMD without showing symptoms itself , hindering containment and culling of sick animals as a remedy . Many early vaccines used dead samples of FMDV to inoculate animals , but those early vaccines sometimes caused real outbreaks . In the 1970s , scientists discovered that a vaccine could be made using only a single key protein from the virus . The task was to produce enough quantities of the protein to be used in the vaccination . On June 18 , 1981 , the US government announced the creation of a vaccine targeted against FMD , the world 's first genetically engineered vaccine . The North American FMD Vaccine Bank is housed at the United States Department of Agriculture 's Foreign Animal Disease Diagnostic Laboratory at Plum Island Animal Disease Center . The Center , located 1.5mi km off the coast of Long Island , NY , is the only place in the United States where scientists can conduct research and diagnostic work on highly contagious animal diseases such as FMD . Because of this limitation , US companies working on FMD usually use facilities in other countries where such diseases are endemic . # Epizootics # # United States 1870-1929 # The US has had nine FMD outbreaks since it was first recognized on the northeastern coast in 1870 ; the most devastating happened in 1914 . It originated from Michigan , but its entry into the stockyards in Chicago turned it into an epizootic . About 3,500 livestock herds were infected across the US , totaling over 170,000 cattle , sheep , and swine . The eradication came at a cost of US$4.5 million . A 1924 outbreak in California resulted not only in the slaughter of 109,000 farm animals , but also 22,000 deer . The US had its latest FMD outbreak in Montebello , California , in 1929 . This outbreak originated in hogs that had eaten infected meat scraps from a tourist steamship that had stocked meat in Argentina . Over 3,600 animals were slaughtered and the disease was contained in less than a month . # United Kingdom 1967 # In October 1967 , a farmer in Shropshire reported a lame sow , which was later diagnosed with FMD . The source was believed to be remains of legally imported infected lamb from Argentina and Chile . The virus spread and , in total , 442,000 animals were slaughtered and the outbreak had an estimated cost of 370 million . # Taiwan 1997 # Taiwan had previous epidemics of FMD in 1913-14 and 192429 , but had since been spared , and considered itself free of FMD as late as in the 1990s . On the 19th of March 1997 , a sow at a farm in Hsinchu Prefecture , Taiwan , was diagnosed with a strain of FMD which only infects swine . Mortality was high , nearing 100% in the infected herd . The cause of the epidemic was not determined , but the farm was near a port city known for its pig-smuggling industry and illegal slaughterhouses . Smuggled swine or contaminated meat are thus likely sources of the disease . The disease spread fast among swine herds in Taiwan , with 200-300 new farms being infected daily . Causes for this include the high swine density in the area , with up to 6,500 hogs per square mile , feeding of pigs with untreated garbage , and the farms ' proximity to slaughterhouses . Other systemic issues , such as lack of laboratory facilities , slow response , and initial lack of a vaccination program , contributed . The farmers allegedly intentionally introduced FMD to their flocks , because the payment offered to farmers for culled swine was at the time higher than their market value . A complicating factor is the endemic spread of swine vesicular disease ( SVD ) in Taiwan . The symptoms are indistinguishable from FMD , which may have led to previous misdiagnosing of FMD as SVD . Laboratory analysis was seldom used for diagnosis , and FMD may thus have gone unnoticed for some time . The swine depopulation was a massive undertaking , with the military contributing substantial manpower . At peak capacity , 200,000 hogs per day were disposed of , mainly by electrocution . Carcasses were disposed of by burning and burial , but burning was avoided in water resource protection areas . In April , industrial incinerators were running around the clock to dispose of the carcasses . Initially , 40,000 combined vaccine doses for the strains O-1 , A-24 , and Asia-1 were available and administered to zoo animals and valuable breeding hogs . At the end of March , half a million new doses for O-1 and Asia-1 were made available . On the May 3rd , 13 million doses of O-1 vaccine arrived , and both the March and May shipments were distributed free of charge . With a danger of vaccination crews spreading the disease , only trained farmers were allowed to administer the vaccine under veterinary supervision . Taiwan had previously been the major exporter of pork to Japan , and among the top 15 pork producers in the world in 1996 . During the outbreak , over 3.8 million swine were destroyed at a cost of US$6.9 billion . The Taiwanese pig industry was devastated as a result , and the export market was in ruins . In 2007 , Taiwan was considered free of FMD , but was still conducting a vaccination program , which restricts the export of meat from Taiwan . # United Kingdom 2001 # The epidemic of foot-and-mouth disease in the United Kingdom in the spring and summer of 2001 was caused by the Type O pan Asia strain of the disease . This episode resulted in more than 2,000 cases of the disease in farms throughout the British countryside . Around ten million sheep and cattle were killed in an eventually successful attempt to halt the disease . The County of Cumbria was the worst affected area of the country , with 843 cases . By the time the disease was halted in October 2001 , the crisis was estimated to have cost Britain 8 billion ( $13 billion ) in costs to the agricultural and support industries , and to the outdoor industry . What made this outbreak so serious was the amount of time between infection being present at the first outbreak locus , and the time when countermeasures were put into operation against the disease , such as transport bans and detergent washing of both vehicles and personnel entering livestock areas . The epidemic was probably caused by pigs which had been fed infected garbage that had not been properly heat-sterilized . Further , the garbage is believed to have contained remains of infected meat had been illegally imported to Britain . # China 2005 # In April 2005 , an Asia-1 strain of FMD appeared in the eastern provinces of Shandong and Jiangsu . During April and May , it spread to suburban Beijing , the northern province of Hebei , and the Xinjiang autonomous region in northwest China . On 13 May , China reported the FMD outbreak to the World Health Organization and the OIE . This was the first time China has publicly admitted to having FMD . China is still reporting FMD outbreaks . In 2007 , reports filed with the OIE documented new or ongoing outbreaks in the provinces of Gansu , Qinghai and Xinjiang . This included reports of domestic yak showing signs of infection . FMD is endemic in pastoral regions of China from Heilongjiang Province in the northeast to Sichuan Province and the Tibetan Autonomous region in the southwest . Chinese domestic media reports often use a euphemism Disease Number Five ( ' ' whobng ' ' ) rather than FMD in reports because of the sensitivity of the FMD issue . In March 2010 , ' ' Southern Rural News ' ' ( ' ' Nanfang Nongcunbao ' ' ) , in an article Breaking the Hoof and Mouth Disease Taboo , noted that FMD has long been covered up in China by referring to it that way . FMD is also called canker ( , literally mouth ulcers ' ' kuchung ' ' ) or hoof jaundice ( ' ' thung ' ' ) in China , so information on FMD in China can be found online using those words as search terms . One can find online many provincial orders and regulations on FMD control antedating China 's acknowledgment that the disease existed in China , for example Guangxi Zhuang Autonomous Region 1991 regulation on preventing the spread of Disease No.5. # United Kingdom 2007 # An infection of foot-and-mouth disease in the United Kingdom was confirmed by the Department for Environment , Food and Rural Affairs , on 3 August 2007 , on farmland located in Normandy , Surrey . All livestock in the vicinity were culled on 4 August . A nationwide ban on the movement of cattle and pigs was imposed , with a 3-km ( 1.9-mi ) protection zone placed around the outbreak sites and the nearby virus research and vaccine production establishments , together with a 10-km ( 6.2-mi ) increased surveillance zone . On 4 August , the strain of the virus was identified as a 01 BFS67-like virus , one linked to vaccines and not normally found in animals , and isolated in the 1967 outbreak . The same strain was used at the nearby Institute for Animal Health and Merial Animal Health Ltd at Pirbright , 2.5 mi away , which is an American/French owned research facility , and was identified as a possible source of infection . On 12 September , a new outbreak of the disease was confirmed in Egham , Surrey , 19km mi from the original outbreak , with a second case being confirmed on a nearby farm on 14 September . These outbreaks caused a cull of all at-risk animals in the area surrounding Egham , including two farms near to the famous four-star Hotel Great Fosters . These outbreaks also caused the closure of Windsor Great Park due to the park containing deer ; the park remained closed for three months . On 19 September 2007 , a suspected case of FMD was found in Solihull , where a temporary control zone was set up by Defra. # Japan and Korea 20102011 # In April 2010 , a report of three incursions of FMD in Japan and South Korea led the United Nations Food and Agriculture Organization ( FAO ) to issue a call for increased global surveillance . Japan veterinary authorities confirmed an outbreak of type O FMD virus , currently more common in Asian countries where FMD is endemic . South Korea was hit by the rarer type A FMD in January , and then suffered type O infection in April . The most serious case of foot-and-mouth outbreak in South Korea 's history started in November 2010 in pig farms in Andong city of Gyeongsangbuk-do , and has since spread in the country rapidly . More than 100 cases of the disease have been confirmed in the country so far , and in January 2011 , South Korean officials started a mass cull of approximately 12% , or around three million in total , of the entire domestic pig population , and 107,000 of three million cattle of the country to halt the outbreak . On 10 Feb 2011 , North Korea reported an outbreak affecting pigs in the region around Pyongyang , by then ongoing since at least December 2010 . Efforts to control the outbreak have been hampered by illicit sales of infected meat . # Bulgaria 2011 # The outbreak was recognised when a wild boar was shot , which had crossed the Bulgarian-Turkish border near the village of Kosti , Burgas Province , in the Strandzha Mountains . The necropsy uncovered foot-and mouth disease . After this , 37 infected animals were discovered in the village of Kosti , and all susceptible animals there were culled . Burgas Province and seven other neighboring provinces declared a quarantine zone . On 14 January , a further outbreak was discovered in the neighboring village of Rezovo , thought to have been carried by a Turkish cattle herd . On 17 January , the presence of the disease was confirmed . The Bulgarian authorities ordered culling of all susceptible livestock in Rezovo . Compensation for the losses in the two villages has been promised . On 31 January , a third focus of infection was discovered in the southeastern Bulgarian village of Gramatikovo . On 25 March , two new outbreaks were discovered in the villages of Granichar and Kirovo. # Economic and ethical issues # Epidemics of FMD have resulted in the slaughter of millions of animals , despite this being a frequently nonfatal disease for adult animals ( 2-5% mortality ) , though young animals can have a high mortality . The Taiwan outbreak that only affected pigs also showed a high mortality for adults . The destruction of animals is primarily to halt further spread , as growth and milk production may be permanently affected , even in animals that have recovered . Due to international efforts to eradicate the disease , infection would also lead to trade bans being imposed on affected countries . Critics of current policies to cull infected herds argue that the financial imperative needs to be balanced against the killing of many animals , especially when a significant proportion of infected animals , most notably those producing milk , would recover from infection and live normal lives , albeit with reduced milk production . On the ethical side , one must also consider FMD is a painful disease for the affected animals . The vesicles/blisters are painful in themselves , and restrict both eating and movement . Through ruptured blisters , the animal is at risk from secondary bacterial infections and , in some cases , permanent disability . 
@@22228064 ICDO = MedlinePlus = 000755 Parkinson 's disease ( PD also known as idiopathic or primary parkinsonism , hypokinetic rigid syndrome/HRS , or paralysis agitans ) is a degenerative disorder of the central nervous system . The motor symptoms of Parkinson 's disease result from the death of dopamine-generating cells in the substantia nigra , a region of the midbrain ; the cause of this cell death is unknown . Early in the course of the disease , the most obvious symptoms are movement-related ; these include shaking , rigidity , slowness of movement and difficulty with walking and gait . Later , thinking and behavioral problems may arise , with dementia commonly occurring in the advanced stages of the disease , whereas depression is the most common psychiatric symptom . Other symptoms include sensory , sleep and emotional problems . Parkinson 's disease is more common in older people , with most cases occurring after the age of 50 . The main motor symptoms are collectively called parkinsonism , or a parkinsonian syndrome . Parkinson 's disease is often defined as a parkinsonian syndrome that is idiopathic ( having no known cause ) , although some atypical cases have a genetic origin . Many risk and protective factors have been investigated : the clearest evidence is for an increased risk of PD in people exposed to certain pesticides and a reduced risk in tobacco smokers . The pathology of the disease is characterized by the accumulation of a protein called alpha-synuclein into inclusions called Lewy bodies in neurons , and from insufficient formation and activity of dopamine produced in certain neurons within parts of the midbrain . Lewy bodies are the pathological hallmark of the idiopathic disorder , and the distribution of the Lewy bodies throughout the Parkinsonian brain varies from one individual to another . The anatomical distribution of the Lewy bodies is often directly related to the expression and degree of the clinical symptoms of each individual . Diagnosis of typical cases is mainly based on symptoms , with tests such as neuroimaging being used for confirmation . Modern treatments are effective at managing the early motor symptoms of the disease , mainly through the use of levodopa and dopamine agonists . As the disease progresses and dopaminergic neurons continue to be lost , these drugs eventually become ineffective at treating the symptoms and at the same time produce a complication called dyskinesia , marked by involuntary writhing movements . Diet and some forms of rehabilitation have shown some effectiveness at alleviating symptoms . Surgery and deep brain stimulation have been used to reduce motor symptoms as a last resort in severe cases where drugs are ineffective . Research directions include investigations into new animal models of the disease and of the potential usefulness of gene therapy , stem cell transplants and neuroprotective agents . Medications to treat non-movement-related symptoms of PD , such as sleep disturbances and emotional problems , also exist . The disease is named after the English doctor James Parkinson , who published the first detailed description in ' ' An Essay on the Shaking Palsy ' ' in 1817 . Several major organizations promote research and improvement of quality of life of those with the disease and their families . Public awareness campaigns include Parkinson 's disease day ( on the birthday of James Parkinson , 11 April ) and the use of a red tulip as the symbol of the disease . People with parkinsonism who have increased the public 's awareness include actor Michael J. Fox , Olympic cyclist Davis Phinney and professional boxer Muhammad Ali . # Classification # The term parkinsonism is used for a motor syndrome whose main symptoms are tremor at rest , stiffness , slowing of movement and postural instability . Parkinsonian syndromes can be divided into four subtypes according to their origin : primary or idiopathic , secondary or acquired , hereditary parkinsonism , and parkinson plus syndromes or multiple system degeneration . Parkinson 's disease is the most common form of parkinsonism and is usually defined as primary parkinsonism , meaning parkinsonism with no external identifiable cause . In recent years several genes that are directly related to some cases of Parkinson 's disease have been discovered . As much as this conflicts with the definition of Parkinson 's disease as an idiopathic illness , genetic parkinsonism disorders with a similar clinical course to PD are generally included under the Parkinson 's disease label . The terms familial Parkinson 's disease and sporadic Parkinson 's disease can be used to differentiate genetic from truly idiopathic forms of the disease . Usually classified as a movement disorder , PD also gives rise to several non-motor types of symptoms such as sensory deficits , cognitive difficulties or sleep problems . Parkinson plus diseases are primary parkinsonisms which present additional features . They include multiple system atrophy , progressive supranuclear palsy , corticobasal degeneration and dementia with Lewy bodies . In terms of pathophysiology , PD is considered a synucleiopathy due to an abnormal accumulation of alpha-synuclein protein in the brain in the form of Lewy bodies , as opposed to other diseases such as Alzheimer 's disease where the brain accumulates tau protein in the form of neurofibrillary tangles . Nevertheless , there is clinical and pathological overlap between tauopathies and synucleinopathies . The most typical symptom of Alzheimer 's disease , dementia , occurs in advanced stages of PD , while it is common to find neurofibrillary tangles in brains affected by PD . Dementia with Lewy bodies ( DLB ) is another synucleinopathy that has similarities with PD , and especially with the subset of PD cases with dementia . However the relationship between PD and DLB is complex and still has to be clarified . They may represent parts of a continuum or they may be separate diseases . # Signs and symptoms # Parkinson 's disease affects movement , producing motor symptoms . Non-motor symptoms , which include autonomic dysfunction , neuropsychiatric problems ( mood , cognition , behavior or thought alterations ) , and sensory and sleep difficulties , are also common . Some of these non-motor symptoms are often present at the time of diagnosis and can precede motor symptoms . # Motor # Four motor symptoms are considered cardinal in PD : tremor , rigidity , slowness of movement , and postural instability . Tremor is the most apparent and well-known symptom . It is the most common ; though around 30% of individuals with PD do not have tremor at disease onset , most develop it as the disease progresses . It is usually a rest tremor : maximal when the limb is at rest and disappearing with voluntary movement and sleep . It affects to a greater extent the most distal part of the limb and at onset typically appears in only a single arm or leg , becoming bilateral later . Frequency of PD tremor is between 4 and 6 hertz ( cycles per second ) . A feature of tremor is ' ' pill-rolling ' ' , the tendency of the index finger of the hand to get into contact with the thumb and perform together a circular movement . The term derives from the similarity between the movement in people with PD and the earlier pharmaceutical technique of manually making pills . Bradykinesia ( slowness of movement ) is another characteristic feature of PD , and is associated with difficulties along the whole course of the movement process , from planning to initiation and finally execution of a movement . Performance of sequential and simultaneous movement is hindered . Bradykinesia is commonly a very disabling symptom in the early stages of the disease . Initial manifestations are problems when performing daily tasks which require fine motor control such as writing , sewing or getting dressed . Clinical evaluation is based in similar tasks such as alternating movements between both hands or both feet . Bradykinesia is not equal for all movements or times . It is modified by the activity or emotional state of the subject , to the point that some people are barely able to walk yet can still ride a bicycle . Generally people with PD have less difficulty when some sort of external cue is provided . Rigidity is stiffness and resistance to limb movement caused by increased muscle tone , an excessive and continuous contraction of muscles . In parkinsonism the rigidity can be uniform ( lead-pipe rigidity ) or ratchety ( cogwheel rigidity ) . The combination of tremor and increased tone is considered to be at the origin of cogwheel rigidity . Rigidity may be associated with joint pain ; such pain being a frequent initial manifestation of the disease . In early stages of Parkinson 's disease , rigidity is often asymmetrical and it tends to affect the neck and shoulder muscles prior to the muscles of the face and extremities . With the progression of the disease , rigidity typically affects the whole body and reduces the ability to move . Postural instability is typical in the late stages of the disease , leading to impaired balance and frequent falls , and secondarily to bone fractures . Instability is often absent in the initial stages , especially in younger people . Up to 40% may experience falls and around 10% may have falls weekly , with number of falls being related to the severity of PD . Other recognized motor signs and symptoms include gait and posture disturbances such as festination ( rapid shuffling steps and a forward-flexed posture when walking ) , speech and swallowing disturbances including voice disorders , mask-like face expression or small handwriting , although the range of possible motor problems that can appear is large . # Neuropsychiatric # Parkinson 's disease can cause neuropsychiatric disturbances which can range from mild to severe . This includes disorders of speech , cognition , mood , behaviour , and thought . Cognitive disturbances can occur in the initial stages of the disease and sometimes prior to diagnosis , and increase in prevalence with duration of the disease . The most common cognitive deficit in affected individuals is executive dysfunction , which can include problems with planning , cognitive flexibility , abstract thinking , rule acquisition , initiating appropriate actions and inhibiting inappropriate actions , and selecting relevant sensory information . Fluctuations in attention and slowed cognitive speed are among other cognitive difficulties . Memory is affected , specifically in recalling learned information . Nevertheless , improvement appears when recall is aided by cues . Visuospatial difficulties are also part of the disease , seen for example when the individual is asked to perform tests of facial recognition and perception of the orientation of drawn lines . A person with PD has two to six times the risk of dementia compared to the general population . The prevalence of dementia increases with duration of the disease . Dementia is associated with a reduced quality of life in people with PD and their caregivers , increased mortality , and a higher probability of needing nursing home care . Behavior and mood alterations are more common in PD without cognitive impairment than in the general population , and are usually present in PD with dementia . The most frequent mood difficulties are depression , apathy and anxiety . Establishing the diagnosis of depression is complicated by symptoms that often occur in Parkinson 's including dementia , decreased facial expression , decreased movement , a state of indifference , and quiet speech . Impulse control behaviors such as medication overuse and craving , binge eating , hypersexuality , or pathological gambling can appear in PD and have been related to the medications used to manage the disease . Psychotic symptomshallucinations or delusionsoccur in 4% of people with PD , and it is assumed that the main precipitant of psychotic phenomena in Parkinsons disease is dopaminergic excess secondary to treatment ; it therefore becomes more common with increasing age and levodopa intake . # Other # In addition to cognitive and motor symptoms , PD can impair other body functions . Sleep problems are a feature of the disease and can be worsened by medications . Symptoms can manifest as daytime drowsiness , disturbances in REM sleep , or insomnia . Alterations in the autonomic nervous system can lead to orthostatic hypotension ( low blood pressure upon standing ) , oily skin and excessive sweating , urinary incontinence and altered sexual function . Constipation and gastric dysmotility can be severe enough to cause discomfort and even endanger health . PD is related to several eye and vision abnormalities such as decreased blink rate , dry eyes , deficient ocular pursuit ( eye tracking ) and saccadic movements ( fast automatic movements of both eyes in the same direction ) , difficulties in directing gaze upward , and blurred or double vision . Changes in perception may include an impaired sense of smell , sensation of pain and paresthesia ( skin tingling and numbness ) . All of these symptoms can occur years before diagnosis of the disease . # Causes # Parkinson 's disease in most people is idiopathic ( having no specific known cause ) . However a small proportion of cases , can be attributed to known genetic factors . Other factors have been associated with the risk of developing PD , but no causal relationships have been proven . # Environmental factors # A number of environmental factors have been associated with an increased risk of Parkinson 's including : pesticide exposure , head injuries , and living in the country or farming . Rural environments and the drinking of well water may be risks as they are an indirect measures of exposure to pesticides . Implicated agents include insecticides , primarily chlorpyrifos and organochlorines and pesticides , such as rotenone or paraquat , and herbicides , such as Agent Orange . Heavy metals exposure has been proposed to be a risk factor , through possible accumulation in the substantia nigra ; however , studies on the issue have been inconclusive . # Genetics # PD traditionally has been considered a non-genetic disorder ; however , around 15% of individuals with PD have a first-degree relative who has the disease . At least 5% of people are now known to have forms of the disease that occur because of a mutation of one of several specific genes . Mutations in specific genes have been conclusively shown to cause PD . These genes code for alpha-synuclein ( SNCA ) , parkin ( PRKN ) , leucine-rich repeat kinase 2 ( LRRK2 or dardarin ) , PTEN-induced putative kinase 1 ( PINK1 ) , DJ-1 and ATP13A2 . In most cases , people with these mutations will develop PD . With the exception of LRRK2 , however , they account for only a small minority of cases of PD . The most extensively studied PD-related genes are SNCA and LRRK2 . Mutations in genes including SNCA , LRRK2 and glucocerebrosidase ( GBA ) have been found to be risk factors for sporadic PD . Mutations in GBA are known to cause Gaucher 's disease . Genome-wide association studies , which search for mutated alleles with low penetrance in sporadic cases , have now yielded many positive results . The role of the SNCA gene is important in PD because the alpha-synuclein protein is the main component of Lewy bodies . Missense mutations of the gene ( in which a single nucleotide is changed ) , and duplications and triplications of the locus containing it have been found in different groups with familial PD . Missense mutations are rare . On the other hand , multiplications of the SNCA locus account for around 2% of familial cases . Multiplications have been found in asymptomatic carriers , which indicate that penetrance is incomplete or age-dependent . The LRRK2 gene ( PARK8 ) encodes for a protein called dardarin . The name dardarin was taken from a Basque word for tremor , because this gene was first identified in families from England and the north of Spain . Mutations in LRRK2 are the most common known cause of familial and sporadic PD , accounting for approximately 5% of individuals with a family history of the disease and 3% of sporadic cases . There are many different mutations described in LRRK2 , however unequivocal proof of causation only exists for a small number . # Pathology # # Anatomical # The basal ganglia , a group of brain structures innervated by the dopaminergic system , are the most seriously affected brain areas in PD . The main pathological characteristic of PD is cell death in the substantia nigra and , more specifically , the ventral ( front ) part of the pars compacta , affecting up to 70% of the cells by the time death occurs . Macroscopic alterations can be noticed on cut surfaces of the brainstem , where neuronal loss can be inferred from a reduction of melanin pigmentation in the substantia nigra and locus coeruleus . The histopathology ( microscopic anatomy ) of the substantia nigra and several other brain regions shows neuronal loss and Lewy bodies in many of the remaining nerve cells . Neuronal loss is accompanied by death of astrocytes ( star-shaped glial cells ) and activation of the microglia ( another type of glial cell ) . Lewy bodies are a key pathological feature of PD . # Pathophysiology # The primary symptoms of Parkinson 's disease result from greatly reduced activity of dopamine-secreting cells caused by cell death in the pars compacta region of the substantia nigra . There are five major pathways in the brain connecting other brain areas with the basal ganglia . These are known as the motor , oculo-motor , associative , limbic and orbitofrontal circuits , with names indicating the main projection area of each circuit . All of them are affected in PD , and their disruption explains many of the symptoms of the disease since these circuits are involved in a wide variety of functions including movement , attention and learning . Scientifically , the motor circuit has been examined the most intensively . A particular conceptual model of the motor circuit and its alteration with PD has been of great influence since 1980 , although some limitations have been pointed out which have led to modifications . In this model , the basal ganglia normally exert a constant inhibitory influence on a wide range of motor systems , preventing them from becoming active at inappropriate times . When a decision is made to perform a particular action , inhibition is reduced for the required motor system , thereby releasing it for activation . Dopamine acts to facilitate this release of inhibition , so high levels of dopamine function tend to promote motor activity , while low levels of dopamine function , such as occur in PD , demand greater exertions of effort for any given movement . Thus the net effect of dopamine depletion is to produce hypokinesia , an overall reduction in motor output . Drugs that are used to treat PD , conversely , may produce excessive dopamine activity , allowing motor systems to be activated at inappropriate times and thereby producing dyskinesias. # Brain cell death # There is speculation of several mechanisms by which the brain cells could be lost . One mechanism consists of an abnormal accumulation of the protein alpha-synuclein bound to ubiquitin in the damaged cells . This insoluble protein accumulates inside neurones forming inclusions called Lewy bodies . According to the Braak staging , a classification of the disease based on pathological findings , Lewy bodies first appear in the olfactory bulb , medulla oblongata and pontine tegmentum , with individuals at this stage being asymptomatic . As the disease progresses , Lewy bodies later develop in the substantia nigra , areas of the midbrain and basal forebrain , and in a last step the neocortex . These brain sites are the main places of neuronal degeneration in PD ; however , Lewy bodies may not cause cell death and they may be protective . In people with dementia , a generalized presence of Lewy bodies is common in cortical areas . Neurofibrillary tangles and senile plaques , characteristic of Alzheimer 's disease , are not common unless the person is demented . Other cell-death mechanisms include proteosomal and lysosomal system dysfunction and reduced mitochondrial activity . Iron accumulation in the substantia nigra is typically observed in conjunction with the protein inclusions . It may be related to oxidative stress , protein aggregation and neuronal death , but the mechanisms are not fully understood . # Diagnosis # A physician will diagnose Parkinson 's disease from the medical history and a neurological examination . There is no lab test that will clearly identify the disease , but brain scans are sometimes used to rule out disorders that could give rise to similar symptoms . People may be given levodopa and resulting relief of motor impairment tends to confirm diagnosis . The finding of Lewy bodies in the midbrain on autopsy is usually considered proof that the person had Parkinson 's disease . The progress of the illness over time may reveal it is not Parkinson 's disease , and some authorities recommend that the diagnosis be periodically reviewed . Other causes that can secondarily produce a parkinsonian syndrome are Alzheimer 's disease , multiple cerebral infarction and drug-induced parkinsonism . Parkinson plus syndromes such as progressive supranuclear palsy and multiple system atrophy must be ruled out . Anti-Parkinson 's medications are typically less effective at controlling symptoms in Parkinson plus syndromes . Faster progression rates , early cognitive dysfunction or postural instability , minimal tremor or symmetry at onset may indicate a Parkinson plus disease rather than PD itself . Genetic forms are usually classified as PD , although the terms ' ' familial Parkinson 's disease ' ' and ' ' familial parkinsonism ' ' are used for disease entities with an autosomal dominant or recessive pattern of inheritance . Medical organizations have created diagnostic criteria to ease and standardize the diagnostic process , especially in the early stages of the disease . The most widely known criteria come from the UK Parkinson 's Disease Society Brain Bank and the U.S. National Institute of Neurological Disorders and Stroke . The PD Society Brain Bank criteria require slowness of movement ( bradykinesia ) plus either rigidity , resting tremor , or postural instability . Other possible causes for these symptoms need to be ruled out . Finally , three or more of the following features are required during onset or evolution : unilateral onset , tremor at rest , progression in time , asymmetry of motor symptoms , response to levodopa for at least five years , clinical course of at least ten years and appearance of dyskinesias induced by the intake of excessive levodopa . Accuracy of diagnostic criteria evaluated at autopsy is 7590% , with specialists such as neurologists having the highest rates . Computed tomography ( CT ) and magnetic resonance imaging ( MRI ) brain scans of people with PD usually appear normal . These techniques are nevertheless useful to rule out other diseases that can be secondary causes of parkinsonism , such as basal ganglia tumors , vascular pathology and hydrocephalus . A specific technique of MRI , diffusion MRI , has been reported to be useful at discriminating between typical and atypical parkinsonism , although its exact diagnostic value is still under investigation . Dopaminergic function in the basal ganglia can be measured with different PET and SPECT radiotracers . Examples are ioflupane ( <sup> 123 </sup> I ) ( trade name ' ' DaTSCAN ' ' ) and iometopane ( ' ' Dopascan ' ' ) for SPECT or fluorodeoxyglucose ( <sup> 18 </sup> F ) for PET . A pattern of reduced dopaminergic activity in the basal ganglia can aid in diagnosing PD . # Prevention # Caffeine consumption appears protective against Parkinson 's disease with a greater decrease in risk occurring with a larger intake of caffeinated beverages such as coffee . Although tobacco smoke decreases life expectancy and quality of life , it may reduce the risk of PD by a third when compared to non-smokers . The basis for this effect is not known , but possibilities include an effect of nicotine as a dopamine stimulant . Tobacco smoke contains compounds that act as MAO inhibitors that also might contribute to this effect . Antioxidants , such as vitamins C and D , have been proposed to protect against the disease but results of studies have been contradictory and no positive effect has been proven . The results regarding fat and fatty acids have been contradictory , with various studies reporting protective effects , risk-increasing effects or no effects . Finally there have been preliminary indications of a possible protective role of estrogens and anti-inflammatory drugs . # Management # There is no cure for Parkinson 's disease , but medications , surgery and multidisciplinary management can provide relief from the symptoms . The main families of drugs useful for treating motor symptoms are levodopa ( usually combined with a dopa decarboxylase inhibitor or COMT inhibitor ) , dopamine agonists and MAO-B inhibitors . The stage of the disease determines which group is most useful . Two stages are usually distinguished : an initial stage in which the individual with PD has already developed some disability for which he needs pharmacological treatment , then a second stage in which an individual develops motor complications related to levodopa usage . Treatment in the initial stage aims for an optimal tradeoff between good symptom control and side-effects resulting from improvement of dopaminergic function . The start of levodopa ( or L-DOPA ) treatment may be delayed by using other medications such as MAO-B inhibitors and dopamine agonists , in the hope of delaying the onset of dyskinesias . In the second stage the aim is to reduce symptoms while controlling fluctuations of the response to medication . Sudden withdrawals from medication or overuse have to be managed . When medications are not enough to control symptoms , surgery and deep brain stimulation can be of use . In the final stages of the disease , palliative care is provided to improve quality of life . # Levodopa # Levodopa has been the most widely used treatment for over 30 years . L-DOPA is converted into dopamine in the dopaminergic neurons by dopa decarboxylase . Since motor symptoms are produced by a lack of dopamine in the substantia nigra , the administration of L-DOPA temporarily diminishes the motor symptoms . Only 510% of L-DOPA crosses the bloodbrain barrier . The remainder is often metabolized to dopamine elsewhere , causing a variety of side effects including nausea , dyskinesias and joint stiffness . Carbidopa and benserazide are peripheral dopa decarboxylase inhibitors , which help to prevent the metabolism of L-DOPA before it reaches the dopaminergic neurons , therefore reducing side effects and increasing bioavailability . They are generally given as combination preparations with levodopa . Existing preparations are carbidopa/levodopa ( co-careldopa ) and benserazide/levodopa ( co-beneldopa ) . Levodopa has been related to dopamine dysregulation syndrome , which is a compulsive overuse of the medication , and punding . There are controlled release versions of levodopa in the form intravenous and intestinal infusions that spread out the effect of the medication . These slow-release levodopa preparations have not shown an increased control of motor symptoms or motor complications when compared to immediate release preparations . Tolcapone inhibits the COMT enzyme , which degrades dopamine , thereby prolonging the effects of levodopa . It has been used to complement levodopa ; however , its usefulness is limited by possible side effects such as liver damage . A similarly effective drug , entacapone , has not been shown to cause significant alterations of liver function . Licensed preparations of entacapone contain entacapone alone or in combination with carbidopa and levodopa . Levodopa preparations lead in the long term to the development of motor complications characterized by involuntary movements called dyskinesias and fluctuations in the response to medication . When this occurs a person with PD can change from phases with good response to medication and few symptoms ( on state ) , to phases with no response to medication and significant motor symptoms ( off state ) . For this reason , levodopa doses are kept as low as possible while maintaining functionality . Delaying the initiation of therapy with levodopa by using alternatives ( dopamine agonists and MAO-B inhibitors ) is common practice . A former strategy to reduce motor complications was to withdraw L-DOPA medication for some time . This is discouraged now , since it can bring dangerous side effects such as neuroleptic malignant syndrome . Most people with PD will eventually need levodopa and later develop motor side effects . # Dopamine agonists # Several dopamine agonists that bind to dopaminergic post-synaptic receptors in the brain have similar effects to levodopa . These were initially used for individuals experiencing on-off fluctuations and dyskinesias as a complementary therapy to levodopa ; they are now mainly used on their own as an initial therapy for motor symptoms with the aim of delaying motor complications . When used in late PD they are useful at reducing the off periods . Dopamine agonists include bromocriptine , pergolide , pramipexole , ropinirole , piribedil , cabergoline , apomorphine and lisuride . Dopamine agonists produce significant , although usually mild , side effects including drowsiness , hallucinations , insomnia , nausea and constipation . Sometimes side effects appear even at a minimal clinically effective dose , leading the physician to search for a different drug . Compared with levodopa , dopamine agonists may delay motor complications of medication use but are less effective at controlling symptoms . Nevertheless , they are usually effective enough to manage symptoms in the initial years . Dyskinesias due to dopamine agonists are rare in younger people who have PD , but along with other side effects , become more common with age at onset . Thus dopamine agonists are the preferred initial treatment for earlier onset , as opposed to levodopa in later onset . Agonists have been related to impulse control disorders ( such as compulsive sexual activity and eating , and pathological gambling and shopping ) even more strongly than levodopa . Apomorphine , a non-orally administered dopamine agonist , may be used to reduce off periods and dyskinesia in late PD . It is administered by intermittent injections or continuous subcutaneous infusions . Since secondary effects such as confusion and hallucinations are common , individuals receiving apomorphine treatment should be closely monitored . Two dopamine agonists that are administered through skin patches ( lisuride and rotigotine ) and are useful for people in the initial stages and possibly to control off states in those in the advanced state . # MAO-B inhibitors # MAO-B inhibitors ( selegiline and rasagiline ) increase the level of dopamine in the basal ganglia by blocking its metabolism . They inhibit monoamine oxidase B ( MAO-B ) which breaks down dopamine secreted by the dopaminergic neurons . The reduction in MAO-B activity results in increased L-DOPA in the striatum . Like dopamine agonists , MAO-B inhibitors used as monotherapy improve motor symptoms and delay the need for levodopa in early disease , but produce more adverse effects and are less effective than levodopa . There are few studies of their effectiveness in the advanced stage , although results suggest that they are useful to reduce fluctuations between on and off periods . An initial study indicated that selegiline in combination with levodopa increased the risk of death , but this was later disproven. # Other drugs # Other drugs such as amantadine and anticholinergics may be useful as treatment of motor symptoms . However , the evidence supporting them lacks quality , so they are not first choice treatments . In addition to motor symptoms , PD is accompanied by a diverse range of symptoms . A number of drugs have been used to treat some of these problems . Examples are the use of quetiapine for psychosis , cholinesterase inhibitors for dementia , and modafinil for daytime sleepiness . A 2010 meta-analysis found that non-steroidal anti-inflammatory drugs ( apart from paracetamol and aspirin ) , have been associated with at least a 15 percent ( higher in long-term and regular users ) reduction of incidence of the development of Parkinson 's disease . # Surgery # Treating motor symptoms with surgery was once a common practice , but since the discovery of levodopa , the number of operations declined . Studies in the past few decades have led to great improvements in surgical techniques , so that surgery is again being used in people with advanced PD for whom drug therapy is no longer sufficient . Surgery for PD can be divided in two main groups : lesional and deep brain stimulation ( DBS ) . Target areas for DBS or lesions include the thalamus , the globus pallidus or the subthalamic nucleus . Deep brain stimulation ( DBS ) is the most commonly used surgical treatment , developed in the 1980s by Alim-Louis Benabid and others . It involves the implantation of a medical device called a brain pacemaker , which sends electrical impulses to specific parts of the brain . DBS is recommended for people who have PD with motor fluctuations and tremor inadequately controlled by medication , or to those who are intolerant to medication , as long as they do not have severe neuropsychiatric problems . Other , less common , surgical therapies involve intentional formation of lesions to suppress overactivity of specific subcortical areas . For example , pallidotomy involves surgical destruction of the globus pallidus to control dyskinesia. # Rehabilitation # There is some evidence that speech or mobility problems can improve with rehabilitation , although studies are scarce and of low quality . Regular physical exercise with or without physiotherapy can be beneficial to maintain and improve mobility , flexibility , strength , gait speed , and quality of life . However , when an exercise program is performed under the supervision of a physiotherapist , there are more improvements in motor symptoms , mental and emotional functions , daily living activities , and quality of life compared to a self-supervised exercise program at home . In terms of improving flexibility and range of motion for people experiencing rigidity , generalized relaxation techniques such as gentle rocking have been found to decrease excessive muscle tension . Other effective techniques to promote relaxation include slow rotational movements of the extremities and trunk , rhythmic initiation , diaphragmatic breathing , and meditation techniques . As for gait and addressing the challenges associated with the disease such as hypokinesia ( slowness of movement ) , shuffling and decreased arm swing ; physiotherapists have a variety of strategies to improve functional mobility and safety . Areas of interest with respect to gait during rehabilitation programs focus on but are not limited to improving gait speed , base of support , stride length , trunk and arm swing movement . Strategies include utilizing assistive equipment ( pole walking and treadmill walking ) , verbal cueing ( manual , visual and auditory ) , exercises ( marching and PNF patterns ) and altering environments ( surfaces , inputs , open vs. closed ) . Strengthening exercises have shown improvements in strength and motor function for people with primary muscular weakness and weakness related to inactivity with mild to moderate Parkinsons disease . However , reports show a significant interaction between strength and the time the medications was taken . Therefore , it is recommended that people with PD should perform exercises 45 minutes to one hour after medications , when they are at their best . Also , due to the forward flexed posture , and respiratory dysfunctions in advanced Parkinsons disease , deep diaphragmatic breathing exercises are beneficial in improving chest wall mobility and vital capacity . Exercise may improve constipation . One of the most widely practiced treatments for speech disorders associated with Parkinson 's disease is the Lee Silverman voice treatment ( LSVT ) . Speech therapy and specifically LSVT may improve speech . Occupational therapy ( OT ) aims to promote health and quality of life by helping people with the disease to participate in as many of their daily living activities as possible . There have been few studies on the effectiveness of OT and their quality is poor , although there is some indication that it may improve motor skills and quality of life for the duration of the therapy . # Palliative care # Palliative care is often required in the final stages of the disease when all other treatment strategies have become ineffective . The aim of palliative care is to maximize the quality of life for the person with the disease and those surrounding him or her . Some central issues of palliative care are : care in the community while adequate care can be given there , reducing or withdrawing drug intake to reduce drug side effects , preventing pressure ulcers by management of pressure areas of inactive people , and facilitating end-of-life decisions for the person as well as involved friends and relatives . # Other treatments # Muscles and nerves that control the digestive process may be affected by PD , resulting in constipation and gastroparesis ( food remaining in the stomach for a longer period of time than normal ) . A balanced diet , based on periodical nutritional assessments , is recommended and should be designed to avoid weight loss or gain and minimize consequences of gastrointestinal dysfunction . As the disease advances , swallowing difficulties ( dysphagia ) may appear . In such cases it may be helpful to use thickening agents for liquid intake and an upright posture when eating , both measures reducing the risk of choking . Gastrostomy to deliver food directly into the stomach is possible in severe cases . Levodopa and proteins use the same transportation system in the intestine and the bloodbrain barrier , thereby competing for access . When they are taken together , this results in a reduced effectiveness of the drug . Therefore , when levodopa is introduced , excessive protein consumption is discouraged and well balanced Mediterranean diet is recommended . In advanced stages , additional intake of low-protein products such as bread or pasta is recommended for similar reasons . To minimize interaction with proteins , levodopa should be taken 30 minutes before meals . At the same time , regimens for PD restrict proteins during breakfast and lunch , allowing protein intake in the evening . Repetitive transcranial magnetic stimulation temporarily improves levodopa-induced dyskinesias . Its usefulness in PD is an open research topic , although recent studies have shown no effect by rTMS . Several nutrients have been proposed as possible treatments ; however there is no evidence that vitamins or food additives improve symptoms . There is no evidence to substantiate that acupuncture and practice of Qigong , or T'ai chi , have any effect on the course of the disease or symptoms . Further research on the viability of Tai chi for balance or motor skills are necessary . Fava beans and velvet beans are natural sources of levodopa and are eaten by many people with PD . While they have shown some effectiveness in clinical trials , their intake is not free of risks . Life-threatening adverse reactions have been described , such as the neuroleptic malignant syndrome . # Prognosis # PD invariably progresses with time . A severity rating method known as the Unified Parkinson 's Disease Rating Scale ( UPDRS ) is the most commonly used metric for clinical study . A modified version known as the MDS-UPDRS is also sometimes used . An older scaling method known as the Hoehn and Yahr scale ( originally published in 1967 ) , and a similar scale known as the Modified Hoehn and Yahr scale , have also been commonly used . The Hoehn and Yahr scale defines five basic stages of progression . Motor symptoms , if not treated , advance aggressively in the early stages of the disease and more slowly later . Untreated , individuals are expected to lose independent ambulation after an average of eight years and be bedridden after ten years . However , it is uncommon to find untreated people nowadays . Medication has improved the prognosis of motor symptoms , while at the same time it is a new source of disability because of the undesired effects of levodopa after years of use . In people taking levodopa , the progression time of symptoms to a stage of high dependency from caregivers may be over 15 years . However , it is hard to predict what course the disease will take for a given individual . The rate of motor decline is greater in those with less impairment at the time of diagnosis , while cognitive impairment is more frequent in those who are over 70 years of age at symptom onset . Since current therapies improve motor symptoms , disability at present is mainly related to non-motor features of the disease . Nevertheless , the relationship between disease progression and disability is not linear . Disability is initially related to motor symptoms . As the disease advances , disability is more related to motor symptoms that do not respond adequately to medication , such as swallowing/speech difficulties , and gait/balance problems ; and also to motor complications , which appear in up to 50% of individuals after 5 years of levodopa usage . Finally , after ten years most people with the disease have autonomic disturbances , sleep problems , mood alterations and cognitive decline . All of these symptoms , especially cognitive decline , greatly increase disability . The life expectancy of people with PD is reduced . Mortality ratios are around twice those of unaffected people . Cognitive decline and dementia , old age at onset , a more advanced disease state and presence of swallowing problems are all mortality risk factors . On the other hand a disease pattern mainly characterized by tremor as opposed to rigidity predicts an improved survival . Death from aspiration pneumonia is twice as common in individuals with PD as in the healthy population . # Epidemiology # PD is the second most common neurodegenerative disorder after Alzheimer 's disease and affects approximately seven million people globally and one million people in the United States . The prevalence ( proportion in a population at a given time ) of PD is about 0.3% of the whole population in industrialized countries . PD is more common in the elderly and prevalence rises from 1% in those over 60 years of age to 4% of the population over 80 . The mean age of onset is around 60 years , although 510% of cases , classified as young onset , begin between the ages of 20 and 50 . PD may be less prevalent in those of African and Asian ancestry , although this finding is disputed . Some studies have proposed that it is more common in men than women , but others failed to detect any differences between the two sexes . The incidence of PD is between 8 and 18 per 100,000 personyears . Many risk factors and protective factors have been proposed , sometimes in relation to theories concerning possible mechanisms of the disease , however none have been conclusively related to PD by empirical evidence . When epidemiological studies have been carried out in order to test the relationship between a given factor and PD , they have often been flawed and their results have in some cases been contradictory . The most frequently replicated relationships are an increased risk of PD in those exposed to pesticides , and a reduced risk in smokers . # History # Several early sources , including an Egyptian papyrus , an Ayurvedic medical treatise , the Bible , and Galen 's writings , describe symptoms resembling those of PD . After Galen there are no references unambiguously related to PD until the 17th century . In the 17th and 18th centuries , several authors wrote about elements of the disease , including Sylvius , Gaubius , Hunter and Chomel . In 1817 an English doctor , James Parkinson , published his essay reporting six cases of paralysis agitans . ' ' An Essay on the Shaking Palsy ' ' described the characteristic resting tremor , abnormal posture and gait , paralysis and diminished muscle strength , and the way that the disease progresses over time . Early neurologists who made further additions to the knowledge of the disease include Trousseau , Gowers , Kinnier Wilson and Erb , and most notably Jean-Martin Charcot , whose studies between 1868 and 1881 were a landmark in the understanding of the disease . Among other advances , he made the distinction between rigidity , weakness and bradykinesia . He also championed the renaming of the disease in honor of James Parkinson . In 1912 Frederic Lewy described microscopic particles in affected brains , later named Lewy bodies . In 1919 Konstantin Tretiakoff reported that the substantia nigra was the main cerebral structure affected , but this finding was not widely accepted until it was confirmed by further studies published by Rolf Hassler in 1938 . The underlying biochemical changes in the brain were identified in the 1950s , due largely to the work of Arvid Carlsson on the neurotransmitter dopamine and Oleh Hornykiewicz on its role on PD . In 1997 , alpha-synuclein was found to be the main component of Lewy bodies . Anticholinergics and surgery ( lesioning of the corticospinal pathway or some of the basal ganglia structures ) were the only treatments until the arrival of levodopa , which reduced their use dramatically . Levodopa was first synthesized in 1911 by Casimir Funk , but it received little attention until the mid 20th century . It entered clinical practice in 1967 and brought about a revolution in the management of PD . By the late 1980s deep brain stimulation emerged as a possible treatment . # Society and culture # # Cost # The costs of PD to society are high , but precise calculations are difficult due to methodological issues in research and differences between countries . The annual cost in the UK is estimated to be between 449 million and 3.3 billion pounds , while the cost per patient per year in the U.S. is probably around $10,000 and the total burden around 23 billion dollars . The largest share of direct cost comes from inpatient care and nursing homes , while the share coming from medication is substantially lower . Indirect costs are high , due to reduced productivity and the burden on caregivers . In addition to economic costs , PD reduces quality of life of those with the disease and their caregivers. # Advocacy # 11 April , the birthday of James Parkinson , has been designated as Parkinson 's disease day . A red tulip was chosen by international organizations as the symbol of the disease in 2005 : it represents the James Parkinson Tulip cultivar , registered in 1981 by a Dutch horticulturalist . Advocacy organizations include the National Parkinson Foundation , which has provided more than $180 million in care , research and support services since 1982 , Parkinson 's Disease Foundation , which has distributed more than $100 million for research and $42 million for education and advocacy programs since its founding in 1957 by William Black ; the American Parkinson Disease Association , founded in 1961 ; and the European Parkinson 's Disease Association , founded in 1992. # Notable cases # Actor Michael J. Fox has PD and has greatly increased the public awareness of the disease . Fox was diagnosed in 1991 when he was 30 , but kept his condition secret from the public for seven years . He has written two autobiographies in which his fight against the disease plays a major role , and appeared before the United States Congress without medication to illustrate the effects of the disease . The Michael J. Fox Foundation aims to develop a cure for Parkinson 's disease . In recent years it has been the major Parkinson 's fundraiser in the U.S. , providing $140 million in funding between 2001 and 2008 . Fox was named one of the 100 people whose power , talent or moral example is transforming the world in 2007 by ' ' Time ' ' magazine , and he received an honorary doctorate in medicine from Karolinska Institutet for his contributions to research in Parkinson 's disease . Professional cyclist and Olympic medalist Davis Phinney , who was diagnosed with young onset Parkinson 's at age 40 , started a foundation in his name in 2004 to support Parkinson 's research , focusing on quality of life for people with the disease . The Davis Phinney Foundation 's mission is to help people living with Parkinson 's disease live well by providing them with information , inspiration and tools . Phinney gives motivational speeches to people with Parkinsons , pushing them to celebrate every victory , however small , like tying their shoes . Muhammad Ali has been called the world 's most famous Parkinson 's patient . He was 42 at diagnosis although he showed signs of Parkinson 's when he was 38 . Whether he has PD or a parkinsonism related to boxing is unresolved . # Research # There is little prospect of dramatic new PD treatments expected in a short time frame . Currently active research directions include the search for new animal models of the disease and studies of the potential usefulness of gene therapy , stem cell transplants and neuroprotective agents . # Animal models # PD is not known to occur naturally in any species other than humans , although animal models which show some features of the disease are used in research . The appearance of parkinsonian symptoms in a group of drug addicts in the early 1980s who consumed a contaminated batch of the synthetic opiate MPPP led to the discovery of the chemical MPTP as an agent that causes a parkinsonian syndrome in non-human primates as well as in humans . Other predominant toxin-based models employ the insecticide rotenone , the herbicide paraquat and the fungicide maneb . Models based on toxins are most commonly used in primates . Transgenic rodent models that replicate various aspects of PD have been developed . Using the neurotoxin 6-hydroxydopamine , also known as 6-OHDA , it creates a model of Parkinsons disease in rats by targeting and destroying dopaminergic neurons in the nigrostriatal pathway when injected into the substantia nigra # Gene therapy # Gene therapy involves the use of a non-infectious virus to shuttle a gene into a part of the brain . The gene used leads to the production of an enzyme that helps to manage PD symptoms or protects the brain from further damage . In 2010 there were four clinical trials using gene therapy in PD . There have not been important adverse effects in these trials although the clinical usefulness of gene therapy is still unknown . One of these reported positive results in 2011 , but the company filed for bankruptcy in March 2012. # Neuroprotective treatments # Investigations on neuroprotection are at the forefront of PD research . Several molecules have been proposed as potential treatments . However , none of them have been conclusively demonstrated to reduce degeneration . Agents currently under investigation include anti-apoptotics ( omigapil , CEP-1347 ) , antiglutamatergics , monoamine oxidase inhibitors ( selegiline , rasagiline ) , promitochondrials ( coenzyme Q10 , creatine ) , calcium channel blockers ( isradipine ) and growth factors ( GDNF ) . Preclinical research also targets alpha-synuclein . A vaccine that primes the human immune system to destroy alpha-synuclein , PD01A ( developed by Austrian company , Affiris ) , has entered clinical trials in humans . # Neural transplantation # Since early in the 1980s , fetal , porcine , carotid or retinal tissues have been used in cell transplants , in which dissociated cells are injected into the substantia nigra in the hope that they will incorporate themselves into the brain in a way that replaces the dopamine-producing cells that have been lost . Although there was initial evidence of mesencephalic dopamine-producing cell transplants being beneficial , double-blind trials to date indicate that cell transplants produce no long-term benefit . An additional significant problem was the excess release of dopamine by the transplanted tissue , leading to dystonias . Stem cell transplants are a recent research target , because stem cells are easy to manipulate and stem cells transplanted into the brains of rodents and monkeys have been found to survive and reduce behavioral abnormalities . Nevertheless , use of fetal stem cells is controversial . It has been proposed that effective treatments may be developed in a less controversial way by use of induced pluripotent stem cells taken from adults . 
@@30206738 Chronic obstructive pulmonary disease ( COPD ) , also known as chronic obstructive lung disease ( COLD ) , and chronic obstructive airway disease ( COAD ) , among others , is a type of obstructive lung disease characterized by chronically poor airflow . It typically worsens over time . The main symptoms include shortness of breath , cough , and sputum production . Most people with chronic bronchitis have COPD . Tobacco smoking is the most common cause of COPD , with a number of other factors such as air pollution and genetics playing a smaller role . In the developing world , one of the common sources of air pollution is from poorly vented cooking and heating fires . Long-term exposure to these irritants causes an inflammatory response in the lungs resulting in narrowing of the small airways and breakdown of lung tissue known as emphysema . The diagnosis is based on poor airflow as measured by lung function tests . In contrast to asthma , the airflow reduction does not improve significantly with the administration of medication . COPD can be prevented by reducing exposure to the known causes . This includes efforts to decrease rates of smoking and to improve indoor and outdoor air quality . COPD treatments include : quitting smoking , vaccinations , rehabilitation , and often inhaled bronchodilators and steroids . Some people may benefit from long-term oxygen therapy or lung transplantation . In those who have periods of acute worsening , increased use of medications and hospitalization may be needed . Worldwide , COPD affects 329 million people or nearly 5% of the population . In 2012 , it ranked as the third-leading cause of death , killing over 3 million people . The number of deaths is projected to increase due to higher smoking rates and an aging population in many countries . It resulted in an estimated economic cost of $2.1 trillion in 2010. # Signs and symptoms # Wheeze2O.ogg title = Wheezing The most common symptoms of COPD are sputum production , shortness of breath and a productive cough . These symptoms are present for a prolonged period of time and typically worsen over time . It is unclear if different types of COPD exist . While previously divided into emphysema and chronic bronchitis , emphysema is only a description of lung changes rather than a disease itself , and chronic bronchitis is simply a descriptor of symptoms that may or may not occur with COPD . # Cough # A chronic cough is usually the first symptom to occur . When it exists for more than three months a year for more than two years , in combination with sputum production and without another explanation , there is by definition chronic bronchitis . This condition can occur before COPD fully develops . The amount of sputum produced can change over hours to days . In some cases the cough may not be present or only occurs occasionally and may not be productive . Some people with COPD attribute the symptoms to a smoker 's cough . Sputum may be swallowed or spat out , depending often on social and cultural factors . Vigorous coughing may lead to rib fractures or a brief loss of consciousness . Those with COPD often have a history of common colds that last a long time . # Shortness of breath # Shortness of breath is often the symptom that bothers people the most . It is commonly described as : my breathing requires effort , I feel out of breath , or I ca n't get enough air in . Different terms , however , may be used in different cultures . Typically the shortness of breath is worse on exertion , of a prolonged duration , and worsens over time . In the advanced stages it occurs during rest and may be always present . It is a source of both anxiety and a poor quality of life in those with COPD . Many people with more advanced COPD breathe through pursed lips and this action can improve shortness of breath in some . # Other features # In COPD , it may take longer to breathe out than to breathe in . Chest tightness may occur but is not common and may be caused by another problem . Those with obstructed airflow may have wheezing or decreased sounds with air entry on examination of the chest with a stethoscope . A barrel chest is a characteristic sign of COPD , but is relatively uncommon . Tripod positioning may occur as the disease worsens . Advanced COPD leads to high pressure on the lung arteries , which strains the right ventricle of the heart . This situation is referred to as cor pulmonale , and leads to symptoms of leg swelling and bulging neck veins . COPD is more common than any other lung disease as a cause of cor pulmonale . Cor pulmonale has become less common since the use of supplemental oxygen . COPD often occurs along with a number of other conditions , due in part to shared risk factors . These conditions include : ischemic heart disease , high blood pressure , diabetes mellitus , muscle wasting , osteoporosis , lung cancer , anxiety disorder and depression . In those with severe disease a feeling of always being tired is common . Fingernail clubbing is not specific to COPD and should prompt investigations for an underlying lung cancer . # Exacerbation # An acute exacerbation of COPD is defined as increased shortness of breath , increased sputum production , a change in the color of the sputum from clear to green or yellow , or an increase in cough in someone with COPD . This may present with signs of increased work of breathing such as fast breathing , a fast heart rate , sweating , active use of muscles in the neck , a bluish tinge to the skin , and confusion or combative behavior in very severe exacerbations . Crackles may also be heard over the lungs on examination with a stethoscope. # Cause # The primary cause of COPD is tobacco smoke , with occupational exposure and pollution from indoor fires being significant causes in some countries . Typically these exposures must occur over several decades before symptoms develop . A person 's genetic makeup also affects the risk . # Smoking # The primary risk factor for COPD globally is tobacco smoking . Of those who smoke about 20% will get COPD , and of those who are lifelong smokers about half will get COPD . In the United States and United Kingdom , of those with COPD , 80-95% are either current smokers or previously smoked . The likelihood of developing COPD increases with the total smoke exposure . Additionally , women are more susceptible to the harmful effects of smoke than men . In non-smokers , secondhand smoke is the cause of about 20% of cases . Other types of smoke , such as marijuana , cigar , and water pipe smoke , also confer a risk . Women who smoke during pregnancy may increase the risk of COPD in their child . # Air pollution # Poorly ventilated cooking fires , often fueled by coal or biomass fuels such as wood and animal dung , lead to indoor air pollution and are one of the most common causes of COPD in developing countries . These fires are a method of cooking and heating for nearly 3 billion people with their health effects being greater among women due to more exposure . They are used as the main source of energy in 80% of homes in India , China and sub-Saharan Africa . People who live in large cities have a higher rate of COPD compared to people who live in rural areas . While urban air pollution is a contributing factor in exacerbations , its overall role as a cause of COPD is unclear . Areas with poor outdoor air quality , including that from exhaust gas , generally have higher rates of COPD . The overall effect in relation to smoking , however , is believed to be small . # Occupational exposures # Intense and prolonged exposure to workplace dusts , chemicals and fumes increase the risk of COPD in both smokers and nonsmokers . Workplace exposures are believed to be the cause in 10-20% of cases . In the United States they are believed to be related to more than 30% of cases among those who have never smoked and probably represent a greater risk in countries without sufficient regulations . A number of industries and sources have been implicated , including high levels of dust in coal mining , gold mining , and the cotton textile industry , occupations involving cadmium and isocyanates , and fumes from welding . Working in agriculture is also a risk . In some professions the risks have been estimated as equivalent to that of half to two packs of cigarettes a day . Silica dust exposure can also lead to COPD , with the risk unrelated to that for silicosis . The negative effects of dust exposure and cigarette smoke exposure appear to be additive or possibly more than additive. # Genetics # Genetics play a role in the development of COPD . It is more common among relatives of those with COPD who smoke than unrelated smokers . Currently , the only clearly inherited risk factor is alpha 1-antitrypsin deficiency ( AAT ) . This risk is particularly high if someone deficient in alpha 1-antitrypsin also smokes . It is responsible for about 1-5% of cases and the condition is present in about 3-4 in 10,000 people . Other genetic factors are being investigated , of which there are likely to be many . # Other # A number of other factors are less closely linked to COPD . The risk is greater in those who are poor , although it is not clear if this is due to poverty itself or other risk factors associated with poverty , such as air pollution and malnutrition . There is tentative evidence that those with asthma and airway hyperreactivity are at increased risk of COPD . Birth factors such as low birth weight may also play a role as do a number of infectious diseases including HIV/AIDS and tuberculosis . Respiratory infections such as pneumonia do not appear to increase the risk of COPD , at least in adults . # Exacerbations # An acute exacerbation ( a sudden worsening of symptoms ) is commonly triggered by infection or environmental pollutants , or sometimes by other factors such as improper use of medications . Infections appear to be the cause of 50 to 75% of cases , with bacteria in 25% , viruses in 25% , and both in 25% . Environmental pollutants include both poor indoor and outdoor air quality . Exposure to personal smoke and secondhand smoke increases the risk . Cold temperature may also play a role , with exacerbations occurring more commonly in winter . Those with more severe underlying disease have more frequent exacerbations : in mild disease 1.8 per year , moderate 2 to 3 per year , and severe 3.4 per year . Those with many exacerbations have a faster rate of deterioration of their lung function . Pulmonary emboli ( blood clots in the lungs ) can worsen symptoms in those with pre-existing COPD . # Pathophysiology # COPD is a type of obstructive lung disease in which chronic incompletely reversible poor airflow ( airflow limitation ) and inability to breathe out fully ( air trapping ) exist . The poor airflow is the result of breakdown of lung tissue ( known as emphysema ) and small airways disease known as obstructive bronchiolitis . The relative contributions of these two factors vary between people . Severe destruction of small airways can lead to the formation of large air pockets -- known as bullae -- that replace lung tissue . This form of disease is called bullous emphysema . COPD develops as a significant and chronic inflammatory response to inhaled irritants . Chronic bacterial infections may also add to this inflammatory state . The inflammatory cells involved include neutrophil granulocytes and macrophages , two types of white blood cell . Those who smoke additionally have Tc1 lymphocyte involvement and some people with COPD have eosinophil involvement similar to that in asthma . Part of this cell response is brought on by inflammatory mediators such as chemotactic factors . Other processes involved with lung damage include oxidative stress produced by high concentrations of free radicals in tobacco smoke and released by inflammatory cells , and breakdown of the connective tissue of the lungs by proteases that are insufficiently inhibited by protease inhibitors . The destruction of the connective tissue of the lungs is what leads to emphysema , which then contributes to the poor airflow and , finally , poor absorption and release of respiratory gases . General muscle wasting that often occurs in COPD may be partly due to inflammatory mediators released by the lungs into the blood . Narrowing of the airways occurs due to inflammation and scarring within them . This contributes to the inability to breathe out fully . The greatest reduction in air flow occurs when breathing out , as the pressure in the chest is compressing the airways at this time . This can result in more air from the previous breath remaining within the lungs when the next breath is started , resulting in an increase in the total volume of air in the lungs at any given time , a process called hyperinflation or air trapping . Hyperinflation from exercise is linked to shortness of breath in COPD , as it is less comfortable to breathe in when the lungs are already partly full . Some also have a degree of airway hyperresponsiveness to irritants similar to those found in asthma . Low oxygen levels and , eventually , high carbon dioxide levels in the blood can occur from poor gas exchange due to decreased ventilation from airway obstruction , hyperinflation and a reduced desire to breathe . During exacerbations , airway inflammation is also increased , resulting in increased hyperinflation , reduced expiratory airflow and worsening of gas transfer . This can also lead to insufficient ventilation and , eventually , low blood oxygen levels . Low oxygen levels , if present for a prolonged period , can result in narrowing of the arteries in the lungs , while emphysema leads to breakdown of capillaries in the lungs . Both these changes result in increased blood pressure in the pulmonary arteries , which may cause cor pulmonale. # Diagnosis # The diagnosis of COPD should be considered in anyone over the age of 35 to 40 who has shortness of breath , a chronic cough , sputum production , or frequent winter colds and a history of exposure to risk factors for the disease . Spirometry is then used to confirm the diagnosis . # Spirometry # Spirometry measures the amount of airflow obstruction present and is generally carried out after the use of a bronchodilator , a medication to open up the airways . Two main components are measured to make the diagnosis : the forced expiratory volume in one second ( FEV <sub> 1 </sub> ) , which is the greatest volume of air that can be breathed out in the first second of a breath , and the forced vital capacity ( FVC ) , which is the greatest volume of air that can be breathed out in a single large breath . Normally , 75-80% of the FVC comes out in the first second and a FEV <sub> 1 </sub> /FVC ratio of less than 70% in someone with symptoms of COPD defines a person as having the disease . Based on these measurements , spirometry would lead to over-diagnosis of COPD in the elderly . The National Institute of Clinical Excellence criteria additionally require a FEV <sub> 1 </sub> of less than 80% of predicted . Evidence for using spirometry among those without symptoms in an effort to diagnose the condition earlier is of uncertain effect and is therefore currently not recommended . A peak expiratory flow ( the maximum speed of expiration ) , commonly used in asthma , is not sufficient for the diagnosis of COPD . # Severity # There are a number of methods to determine how much COPD is affecting a given individual . The modified British Medical Research Council questionnaire ( mMRC ) or the COPD assessment test ( CAT ) are simple questionnaires that may be used to determine the severity of symptoms . Scores on CAT range from 040 with the higher the score , the more severe the disease . Spirometry may help to determine the severity of airflow limitation . This is typically based on the FEV <sub> 1 </sub> expressed as a percentage of the predicted normal for the person 's age , gender , height and weight . Both the American and European guidelines recommended partly basing treatment recommendations on the FEV <sub> 1 </sub> . The GOLD guidelines suggest dividing people into four categories based on symptoms assessment and airflow limitation . Weight loss and muscle weakness , as well as the presence of other diseases , should also be taken into account . # Other tests # A chest X-ray and complete blood count may be useful to exclude other conditions at the time of diagnosis . Characteristic signs on X-ray are overexpanded lungs , a flattened diaphragm , increased retrosternal airspace , and bullae while it can help exclude other lung diseases , such as pneumonia , pulmonary edema or a pneumothorax . A high-resolution computed tomography scan of the chest may show the distribution of emphysema throughout the lungs and can also be useful to exclude other lung diseases . Unless surgery is planned , however , this rarely affects management . An analysis of arterial blood is used to determine the need for oxygen ; this is recommended in those with an FEV <sub> 1 </sub> less than 35% predicted , those with a peripheral oxygen saturation of less than 92% and those with symptoms of congestive heart failure . In areas of the world where alpha-1 antitrypsin deficiency is common , people with COPD ( particularly those below the age of 45 and with emphysema affecting the lower parts of the lungs ) should be considered for testing . <gallery> File:COPD.JPGalt=A black and white image , with a small white heart in the middle and large black lungs around itChest X-ray demonstrating severe COPD . Note the small heart size in comparison to the lungs . File:Barrowchest.JPGA lateral chest x-ray of a person with emphysema . Note the barrel chest and flat diaphragm . Image:BullaCXR.PNGLung bulla as seen on CXR in a person with severe COPD Medical X-Ray imaging WFH07 nevit.jpgA severe case of bullous emphysema File:Bullus emphasemaCT.pngAxial CT image of the lung of a person with end-stage bullous emphysema. </gallery> # Differential diagnosis # COPD may need to be differentiated from other causes of shortness of breath such as congestive heart failure , pulmonary embolism , pneumonia or pneumothorax . Many people with COPD mistakenly think they have asthma . The distinction between asthma and COPD however can not be made via spirometry . Tuberculosis may also present with a chronic cough and should be considered in locations where it is common . Less common conditions that may present similarly include bronchopulmonary dysplasia and obliterative bronchiolitis . Chronic bronchitis may occur with normal airflow and in this situation it is not classified as COPD . # Prevention # Most cases of COPD are potentially preventable through decreasing exposure to smoke and improving air quality . Annual influenza vaccinations in those with COPD reduces exacerbations , hospitalizations and death . Pneumococcal vaccination may also be beneficial . # Smoking cessation # Keeping people from starting smoking is a key aspect of preventing COPD . The policies of governments , public health agencies and anti-smoking organizations can reduce smoking rates by discouraging people from starting and encouraging people to stop smoking . Smoking bans in public areas and places of work are important measures to decrease exposure to secondhand smoke and while many places have instituted bans more are recommended . In those who smoke , stopping smoking is the only measure shown to slow down the worsening of COPD . Even at a late stage of the disease , it can reduce the rate of worsening lung function and delay the onset of disability and death . Smoking cessation starts with the decision to stop smoking , leading to an attempt at quitting . Often several attempts are required before long-term abstinence is achieved . Attempts over 5 years lead to success in nearly 40% of people . Some smokers can achieve long-term smoking cessation through willpower alone . Smoking , however , is highly addictive , and many smokers need further support . The chance of quitting is improved with social support , engagement in a smoking cessation program and the use of medications such as nicotine replacement therapy , bupropion or varenicline. # Occupational health # A number of measures have been taken to reduce the likelihood that workers in at-risk industriessuch as coal mining , construction and stonemasonrywill develop COPD . Examples of these measures include : the creation of public policy , education of workers and management about the risks , promoting smoking cessation , checking workers for early signs of COPD , use of respirators , and dust control . Effective dust control can be achieved by improving ventilation , using water sprays and by using mining techniques that minimize dust generation . If a worker develops COPD , further lung damage can be reduced by avoiding ongoing dust exposure , for example by changing the work role . # Air pollution # Both indoor and outdoor air quality can be improved , which may prevent COPD or slow the worsening of existing disease . This may be achieved by public policy efforts , cultural changes , and personal involvement . A number of developed countries have successfully improved outdoor quality through regulations . This has resulted in improvements of the lung function of their populations . Those with COPD may experience fewer symptoms if they stay indoors on days when outdoor air quality is poor . One key effort is to reduce exposure to smoke from cooking and heating fuels through improved ventilation of homes and better stoves and chimneys . Proper stoves may improve indoor air quality by 85% . Using alternative energy sources such as solar cooking and electrical heating is effective , as is using fuels such as kerosene or coal rather than biomass . # Management # There is no known cure for COPD , but the symptoms are treatable and its progression can be delayed . The major goals of management are to reduce risk factors , manage stable COPD , prevent and treat acute exacerbations , and manage associated illnesses . The only measures that have been shown to reduce mortality are smoking cessation and supplemental oxygen . Stopping smoking decreases the risk of death by 18% . Other recommendations include : influenza vaccination once a year , pneumococcal vaccination once every 5 years , and reduction in exposure to environmental air pollution . In those with advanced disease , palliative care may reduce symptoms , with morphine improving the feelings of shortness of breath . Noninvasive ventilation may be used to support breathing . # Exercise # Pulmonary rehabilitation is a program of exercise , disease management and counseling , coordinated to benefit the individual . In those who have had a recent exacerbation , pulmonary rehabilitation appears to improve the overall quality of life and the ability to exercise , and reduce mortality . It has also been shown to improve the sense of control a person has over their disease , as well as their emotions . Breathing exercises in and of themselves appear to have a limited role . Being either underweight or overweight can affect the symptoms , degree of disability and prognosis of COPD . People with COPD who are underweight can improve their breathing muscle strength by increasing their calorie intake . When combined with regular exercise or a pulmonary rehabilitation program , this can lead to improvements in COPD symptoms . Supplemental nutrition may be useful in those who are malnourished . # Bronchodilators # Inhaled bronchodilators are the primary medications used and result in a small overall benefit . There are two major types , <sub> 2 </sub> agonists and anticholinergics ; both exist in long-acting and short-acting forms . They reduce shortness of breath , wheeze and exercise limitation , resulting in an improved quality of life . It is unclear if they change the progression of the underlying disease . In those with mild disease , short-acting agents are recommended on an as needed basis . In those with more severe disease , long-acting agents are recommended . If long-acting bronchodilators are insufficient inhaled corticosteroids are typically added . With respect to long-acting agents , it is unclear if tiotropium ( a long-acting anticholinergic ) or long-acting beta agonists ( LABAs ) are better , and it may be worth trying each and continuing the one that worked best . Both types of agent appear to reduce the risk of acute exacerbations by 15-25% . While using both at the same time may offer a benefit , this benefit , if any , is of questionable significance . There are several short-acting <sub> 2 </sub> agonists available including salbutamol ( Ventolin ) and terbutaline . They provide some relief of symptoms for four to six hours . Long-acting <sub> 2 </sub> agonists such as salmeterol and formoterol are often used as maintenance therapy . Some feel the evidence of benefits is limited while others view the evidence of benefit as established . Long-term use appears safe in COPD with adverse effects include shakiness and heart palpitations . When used with inhaled steroids they increase the risk of pneumonia . While steroids and LABAs may work better together , it is unclear if this slight benefit outweighs the increased risks . There are two main anticholinergics used in COPD , ipratropium and tiotropium . Ipratropium is a short-acting agent while tiotropium is long-acting . Tiotropium is associated with a decrease in exacerbations and improved quality of life , and tiotropium provides those benefits better than ipratropium . It does not appear to affect mortality or the over all hospitalization rate . Anticholinergics can cause dry mouth and urinary tract symptoms . They are also associated with increased risk of heart disease and stroke . Aclidinium , another long acting agent which came to market in 2012 , has been used as an alternative to tiotropium. # Corticosteroids # Corticosteroids are usually used in inhaled form but may also be used as tablets to treat and prevent acute exacerbations . While inhaled corticosteroids ( ICS ) have not shown benefit for people with mild COPD , they decrease acute exacerbations in those with either moderate or severe disease . When used in combination with a LABA they decrease mortality more than either ICS or LABA alone . By themselves they have no effect on overall one-year mortality and are associated with increased rates of pneumonia . It is unclear if they affect the progression of the disease . Long-term treatment with steroid tablets is associated with significant side effects . # Other medication # Long-term antibiotics , specifically those from the macrolide class such as erythromycin , reduce the frequency of exacerbations in those who have two or more a year . This practice may be cost effective in some areas of the world . Concerns include that of antibiotic resistance and hearing problems with azithromycin . Methylxanthines such as theophylline generally cause more harm than benefit and thus are usually not recommended , but may be used as a second-line agent in those not controlled by other measures . Mucolytics may be useful in some people who have very thick mucous but are generally not needed . Cough medicines are not recommended . # Oxygen # Supplemental oxygen is recommended in those with low oxygen levels at rest ( a partial pressure of oxygen of less than 5055 mmHg or oxygen saturations of less than 88% ) . In this group of people it decreases the risk of heart failure and death if used 15 hours per day and may improve people 's ability to exercise . In those with normal or mildly low oxygen levels , oxygen supplementation may improve shortness of breath . There is a risk of fires and little benefit when those on oxygen continue to smoke . In this situation some recommend against its use . During acute exacerbations , many require oxygen therapy ; the use of high concentrations of oxygen without taking into account a person 's oxygen saturations , may lead to increased levels of carbon dioxide and worsened outcomes . In those at high risk of high carbon dioxide levels , oxygen saturations of 8892% are recommended , while for those without this risk recommended levels are 94-98%. # Surgery # For those with very severe disease surgery is sometimes helpful and may include lung transplantation or lung volume reduction surgery . Lung volume reduction surgery involves removing the parts of the lung most damaged by emphysema allowing the remaining , relatively good lung to expand and work better . Lung transplantation is sometimes performed for very severe COPD , particularly in younger individuals . # Exacerbations # Acute exacerbations are typically treated by increasing the usage of short-acting bronchodilators . This commonly includes a combination of a short-acting inhaled beta agonist and anticholinergic . These medications can be given either via a metered-dose inhaler with a spacer or via a nebulizer with both appearing to be equally effective . Nebulization may be easier for those who are more unwell . Oral corticosteroids improve the chance of recovery and decrease the overall duration of symptoms . In those with a severe exacerbation , antibiotics improve outcomes . A number of different antibiotics may be used including : amoxicillin , doxycycline or azithromycin ; it is unclear if one is better than the others . There is no clear evidence for those with less severe cases . Non-invasive positive pressure ventilation in those with acutely raised CO <sub> 2 </sub> levels ( type 2 respiratory failure ) decreases the probability of death from or needing intensive care admission for mechanical ventilation . Additionally , theophylline may have a role in those who do not respond to other measures . Less than 20% of exacerbations require hospital admission . In those without acidosis from respiratory failure , home care ( hospital at home ) may be able to help avoid some admissions. # Prognosis # COPD usually gets gradually worse over time and can ultimately result in death . It is estimated that 3% of all disability is related to COPD . The proportion of disability from COPD globally has decreased from 1990 to 2010 due to improved indoor air quality primarily in Asia . The overall number of years lived with disability from COPD , however , has increased . The rate at which COPD worsens varies with the presence of factors that predict a poor outcome including : severe airflow obstruction , little ability to exercise , shortness of breath , significantly underweight or overweight , congestive heart failure , continued smoking , and frequent exacerbations . Long-term outcomes in COPD can be estimated using the BODE index which gives a score of zero to ten depending on FEV <sub> 1 </sub> , body-mass index , the distance walked in six minutes , and the modified MRC dyspnea scale . Significant weight loss is a bad sign . Results of spirometry are also a good predictor of the future progress of the disease but not as good as the BODE index . # Epidemiology # Globally , as of 2010 , COPD affected approximately 329 million people ( 4.8% of the population ) and is slightly more common in men than women . This is as compared to 64 million being affected in 2004 . The increase in the developing world between 1970 and the 2000s is believed to be related to increasing rates of smoking in this region , an increasing population and an aging population due to less deaths from other causes such as infectious diseases . Some developed countries have seen increased rates , some have remained stable and some have seen a decrease in COPD prevalence . The global numbers are expected to continue increasing as risk factors remain common and the population continues to get older . Between 1990 and 2010 the number of deaths from COPD has decreased slightly from 3.1 million to 2.9 million . Overall it is the fourth-leading cause of death . In some countries , mortality has decreased in men but increased in women . This is most likely due to rates of smoking in women and men becoming more similar . COPD is more common in older people ; it affects 34-200 out of 1000 people older than 65 years , depending on the population looked at . In England , an estimated 0.84 million people ( of 50 million ) have a diagnosis of COPD ; translating into approximately one person in 59 receiving a diagnosis of COPD at some point in their lives . In the most socioeconomically deprived parts of the country , one in 32 people were diagnosed with COPD , compared with one in 98 in the most affluent areas . In the United States approximately 6.3% of the adult population , totaling approximately 15 million people , have been diagnosed with COPD . 25 million people may have COPD if currently undiagnosed cases are included . In 2011 , there were approximately 730,000 hospitalizations in the United States for COPD . # History # The word emphysema is derived from the Greek ' ' emphysan ' ' meaning ' ' inflate ' ' -itself composed of ' ' en ' ' , meaning ' ' in ' ' , and ' ' physan ' ' , meaning ' ' breath , blast ' ' . The term chronic bronchitis came into use in 1808 while the term COPD is believed to have first been used in 1965 . Previously it has been known by a number of different names including : chronic obstructive bronchopulmonary disease , chronic obstructive respiratory disease , chronic airflow obstruction , chronic airflow limitation , chronic obstructive lung disease , nonspecific chronic pulmonary disease , and diffuse obstructive pulmonary syndrome . The terms chronic bronchitis and emphysema were formally defined in 1959 at the CIBA guest symposium and in 1962 at the American Thoracic Society Committee meeting on Diagnostic Standards . Early descriptions of probable emphysema include : in 1679 by T. Bonet of a condition of voluminous lungs and in 1769 by Giovanni Morgagni of lungs which were turgid particularly from air . In 1721 the first drawings of emphysema were made by Ruysh . These were followed by pictures by Matthew Baillie in 1789 and descriptions of the destructive nature of the condition . In 1814 Charles Badham used catarrh to describe the cough and excess mucus in chronic bronchitis . Ren Laennec , the physician who invented the stethoscope , used the term emphysema in his book ' ' A Treatise on the Diseases of the Chest and of Mediate Auscultation ' ' ( 1837 ) to describe lungs that did not collapse when he opened the chest during an autopsy . He noted that they did not collapse as usual because they were full of air and the airways were filled with mucus . In 1842 , John Hutchinson invented the spirometer , which allowed the measurement of vital capacity of the lungs . However , his spirometer could only measure volume , not airflow . Tiffeneau and Pinelli in 1947 described the principles of measuring airflow . Early treatments included garlic , cinnamon and ipecac , among others . Modern treatments were developed during the second half of the 20th century . *277228;13050;!-- # Artists with multiple entries # Three entries  Birds of Tokyo ( 4 , 47 , 87 )  Mark Ronson &amp; The Business Intl ( 10 , 17 , 35 )  Pendulum ( 11 , 48 , 69 )  Washington ( 20 , 59 , 84 )  Bliss n Eso ( 23 , 41 , 53 )  Gorillaz ( 37 , 42 , 78 )  Arcade Fire ( 58 , 63 , 83 )  Gypsy &amp; The Cat ( 64 , 71 , 73 ) Two entries  Angus &amp; Julia Stone ( 1 , 62 )  Little Red ( 2 , 79 )  Ou Est Le Swimming Pool ( 3 , 61 )  Boy &amp; Bear ( 5 , 45 )  Art vs . Science ( 9 , 90 )  Sia ( 13 , 56 )  Kanye West ( 14 , 88 )  The Jezabels ( 16 , 49 )  Two Door Cinema Club ( 21 , 72 )  Children Collide ( 22 , 60 )  Crystal Castles ( 25 , 44 )  Yeasayer ( 30 , 51 )  The National ( 31 , 93 )  Tame Impala ( 33 , 74 )  The Naked and Famous ( 34 , 38 )  Hot Chip ( 50 , 85 )  Vampire Weekend ( 55 , 67 )  Dead Letter Circus ( 65 , 99 )  The Black Keys ( 80 , 82 ) # Countries represented #  : 51 songs  : 21 songs  : 19 songs  : 5 songs  : 2 songs  : 1 song  : 1 song # Top 20 Albums of 2010 # Triple J Listeners voted for their favorite album of 2010 in a similar format to the Hottest 100 . Voters were allowed to vote for any album released in 2010 and were limited to ten votes . Bold Indicates the winner of the Hottest 100 . ' ' Italics ' ' Indicates winner of the J Award # CD Release # # Angus &amp; Julia Stone - Big Jet Plane ( #1 ) # Little Red - Rock It ( #2 ) # Ou Est Le Swimming Pool - Dance the Way I Feel ( #3 ) # Cee-Lo Green - Fuck You ! ( #7 ) # Sia - Clap Your Hands ( #13 ) # The Wombats - Tokyo ( Vampires and Wolves ) ( #8 ) # Birds of Tokyo - Plans ( #4 ) # Boy &amp; Bear - Fall At Your Feet ( #5 ) # Mark Ronson &amp; the Business Intl . Featuring Boy George and Andrew Wyyat - Somebody To Love Me ( #10 ) # Foster the People - Pumped Up Kicks ( #32 ) # Washington - Sunday Best ( #20 ) # Two Door Cinema Club - Undercover Martyn ( #21 ) # Cloud Control - There 's Nothing In the Water We Ca n't Fight ( #18 ) # Kanye West Featuring Pusha T - Runaway ( #14 ) # Gypsy &amp; the Cat - Jona Vark ( #64 ) # The National - Bloodbuzz Ohio ( #31 ) # Children Collide - Jellylegs ( #22 ) # Bliss N Eso - Addicted ( #23 ) # Duck Sauce - Barbra Streisand ( #15 ) # Pendulum - Witchcraft ( #48 ) # Florence + the Machine &amp; Dizzee Rascal - You 've Got the Dirtee Love ( Live ) ( #27 ) # Yeasayer - O.N.E ( #30 ) # Adrian Lux - Teenage Crime ( #6 ) # Tame Impala - Solitude Is Bliss ( #33 ) # Sparkadia - Talking Like I 'm Falling Down Stairs ( #24 ) # Crystal Castles Featuring Robert Smith - Not In Love ( #26 ) # Art vs . Science - Magic Fountain ( #9 ) # Darwin Deez - Radar Detector ( #28 ) # Arcade Fire - The Suburbs ( #58 ) # Flight Facilities Featuring Giselle - Crave You ( #19 ) # Drapht - Rapunzel ( #12 ) # The Naked and Famous - Punching In A Dream ( #34 ) # Gorillaz Featuring Daley - Doncamatic ( #37 ) # Illy Featuring Owl Eyes - It Ca n't Wait ( #29 ) # The Jezabels - Mace Spray ( #16 ) # Bag Raiders - Way Back Home ( #46 ) # Gotye - Eyes Wide Open ( #25 ) # Gyroscope - Baby , I 'm Gettin ' Better ( #40 ) # Hot Chip - One Life Stand ( #50 ) # Miami Horror Featuring Alan Palomo - Holidays ( #54 ) # The John Steel Singers - Overpass ( #52 ) # Angus &amp; Julia Stone - Big Jet Plane ( Live ) # DVD Release # # Angus &amp; Julia Stone - Big Jet Plane # Little Red - Rock It # Ou Est Le Swimming Pool - Dance the Way I Feel # Birds of Tokyo - Plans # Adrian Lux - Teenage Crime # Cee-Lo Green - Fuck You # The Wombats - Tokyo ( Vampires &amp; Wolves ) # Art vs . Science - Magic Fountain # Mark Ronson &amp; the Business Intl - Somebody to Love Me # Drapht - Rapunzel # Sia - Clap Your Hands # Duck Sauce - Barbra Streisand # The Jezabels - Mace Spray # Cloud Control - There 's Nothing In the Water We Ca n't Fight # Flight Facilities Featuring Giselle - Crave You # Washington - Sunday Best # Two Door Cinema Club - Undercover Martyn # Children Collide - Jellylegs # Bliss n Eso - Addicted # Sparkadia - Talking Like I 'm Falling Down Stairs # Gotye - Eyes Wide Open # Darwin Deez - Radar Detector # Illy Featuring Owl Eyes - It Ca n't Wait # Yeasayer - O.N.E . # The National - Bloodbuzz Ohio # Tame Impala - Solitude Is Bliss # The Naked and Famous - Punching In A Dream # Chiddy Bang - Opposite of Adults # Gorillaz Featuring Daley - Doncomatic # John Butler Trio - Revolution # Gyroscope - Baby , I 'm Gettin ' Better # Yolanda Be Cool vs DCUP - We Speak No Americano # Boy &amp; Bear - Rabbit Song # Bag Raiders - Way Back Home # Hot Chip - One Life Stand # The John Steel Singers - Overpass # Miami Horror Featuring Alan Palamo - Holidays # Vampire Weekend - Giving Up the Gun # Arcade Fire - The Suburbs # Hungry Kids of Hungary - Coming Around # Big Boi Featuring Cutty - Shutterbugg # Klaxons - Echoes # Evil Eddie - Queensland # The Bedroom Philosopher - Northcote ( So Hungover ) # Angus &amp; Julia Stone - Big Jet Plane ( Live ) # Trivia #  John Butler Trio score the #39 position for the second year in a row .  Both members of Gnarls Barkley got a respective track in the list with different bands ; Danger Mouse with Broken Bells and Cee-Lo Green with a solo track .  Ian Kenny has now appeared in the Hottest 100 every year since 2005 with both Karnivool and Birds of Tokyo .  Angus &amp; Julia Stone are the first Australian band to win the Hottest 100 since Augie March in 2006.  For a second year in a row an Triple J Unearthed artist has cracked the Top 10 ( Art vs . Science #2 in 2009 , and Little Red #2 , Boy &amp; Bear #5 and Art vs Science #9 in 2010 ) .  For the first time since 2005 no artist from France appeared in the list .  Chiddy Bangs track samples the song Kids by MGMT which came #5 in the 2008 countdown . 
@@35319154 Occupational safety and health ( OSH ) also commonly referred to as occupational health and safety ( OHS ) or workplace health and safety ( WHS ) is an area concerned with the safety , health and welfare of people engaged in work or employment . The goals of occupational safety and health programs include to foster a safe and healthy work environment . OSH may also protect co-workers , family members , employers , customers , and many others who might be affected by the workplace environment . In the United States the term occupational health and safety is referred to as occupational health and occupational and non-occupational safety and includes safety for activities outside of work . Occupational safety and health can be important for moral , legal , and financial reasons . In common-law jurisdictions , employers have a common law duty ( reflecting an underlying moral obligation ) to take reasonable care for the safety of their employees , Statute law may build upon this to impose additional general duties , introduce specific duties and create government bodies with powers to regulate workplace safety issues : details of this will vary from jurisdiction to jurisdiction . . Good OSH practices can also reduce employee injury and illness related costs , including medical care , sick leave and disability benefit costs . # Definition # As defined by the World Health Organization ( WHO ) occupational health deals with all aspects of health and safety in the workplace and has a strong focus on primary prevention of hazards . Health has been defined as a state of complete physical , mental and social well-being and not merely the absence of disease or infirmity . Occupational health is a multidisciplinary field of healthcare concerned with enabling an individual to undertake their occupation , in the way that causes least harm to their health . Health has been defined as It contrasts , for example , with the promotion of ' ' health and safety at work ' ' , which is concerned with preventing harm from any incidental hazards , arising in the workplace . Since 1950 , the International Labour Organization ( ILO ) and the World Health Organization ( WHO ) have shared a common definition of occupational health . It was adopted by the Joint ILO/WHO Committee on Occupational Health at its first session in 1950 and revised at its twelfth session in 1995 . The definition reads : # Occupational health should aim at : the promotion and maintenance of the highest degree of physical , mental and social well-being of workers in all occupations ; the prevention amongst workers of departures from health caused by their working conditions ; the protection of workers in their employment from risks resulting from factors adverse to health ; the placing and maintenance of the worker in an occupational environment adapted to his physiological and psychological capabilities ; and , to summarize , the adaptation of work to man and of each man to his job . # Those in the field of occupational health come from a wide range of disciplines and professions including medicine , psychology , epidemiology , physiotherapy and rehabilitation , occupational therapy , occupational medicine , human factors and ergonomics , and many others . Professionals advise on a broad range of occupational health matters . These include how to avoid particular pre-existing conditions causing a problem in the occupation , correct posture for the work , frequency of rest breaks , preventative action that can be undertaken , and so forth . # History # The research and regulation of occupational safety and health are a relatively recent phenomenon . As labor movements arose in response to worker concerns in the wake of the industrial revolution , worker 's health entered consideration as a labor-related issue . In 1833 , HM Factory Inspectorate was formed in the United Kingdom with a remit to inspect factories and ensure the prevention of injury to child textile workers . In 1840 a Royal Commission published its findings on the state of conditions for the workers of the mining industry that documented the appallingly dangerous environment that they had to work in and the high frequency of accidents . The commission sparked public outrage which resulted in the Mines Act of 1842 . The act set up an inspectorate for mines and collieries which resulted in many prosecutions and safety improvements , and by 1850 , inspectors were able to enter and inspect premises at their discretion . Otto von Bismarck inaugurated the first social insurance legislation in 1883 and the first worker 's compensation law in 1884 the first of their kind in the Western world . Similar acts followed in other countries , partly in response to labor unrest . # Workplace hazards # Although work provides many economic and other benefits , a wide array of workplace hazards also present risks to the health and safety of people at work . These include but are not limited to , chemicals , biological agents , physical factors , adverse ergonomic conditions , allergens , a complex network of safety risks , and a broad range of psychosocial risk factors . # Physical and mechanical hazards # Physical hazards are a common source of injuries in many industries . They are perhaps unavoidable in certain industries , such as construction and mining , but over time people have developed safety methods and procedures to manage the risks of physical danger in the workplace . Employment of children may pose special problems . Falls are a common cause of occupational injuries and fatalities , especially in construction , extraction , transportation , healthcare , and building cleaning and maintenance . An engineering workshop specialising in the fabrication and welding of components has to follow the Personal Protective Equipment ( PPE ) at work regulations 1992 . It is an employers duty to provide all equipment ( including clothing affording protection against the weather ) which is intended to be worn or held by a person at work which protects him against one or more risks to his health and safety . In a fabrication and welding workshop an employer would be required to provide face and eye protection , safety footwear , overalls and other necessary PPE . Machines are commonplace in many industries , including manufacturing , mining , construction and agriculture , and can be dangerous to workers . Many machines involve moving parts , sharp edges , hot surfaces and other hazards with the potential to crush , burn , cut , shear , stab or otherwise strike or wound workers if used unsafely . Various safety measures exist to minimize these hazards , including lockout-tagout procedures for machine maintenance and roll over protection systems for vehicles . According to the United States Bureau of Labor Statistics , machine-related injuries were responsible for 64,170 cases that required days away from work in 2008 . More than a quarter of these cases required more than 31 days spent away from work . That same year , machines were the primary or secondary source of over 600 work-related fatalities . Machines are also often involved indirectly in worker deaths and injuries , such as in cases in which a worker slips and falls , possibly upon a sharp or pointed object . The transportation sector bears many risks for the health of commercial drivers , too , for example from vibration , long periods of sitting , work stress and exhaustion . These problems occur in Europe but in other parts of the world the situation is even worse . More drivers die in accidents due to security defects in vehicles . Long waiting times at borders cause that drivers are away from home and family much longer and even increase the risk of HIV infections . Confined spaces also present a work hazard . The National Institute of Occupational Safety and Health defines confined space as having limited openings for entry and exit and unfavorable natural ventilation , and which is not intended for continuous employee occupancy . Spaces of this kind can include storage tanks , ship compartments , sewers , and pipelines . Confined spaces can pose a hazard not just to workers , but also to people who try to rescue them . Noise also presents a fairly common workplace hazard : occupational hearing loss is the most common work-related injury in the United States , with 22 million workers exposed to hazardous noise levels at work and an estimated $242 million spent annually on worker 's compensation for hearing loss disability . Noise is not the only source of occupational hearing loss ; exposure to chemicals such as aromatic solvents and metals including lead , arsenic , and mercury can also cause hearing loss . Temperature extremes can also pose a danger to workers . Heat stress can cause heat stroke , exhaustion , cramps , and rashes . Heat can also fog up safety glasses or cause sweaty palms or dizziness , all of which increase the risk of other injuries . Workers near hot surfaces or steam also are at risk for burns . Dehydration may also result from overexposure to heat . Cold stress also poses a danger to many workers . Overexposure to cold conditions or extreme cold can lead to hypothermia , frostbite , trench foot , or chilblains . Electricity poses a danger to many workers . Electrical injuries can be divided into four types : fatal electrocution , electric shock , burns , and falls caused by contact with electric energy . Vibrating machinery , lighting , and air pressure can also cause work-related illness and injury . Asphyxiation is another potential work hazard in certain situations . Musculoskeletal disorders are avoided by the employment of good ergonomic design and the reduction of repeated strenuous movements or lifts # Biological and chemical hazards # # # Biological hazards # #  Bacteria  Virus  Fungi * Mold  Blood-borne pathogens  Tuberculosis # # Chemical hazards # #  Acids  Bases  Heavy metals  Lead  Solvents  Petroleum  Particulates  Asbestos and other fine dust/fibrous materials  Silica  Fumes ( noxious gases/vapors )  Highly-reactive chemicals  Fire , conflagration and explosion hazards :  Explosion  Deflagration  Detonation  Conflagration # Psychosocial hazards # Employers in most OECD countries have an obligation not only to protect the physical health of their employees but also the psychological health . Therefore as part of a risk management framework psychological or psychosocial hazards ( risk factors ) need to be identified and controlled for in the workplace . Psychosocial hazards are related to the way work is designed , organised and managed , as well as the economic and social contexts of work and are associated with psychiatric , psychological and/or physical injury or illness . Linked to psychosocial risks are issues such as occupational stress and workplace violence which are recognized internationally as major challenges to occupational health and safety . According to a survey by the European Agency for Safety and Health at Work , the most important emerging psychosocial risks are :  Precarious work contracts  Increased worker vulnerability due to globalization  New forms of employment contracts  Feeling of job insecurity  Aging workforce  Long working hours  Work intensification  Lean production and outsourcing  High emotional demands  Poor work-life balance # By industry # Specific occupational safety and health risk factors vary depending on the specific sector and industry . Construction workers might be particularly at risk of falls , for instance , whereas fishermen might be particularly at risk of drowning . The United States Bureau of Labor Statistics identifies the fishing , aviation , lumber , metalworking , agriculture , mining and transportation industries as among some of the more dangerous for workers . Similarly psychosocial risks such as workplace violence are more pronounced in certain occupational groups such as health care employees , correctional officers and teachers . # Construction # Construction is one of the most dangerous occupations in the world , incurring more occupational fatalities than any other sector in both the United States and in the European Union . In 2009 , the fatal occupational injury rate among construction workers in the United States was nearly three times that for all workers . Falls are one of the most common causes of fatal and non-fatal injuries among construction workers . Proper safety equipment such as harnesses and guardrails and procedures such as securing ladders and inspecting scaffolding can curtail the risk of occupational injuries in the construction industry . Due to the fact that accidents may have disastrous consequences for employees as well as organizations , it is of utmost importance to ensure health and safety of workers and compliance with HSE construction requirements . Health and safety legislation in the construction industry involves many rules and regulations . For example , the role of the Construction Design Management ( CDM ) Coordinator as a requirement has been aimed at improving health and safety on-site . The 2010 National Health Interview Survey Occupational Health Supplement ( NHIS-OHS ) identified work organization factors and occupational psychosocial and chemical/physical exposures which may increase some health risks . Among all U.S. workers in the construction sector , 44% had non-standard work arrangements ( were not regular permanent employees ) compared to 19% of all U.S. workers , 15% had temporary employment compared to 7% of all U.S. workers , and 55% experienced job insecurity compared to 32% of all U.S. workers . Prevalence rates for exposure to physical/chemical hazards were especially high for the construction sector . Among nonsmoking workers , 24% of construction workers were exposed to secondhand smoke while only 10% of all U.S. workers were exposed . Other physical/chemical hazards with high prevalence rates in the construction industry were frequently working outdoors ( 73% ) and frequent exposure to vapors , gas , dust , or fumes ( 51% ) . # Agriculture # Agriculture workers are often at risk of work-related injuries , lung disease , noise-induced hearing loss , skin disease , as well as certain cancers related to chemical use or prolonged sun exposure . On industrialized farms , injuries frequently involve the use of agricultural machinery . The most common cause of fatal agricultural injuries in the United States is tractor rollovers , which can be prevented by the use of roll over protection structures which limit the risk of injury in case a tractor rolls over . Pesticides and other chemicals used in farming can also be hazardous to worker health , and workers exposed to pesticides may experience illnesses or birth defects . As an industry in which families , including children , commonly work alongside their families , agriculture is a common source of occupational injuries and illnesses among younger workers . Common causes of fatal injuries among young farm worker include drowning , machinery and motor vehicle-related accidents . The 2010 NHIS-OHS found elevated prevalence rates of several occupational exposures in the agriculture , forestry , and fishing sector which may negatively impact health . These workers often worked long hours . The prevalence rate of working more than 48 hours a week among workers employed in these industries was 37% , and 24% worked more than 60 hours a week . Of all workers in these industries , 85% frequently worked outdoors compared to 25% of all U.S. workers . Additionally , 53% were frequently exposed to vapors , gas , dust , or fumes , compared to 25% of all U.S. workers . # Service sector # As the number of service sector jobs has risen in developed countries , more and more jobs have become sedentary , presenting a different array of health problems than those associated with manufacturing and the primary sector . Contemporary problems such as the growing rate of obesity and issues relating to occupational stress , workplace bullying , and overwork in many countries have further complicated the interaction between work and health . According to data from the 2010 NHIS-OHS , hazardous physical/chemical exposures in the service sector were lower than national averages . On the other hand , potentially harmful work organization characteristics and psychosocial workplace exposures were relatively common in this sector . Among all workers in the service industry , 30% experienced job insecurity in 2010 , 27% worked non-standard shifts ( not a regular day shift ) , 21% had non-standard work arrangements ( were not regular permanent employees ) . # Mining and oil &amp; gas extraction # According to data from the 2010 NHIS-OHS , workers employed in mining and oil &amp; gas extraction industries had high prevalence rates of exposure to potentially harmful work organization characteristics and hazardous chemicals . Many of these workers worked long hours : 50% worked more than 48 hours a week and 25% worked more than 60 hours a week in 2010 . Additionally , 42% worked non-standard shifts ( not a regular day shift ) . These workers also had high prevalence of exposure to physical/chemical hazards . In 2010 , 39% had frequent skin contact with chemicals . Among nonsmoking workers , 28% of those in mining and oil and gas extraction industries had frequent exposure to secondhand smoke at work . About two-thirds were frequently exposed to vapors , gas , dust , or fumes at work . # Healthcare and Social Assistance # Healthcare workers are exposed to many hazards that can adversely affect their health and well-being . Long hours , changing shifts , physically demanding tasks , violence , and exposures to infectious diseases and harmful chemicals are examples of hazards that put these workers at risk for illness and injury . According to the Bureau of Labor statistics , U.S. hospitals recorded 253,700 work-related injuries and illnesses in 2011 , which is 6.8 work-related injuries and illnesses for every 100 full-time employees . The injury and illness rate in hospitals is higher than the rates in construction and manufacturing two industries that are traditionally thought to be relatively hazardous . The is a secure electronic surveillance system developed by the National Institute for Occupational Safety and Health ( NIOSH ) to address health and safety risks among health care personnel . OHSN uses existing data to characterize risk of injury and illness among health care workers . Hospitals and other healthcare facilities can upload the occupational injury data they already collect to the secure database for analysis and benchmarking with other de-identified facilities . NIOSH works with OHSN participants in identifying and implementing timely and targeted interventions . OHSN modules currently focus on three high risk and preventable events that can lead to injuries or musculoskeletal disorders among healthcare personnel : musculoskeletal injuries from patient handling activities ; slips , trips , and falls ; and workplace violence . OHSN enrollment is open to all healthcare facilities . # Workplace fatalities statistics # # European Union # In most countries males comprise the vast majority of workplace fatalities . In the EU as a whole , 94% of death were of males . In the UK the disparity was even greater with males comprising 97.4% of workplace deaths . In the UK there were 171 fatal injuries at work in financial year 2011-2 , compared with 651 in calendar year 1974 ; the fatal injury rate declined over that period from 2.9 fatalities per 100,000 workers to 0.6 per 100,000 workers # United States # The Bureau of Labor Statistics of the United States Department of Labor compiles information about workplace fatalities in the United States . In 1970 , an estimated 14,000 workers were killed on the job by 2010 , the workforce had doubled , but workplace deaths were down to about 4,500 . The Bureau also compiles information about the most dangerous jobs . The most recent information comes from the year 2006 , during which 5,840 people died on the job . # Management systems # # International # In 2001 , the International Labor Organization ( ILO ) published ILO-OSH 2001 , also titled Guidelines a on occupational safety and health management systems to assist organizations with introducing OSH management systems . These guidelines encourage continual improvement in employee health and safety , achieved via a constant process of policy , organization , planning &amp; implementation , evaluation , and action for improvement , all supported by constant auditing to determine the success of OSH actions . The ILO management system was created to assist employers to keep pace with rapidly shifting and competitive industrial environments . The ILO recognizes that national legislation is essential , but sometimes insufficient on its own to address the challenges faced by industry , and therefore elected to ensure free and open distribution of administrative tools in the form of occupational health and safety management system guidance for everyone . This open access forum is intended to provide the tools for industry to create safe and healthy working environments and foster positive safety cultures within the organizations . OHSAS 18001 The British Standards Occupational Health and Safety management Systems Requirements Standard BS OHSAS 18001 was developed within the framework of the ISO standards series . Allowing it to integrate better into the larger system of ISO certifications . ISO 9001 Quality Management Systems and ISO 14001 Environmental Management System can work in tandem with BS OHSAS 18001/18002 to complement each other and form a better overall system . Each component of the system is specific , auditable , and accreditable by a third party after review . Also Standards Australia and the Association Franaise de Normalisation ( AFNOR ) in France have developed occupational safety and health management standards . # United Kingdom # Guidance note HSG65 : Successful Health and Safety Management , published by the British non-departmental public body Health and Safety Executive , promotes a systematic management of health and safety through a six step system , policy , organizing , planning and implementing , measuring performance , reviewing performance . These components are all linked to an audit system providing for evaluation and a feedback loop to improve performance . This systematic approach allows flexibility for the company through good business planning to strategically apply resources according to risk priorities . # National legislation and public organizations # Occupational safety and health practice vary among nations with different approaches to legislation , regulation , enforcement , and incentives for compliance . In the EU , for example , some member states promote OSH by providing public monies as subsidies , grants or financing , while others have created tax system incentives for OSH investments . A third group of EU member states has experimented with using workplace accident insurance premium discounts for companies or organisations with strong OSH records . # European Union # In the European Union , member states have enforcing authorities to ensure that the basic legal requirements relating to occupational health and safety are met . In many EU countries , there is strong cooperation between employer and worker organisations ( e.g. unions ) to ensure good OSH performance as it is recognized this has benefits for both the worker ( through maintenance of health ) and the enterprise ( through improved productivity and quality ) . In 1996 , the European Agency for Safety and Health at Work was founded . Member states of the European Union have all transposed into their national legislation a series of directives that establish minimum standards on occupational health and safety . These directives ( of which there are about 20 on a variety of topics ) follow a similar structure requiring the employer to assess the workplace risks and put in place preventive measures based on a hierarchy of control . This hierarchy starts with elimination of the hazard and ends with personal protective equipment . However , certain EU member states admit to having lacking quality control in occupational safety services , to situations in which risk analysis takes place without any on-site workplace visits and to insufficient implementation of certain EU OSH directives . Based on this , it is hardly surprising that the total societal costs of work-related health problems and accidents vary from 2.6% to 3.8% of GNP between the EU member states . # United Kingdom # In the UK , health and safety legislation is drawn up and enforced by the Health and Safety Executive and local authorities ( the local council ) under the Health and Safety at Work etc . Act 1974 ( HASAWA ) . HASAWA introduced ( section 2 ) a general duty on an employer to ensure , so far as is reasonably practicable , the health , safety and welfare at work of all his employees ; with the intention of giving a legal framework supporting ' codes of practice ' not in themselves having legal force but establishing a strong presumption as to what was reasonably practicable ( deviations from them could be justified by appropriate risk assessment ) . The previous reliance on detailed prescriptive rule-setting was seen as having failed to respond rapidly enough to technological change , leaving new technologies potentially un-regulated or inappropriately regulated . HSE has continued to make some regulations giving absolute duties ( where something must be done with no ' reasonable practicability ' test ) but in the UK the regulatory trend is away from prescriptive rules , and towards ' goal setting ' and risk assessment . Recent major changes to the laws governing asbestos and fire safety management embrace the concept of risk assessment . For the UK , the government organisation dealing with occupational health has been the Employment Medical Advisory Service but in 2014 a new occupational health organisation - the Health and Work Service - was created to provide advice and assistance to employers in order to get back to work employees on long-term sick-leave . The service , funded by government , will offer medical assessments and treatment plans , on a voluntary basis , to people on long term absence from their employer ; in return , the government will no longer foot the bill for Statutory Sick Pay provided by the employer to the individual . # Denmark # In Denmark , occupational safety and health is regulated by the Danish Act on Working Environment and cooperation at the workplace . The Danish Working Environment Authority carries out inspections of companies , draws up more detailed rules on health and safety at work and provides information on health and safety at work . The result of each inspection is made public on the web pages of the Danish Working Environment Authority so that the general public , current and prospective employees , customers and other stakeholders can inform themselves about whether a given organization has passed the inspection , should they wish to do so . # United States # In the United States , President Richard Nixon signed the Occupational Safety and Health Act into law on the 29th day of December 1970 . The act created the three agencies that administer it . They include the Occupational Safety and Health Administration , National Institute for Occupational Safety and Health , and the Occupational Safety and Health Review Commission . The act authorized the Occupational Safety and Health Administration ( OSHA ) to regulate private employers in the 50 states , the District of Columbia , and territories . The Act establishing it includes ageneral duty clause ( 29 U.S.C. 654 , 5(a) requiring an employer to comply with the Act and regulations derived from it , and to provide employees with employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees . OSHA was established in 1971 under the Department of Labor . It has headquarters in Washington , DC and ten regional offices , further broken down into districts , each organized into three sections ; compliance , training , and assistance . Its stated mission is ' ' to assure safe and healthful working conditions for working men and women by setting and enforcing standards and by providing training , outreach , education and assistance . ' ' The original plan was for OSHA to oversee 50 state plans with OSHA funding 50% of each plan . Unfortunately it has not worked out that way . There are currently 26 approved state plans ( 4 cover only public employees ) and no other states want to participate . OSHA manages the plan in the states not participating . OSHA develops safety standards in the Code of Federal Regulation and enforces those safety standards through compliance inspections conducted by Compliance Officers ; enforcement resources are focussed on high-hazard industries . Worksites may apply to enter OSHA 's Voluntary Protection Program ( VPP ) ; a successful application leads to an on-site inspection ; if this is passed the site gains VPP status and OSHA no longer inspect it annually nor ( normally ) visit it unless there is a fatal accident or an employee complaint until VPP revalidation ( after 3-5 years ) ( VPP sites have injury and illness rates less than half the average for their industry ) . It has 73 specialists in local offices to provide tailored information and training to employers and employees at little or no cost Similarly OSHA produces a range of publications , provides advice to employers and funds consultation services available for small businesses . OSHA 's Alliance Program enables groups committed to worker safety and health to work with it to develop compliance assistance tools and resources , share information with workers and employers , and educate them about their rights and responsibilities . OSHA also has a Strategic Partnership Program that zeros in on specific hazards or specific geographic areas . OSHA manages Susan B. Harwood grants to nonprofit companies to train workers and employers to recognize , avoid , and prevent safety and health hazards in the workplace . Grants focus on small business , hard-to-reach workers and high-hazard industries . # Canada # In Canada , workers are covered by provincial or federal labour codes depending on the sector in which they work . Workers covered by federal legislation ( including those in mining , transportation , and federal employment ) are covered by the Canada Labour Code ; all other workers are covered by the health and safety legislation of the province in which they work . The Canadian Centre for Occupational Health and Safety ( CCOHS ) , an agency of the Government of Canada , was created in 1966 by an Act of Parliament . The act was based on the belief that all Canadians had ... a fundamental right to a healthy and safe working environment . CCOHS is mandated to promote safe and healthy workplaces to help prevent work-related injuries and illnesses . The CCOHS maintains a useful ( partial ) list of OSH regulations for Canada and its provinces . # Malaysia # In Malaysia , the Department of Occupational Safety and Health ( DOSH ) under the Ministry of Human Resource is responsible to ensure that the safety , health and welfare of workers in both the public and private sector is upheld . DOSH is responsible to enforce the Factories and Machinery Act 1967 and the Occupational Safety and Health Act 1994. # People 's Republic of China # In the People 's Republic of China , the Ministry of Health is responsible for occupational disease prevention and the State Administration of Work Safety for safety issues at work . On the provincial and municipal level , there are Health Supervisions for occupational health and local bureaus of Work Safety for safety . The Occupational Disease Control Act of PRC came into force on May 1 , 2002. and Work safety Act of PRC on November 1 , 2002 . The Occupational Disease Control Act is under revising . The prevention of occupational disease is still in its initial stage compared with industried countries such as the US or UK. # South Africa # In South Africa the Department of Labour is responsible for occupational health and safety inspection and enforcement in commerce and industry apart from mining and energy production , where the Department of Mineral Resources is responsible . The main statutory legislation on Health and Safety in the jurisdiction of the Department of Labour is ' ' Act No. 85 of 1993 : Occupational Health and Safety Act as amended by Occupational Health and Safety Amendment Act , No. 181 Of 1993 . ' ' Regulations to the OHS Act include :  ' ' Certificate of Competency Regulations , 1990 ' '  ' ' Construction Regulations , 2003 ' '  ' ' Diving Regulations 2009 ' '  ' ' Driven Machinery Regulations , 1988 ' '  ' ' Environmental Regulations for Workplaces , 1987 ' '  ' ' General Machinery regulations , 1988 ' '  ' ' General Safety Regulations , 1986 ' '  ' ' Noise induced hearing loss regulations , 2003 ' '  ' ' Pressure Equipment Regulations , 2004 ' ' # Professional roles and responsibilities # The roles and responsibilities of OSH professionals vary regionally , but may include evaluating working environments , developing , endorsing and encouraging measures that might prevent injuries and illnesses , providing OSH information to employers , employees , and the public , providing medical examinations , and assessing the success of worker health programs . # Europe # In Norway , the main required tasks of an Occupational Health and Safety Practitioner include :  Systematic evaluations of the working environment  Endorsing preventative measures which eliminate reasons for illnesses in the work place  Giving information in the subject of employees health  Giving information on occupational hygiene , ergonomics and also environmental and safety risks in the work place In the Netherlands , required tasks for health and safety staff are only summarily defined , and include :  Voluntary medical examinations  A consulting room on the work environment for the workers  Health check assessments ( if needed for the job concerned ) The main influence on the Dutch law on the job of the safety professional is through the requirement on each employer to use the services of a certified working conditions service to advise them on health and safety . A certified service must employ sufficient numbers of four types of certified experts to cover the risks in the organisations which use the service :  A safety professional  An occupational hygienist  An occupational physician  A work and organisation specialist . It shows in Table 1 ( based on the European Network of Safety and Health Practitioner Organisations ENHSPO survey to ) that in Norway , 37% of Health and Safety practitioners had a MSc education level , and 14% in the Netherlands ; 44% were BSc graduates and 63% in the Netherlands ; and 19% were of a Technician level and 23% in the Netherlands . # USA # The main tasks undertaken by the OHS practitioner in the USA include :  Develop processes , procedures , criteria , requirements , and methods to attain the best possible management of the hazards and exposures that can cause injury to people , and damage property , or the environment ;  Apply good business practices and economic principles for efficient use of resources to add to the importance of the safety processes ;  Promote other members of the company to contribute by exchanging ideas and other different approaches to make sure that every one in the corporation possess OHS knowledge and have functional roles in the development and execution of safety procedures ;  Assess services , outcomes , methods , equipment , workstations , and procedures by using qualitative and quantitative methods to recognise the hazards and measure the related risks ;  Examine all possibilities , effectiveness , reliability , and expenditure to attain the best results for the company concerned Knowledge required by the OHS professional in USA include :  Constitutional and case law controlling safety , health , and the environment  Operational procedures to plan/develop safe work practices  Safety , health and environmental sciences  Design of hazard control systems ( i.e. fall protection , scaffoldings )  Design of recordkeeping systems that take collection into account , as well as storage , interpretation , and dissemination  Mathematics and statistics  Processes and systems for attaining safety through design Some skills required by the OHS professional in the USA include ( but are not limited to ) :  Understanding and relating to systems , policies and rules  Holding checks and having control methods for possible hazardous exposures  Mathematical and statistical analysis  Examining manufacturing hazards  Planning safe work practices for systems , facilities , and equipment  Understanding and using safety , health , and environmental science information for the improvement of procedures  Interpersonal communication skills # Differences across countries and regions # Because different countries take different approaches to ensuring occupational safety and health , areas of OSH need and focus also vary between countries and regions . Similar to the findings of the ENHSPO survey conducted in Australia , the Institute of Occupational Medicine found that in the UK , there is a need to put a greater emphasis on work-related illness . In contrast , in Australia and the USA a major responsibility of the OHS professional is to keep company directors and managers aware of the issues that they face in regards to Occupational Health and Safety principles and legislation . However , in some other areas of Europe , it is precisely this which has been lacking : Nearly half of senior managers and company directors do not have an up-to-date understanding of their health and safety-related duties and responsibilities. # Identifying safety and health hazards # # Hazards , risks , outcomes # The terminology used in OSH varies between countries , but generally speaking :  A hazard is something that can cause harm if not controlled .  The outcome is the harm that results from an uncontrolled hazard .  A risk is a combination of the probability that a particular outcome will occur and the severity of the harm involved . Hazard , risk , and outcome are used in other fields to describe e.g. environmental damage , or damage to equipment . However , in the context of OSH , harm generally describes the direct or indirect degradation , temporary or permanent , of the physical , mental , or social well-being of workers . For example , repetitively carrying out manual handling of heavy objects is a hazard . The outcome could be a Musculoskeletal disorders # Hazard identification # Hazard identification or assessment is an important step in the overall risk assessment and risk management process . It is where individual work hazards are identified , assessed and controlled/eliminated as close to source ( location of the hazard ) as reasonable and possible . As technology , resources , social expectation or regulatory requirements change , hazard analysis focuses controls more closely toward the source of the hazard . Thus hazard control is a dynamic program of prevention . Hazard-based programs also have the advantage of not assigning or implying there are acceptable risks in the workplace . A hazard-based program may not be able to eliminate all risks , but neither does it accept satisfactory but still risky outcomes . And as those who calculate and manage the risk are usually managers while those exposed to the risks are a different group , workers , a hazard-based approach can by-pass conflict inherent in a risk-based approach . # Risk assessment # Modern occupational safety and health legislation usually demands that a risk assessment be carried out prior to making an intervention . It should be kept in mind that risk management requires risk to be managed to a level which is as low as is reasonably practical . This assessment should :  Identify the hazards  Identify all affected by the hazard and how  Evaluate the risk  Identify and prioritize appropriate control measures The calculation of risk is based on the likelihood or probability of the harm being realized and the severity of the consequences . This can be expressed mathematically as a Quantitative property The assessment should be recorded and reviewed periodically and whenever there is a significant change to work practices . The assessment should include practical recommendations to control the risk . Once recommended controls are implemented , the risk should be re-calculated to determine of it has been lowered to an acceptable level . Generally speaking , newly introduced controls should lower risk by one level , i.e. , from high to medium or from medium to low . # Contemporary developments # On an international scale , the World Health Organization ( WHO ) and the International Labour Organization ( ILO ) have begun focusing on labour environments in developing nations with projects such as Healthy Cities . Many of these developing countries are stuck in a situation in which their relative lack of resources to invest in OSH leads to increased costs due to work-related illnesses and accidents . As a 2007 Factsheet from the European Agency for Safety and Health at Work states : Countries with less developed OSH systems spend a far higher percentage of GDP on work-related injury and illness taking resources away from more productive activities . . . The ILO estimates that work-related illness and accidents cost up to 10% of GDP in Latin America , compared with just 2.6% to 3.8% in the EU. # Nanotechnology # Nanotechnology is an example of a new , relatively unstudied technology . A Swiss survey of one hundred thirty eight companies using or producing nanoparticulate matter in 2006 , resulted in forty completed questionnaires . Sixty five per cent of respondent companies stated they did not have a formal risk assessment process for dealing with nanoparticulate matter . Nanotechnology already presents new issues for OSH professionals that will only become more difficult as nanostructures become more complex . The size of the particles renders most containment and personal protective equipment ineffective . The toxicology values for macro sized industrial substances are rendered inaccurate due to the unique nature of nanoparticulate matter . As nanoparticulate matter decreases in size its relative surface area increases dramatically , increasing any catalytic effect or chemical reactivity substantially versus the known value for the macro substance . This presents a new set of challenges in the near future to rethink contemporary measures to safeguard the health and welfare of employees against a nanoparticulate substance that most conventional controls have not been designed to manage . # Education # There are multiple levels of training applicable to the field of Occupational Health and Safety ( OSH ) . Programs range from individual non-credit certificates , focusing on specific areas of concern , to full doctoral programs . The University of Southern California was one of the first schools in the nation to offer a Ph.D . program focusing on the field . Further , multiple masters degree programs exist , such as that of the Indiana State University who offer a master of science ( MS ) and a master of arts ( MA ) in OSH . Graduate programs are designed to train educators , as well as , high-level practitioners . Many OSH generalists focus on undergraduate studies ; programs within schools , such as that of the University of North Carolina 's online Bachelor of Science in Environmental Health and Safety , fill a large majority of hygienist needs . However , smaller companies often do nt have full-time safety specialists on staff , thus , they appoint a current employee to the responsibility . Individuals finding themselves in positions such as these , or for those enhancing marketability in the job-search and promotion arena , may seek out a credit certificate program . For example , the University of Connecticut 's online OSH Certificate , provides students familiarity with overarching concepts through a 15-credit ( 5-course ) program . Programs such as these are often adequate tools in building a strong educational platform for new safety managers with a minimal outlay of time and money . Further , most hygienists seek certification by organizations which train in specific areas of concentration , focusing on isolated workplace hazards . The American Society for Safety Engineers ( ASSE ) , American Board of Industrial Hygiene ( ABIH ) , and American Industrial Hygiene Association ( AIHA ) offer individual certificates on many different subjects from forklift operation to waste disposal and are the chief facilitators of continuing education in the OSH sector . In the U.S. the training of safety professionals is supported by National Institute for Occupational Safety and Health through their NIOSH Education and Research Centers. # World Day for Safety and Health at Work # On April 28 The International Labour Organisation celebrates World Day for Safety and Health to raise awareness of safety in the workplace . Occurring annually since 2003 , each year it focuses on a specific area and bases a campaign around the theme .