Telehealth Clinic

On the day, a nurse or health professional at the Queensland Health facility will be in the room with the patient. Before the clinic starts, the nurse will outline what the patient can expect during the consultation and may even take some preliminary patient readings (e.g. blood pressure, heart rate etc.)

Once the videoconference starts, it will be as if the patient, nurse and doctor are sitting in the room together. They can ask each other questions, review history and even see real-time images of a specific area of the patient if required.

Telehealth patients can expect to:

• Receive care in person if they do not wish to have a telehealth appointment.
• Be respected if the patient refuses a telehealth appointment.
• Have a carer, friend, family member or guardian present at the appointment.
• Have the option of having an interpreter, health worker or multicultural worker present if required.
• Always be introduced to everyone in the telehealth appointment and have the right to decide whether the patient wants them involved.
• Choose to end the appointment at any time and ask for an appointment in person.
• Get the equivalent standard of care that the patient would be received in an in-person appointment.
• Receive health care that respects your privacy and confidentiality.
• Receive care from health care providers who are educated and trained to use the telehealth equipment and to conduct telehealth appointments.

When the telehealth appointment is finished, the nurse will complete forms, scripts or other paperwork for the patient and may even organise the next appointment.

Minister Consults on Dental Reform in Australia

The Minister for Health and Ageing, Nicola Roxon, today visited The Royal Dental Hospital of Melbourne to discuss recommendations from the National Health and Hospital Reform Commission with dental health professionals.

Dental health is among the starkest indicators of inequality for Australians today and improving access to dental health care is a key priority identified National Health and Hospitals Reform Commission’s Report A Healthier Future for all Australians.

A recommendation from the Commission includes the establishment of a universal dental scheme to provide preventative and restorative dental care, as well as dentures, through ‘Denticare Australia’. The additional costs of Denticare would be funded by an increase in the Medicare Levy of 0.75 per cent of taxable income.

The Rudd Government is taking concrete steps to improve Australia's health and hospital system after twelve years of neglect by the previous Liberal Government.

The $490 million Medicare Teen Dental Plan provides eligible teenagers with access to preventative dental checks. More than 470,000 consultations have been undertaken by teenagers since its introduction in August last year.

On her visit to the Hospital, Minister Roxon went on a tour of the Hospital’s facilities meeting with a family benefiting from the Teen Dental Program, which provides $150 for eligible teenagers to receive a check up under this important dental program.

The Royal Dental Hospital of Melbourne consultation is the 41st across the country to road-test the National Health and Hospital Reform Commission's proposed reforms.

The National Health and Hospitals Reform Commission report made recommendations for system-wide changes to Australian health care.

At today’s Royal Dental Hospital of Melbourne consultation Minister Roxon outlined the Commission’s recommendations and met with the dental sector’s professionals to discuss their priorities to improve oral health around the country.

Additional Health Risks

Less common health conditions associated with increased weight include asthma, hepatic steatosis, sleep apnea and Type 2 diabetes.

• Asthma is a disease of the lungs in which the airways become blocked or narrowed causing breathing difficulty. Studies have identified an association between childhood overweight and asthma.
  
• Hepatic steatosis is the fatty degeneration of the liver caused by a high concentration of liver enzymes. Weight reduction causes liver enzymes to normalize.
• Sleep apnea is a less common complication of overweight for children and adolescents. Sleep apnea is a sleep-associated breathing disorder defined as the cessation of breathing during sleep that lasts for at least 10 seconds. Sleep apnea is characterized by loud snoring and labored breathing. During sleep apnea, oxygen levels in the blood can fall dramatically. One study estimated that sleep apnea occurs in about 7% of overweight children.
• Type 2 diabetes is increasingly being reported among children and adolescents who are overweight.⁷ While diabetes and glucose intolerance, a precursor of diabetes, are common health effects of adult obesity, only in recent years has Type 2 diabetes begun to emerge as a health-related problem among children and adolescents. Onset of diabetes in children and adolescents can result in advanced complications such as CVD and kidney failure.

In addition, studies have shown that obese children and teens are more likely to become obese as adults.

The Governor's Health Care Plan

The Health Care Security and Cost Reduction Act

Affordable And Accessible Health Coverage For California

The Health Care Security and Cost Reduction Act ensures that every Californian has access to health coverage.

Assembly Bill X1 1, the Health Care Security and Cost Reduction Act:

• Requires that all Californians take responsibility for their health coverage (individual mandate).
• Guarantees that no Californian will be turned away from buying insurance based on their age or medical history (guarantee issue).
• Spreads responsibility across individuals, government, hospitals and employers (shared responsibility).
• Makes coverage more affordable for individuals and families through tax credits and subsidies.
• Helps keep hospitals and emergency rooms open by increasing Medi-Cal reimbursement rates.
• Allows individuals to choose their health coverage and keep their current insurance.

The Health Care Security and Cost Reduction Act ensures that every Californian takes responsibility for their health care.

This legislation establishes a variety of options to achieve this: It provides assistance to low- and middle-income families; creates a purchasing pool that allows individuals to benefit from affordable rates; expands eligibility for programs such as Medi-Cal and the Healthy Families Program; and increases access to community clinics and county-based health care programs; and other measures.

Everyone who already has insurance can keep it.

No one will be forced to change insurance plans under the Health Care Security and Cost Reduction Act. Californians who currently have health insurance will be able to keep the insurance they have, and will have more options should they choose to change.

The Health Care Security and Cost Reduction Act lowers costs and expands choice.

Like the current health care system, the Health Care Security and Cost Reduction Act is market-based and competitive. The fundamental difference is that now insured Californians will no longer be forced to cover the uninsured and all Californians will be able to buy insurance.

The Health Care Security and Cost Reduction Act guarantees that everyone can get insurance.

Under this legislation, Californians who want to buy insurance can, regardless of their age or medical history.

• When fully implemented, insurers will only be able to vary rates based on age, family size and geography. New rating rules will be phased in over a four-year period. During this time, limited variations based on medical history will be allowed and reforms will limit how much older people are charged.
• The plan also brings greater transparency to the insurance market by requiring insurers to spend at least 85 percent of every premium dollar on patient care.

The Health Care Security and Cost Reduction Act puts affordable coverage within everyone's reach.

This legislation increases affordability for everyone and controls rising medical costs by expanding coverage, improving access to preventive care and reducing costly, unnecessary emergency room visits. It:

• Provides affordable coverage. The state will create a new purchasing pool that will provide access to subsidized, affordable coverage to individuals and families with incomes between 100-250 percent of the poverty level. As a result, low-and-middle income people will be able to buy an affordable health insurance plan. The Act limits how much Californians will contribute toward the cost of their premium based on income.
  • 100-150 percent of poverty: No contribution
  • 151-250 percent of poverty: Premium limited to no more than 5 percent of income
• Protects middle-income Californians. The Act protects working families with higher incomes as well.
  • It provides a tax credit: Those earning between 250-400 percent of poverty will receive a tax credit if the cost of buying insurance exceeds 5.5 percent of income. The Act also calls for an additional tax credit to make health care more affordable for early retirees.
  • It helps people pay their premiums: Anyone with an income above 250 percent of poverty who works for an employer who doesn't offer coverage will get a contribution toward their premium.
• Expands Medi-Cal. This legislation makes Medi-Cal available to childless adults with incomes up to 100 percent of the poverty level.
• Expands the Healthy Families Program. The legislation expands Medi-Cal and the Healthy Families Program to provide no/low-cost comprehensive health coverage to all children with family incomes below 300 percent of the federal poverty level. This means that more low-income children will be able to go to the doctor instead of going to an emergency room.
• Provides a strong community clinic safety net. The Act increases funding for the Early Access to Primary Care Program to provide cost-effective clinic services to low-income Californians who aren't eligible for other state subsidized coverage.
• Allows affordability and limited hardship exemptions. The Act recognizes that some lower income people who aren't eligible for state subsidized coverage (coverage through the pool, Healthy Families, Medi-Cal) may not be able to afford to buy insurance.
  • So, to ensure that these people are getting primary care but not misusing our emergency rooms, the Act provides them with low-cost ways to get care through clinics and county-based services. Specifically, the legislation:
    • Provides an exemption to people with incomes below 250 percent of poverty, whose cost for the required coverage exceeds 5 percent of their income, to opt out of the individual requirement to purchase insurance.
    • Allows Managed Risk Medical Insurance Board (MRMIB) to grant limited temporary or permanent exemptions to people who demonstrate that they are facing significant financial hardship or otherwise cannot afford coverage.

The Health Care Security and Cost Reduction Act gives working Californians and employers tax breaks.

The legislation requires employers to let employees pay their health insurance premiums on a pre-tax basis through IRS Code Section 125 plans. This will bring significant tax savings to middle-income Californians and their employers. By paying for health care benefits on a pre-tax basis, employees and employers will save approximately $2 billion dollars in state and federal income taxes and federal payroll taxes. The expected cost to an employer to establish a Section 125 plans is $200 or less.

The Health Care Security and Cost Reduction Act protects patients, providers and the state budget.

• Requires that insurers spend no less than 85 cents of every premium dollar on your medical care.
• Increases access and promotes affordable care by reforming regulations, expanding the use of nurse practitioners and physician assistants, enhancing retail clinics, and other measures.
• Promotes the use of health information technology and requires that all health providers have the capacity to e-prescribe by 2012.
• Promotes quality improvements and increases access to price and quality information through a significant transparency initiative and pay-for-performance efforts.
• Reduces pressure on California's General Fund by securing new federal funds that will raise Medi-Cal reimbursements to doctors and hospitals.

The Health Care Security and Cost Reduction Act promotes prevention, wellness and personal responsibility to keep Californians healthier and costs lower.

The legislation rewards healthy choices and tackles chronic conditions, like obesity and diabetes, to promote better health and contain costs. AB X1 1:

• Structures health benefits to promote prevention, wellness and healthy lifestyles.
• Requires health plans and insurers to offer benefits packages that reward individuals who meet certain health goals.
• Creates diabetes, obesity and smoking cessation initiatives to improve the lives of Californians and keep down medical costs.

Graph 1: How California Will Pay For Health Care Reform

California voters will be asked to approve how the AB X1 1 is financed on the November 2008 ballot.

Federal Funding	$4.6 billion
Individuals*	$2.1 billion
4 Percent Hospital Fee	$2.3 billion
Employer Contribution	$2.6 billion
Tobacco Revenues	$1.5 billion
County and Other Funds	$1.6 billion

* The $2.1 billion from individuals does not represent any new dollars from individuals paying for their insurance now.

Graph 2: How The Federal Poverty Level Translates To Earnings

	Annual Income	Percent of Federal Poverty Level	Monthly Income	5 Percent of Monthly Income	5.5 Percent of Monthly Income
Individual	$10,210	100%	$851	$43	$47
	$15,315	150%	$1,276	$64	$70
	$20,420	200%	$1,702	$85	$94
	$25,525	250%	$2,127	$106	$117
	$30,630	300%	$2,553	$128	$140
	$35,735	350%	$2,978	$149	$164
	$40,840	400%	$3,403	$170	$187
Couple	$13,690	100%	$1,141	$57	$63
	$20,535	150%	$1,711	$86	$94
	$27,380	200%	$2,282	$114	$125
	$34,225	250%	$2,852	$143	$157
	$41,070	300%	$3,423	$171	$188
	$47,915	350%	$3,993	$200	$220
	$54,760	400%	$4,563	$228	$251
Family of Four	$20,650	100%	$1,721	$86	$95
	$30,975	150%	$2,581	$129	$142
	$41,300	200%	$3,442	$172	$189
	$51,625	250%	$4,302	$215	$237
	$61,950	300%	$5,163	$258	$284
	$72,275	350%	$6,023	$301	$331
	$82,600	400%	$6,883	$344	$379

Food and Nutrition Information Center

The Food and Nutrition Information Center (FNIC) at USDA's National Agricultural Library (NAL) has launched a redesigned website featuring several improvements to make it easier for nutrition educators, health professionals and government personnel to find and use the site's excellent nutrition information.

The FNIC website is easier to navigate to nutrition topics of interest, including topics such as food labeling, lifecycle nutrition, and professional and career resources in nutrition. Users will find it easier to get to popular resources such as USDA's food composition database by using the "I Want To..." boxes found on the right side of web pages. The long-time favorite "Topics A-Z," which covers over 70 nutrition topics, can be found along the top bar of the webpages. In addition, the site is now more attractive with many colorful graphics.

The FNIC site serves as the central location for several special program websites, including two- the Healthy Meals Resource System, and the Food Stamp Nutrition Connection --which also launched redesigned websites paralleling the FNIC upgrade.

The Healthy Meals Resource System for Child Nutrition Professionals has a new search environment and enhancements which add to its rich collection of resources and database of training materials. Users of the redesigned site can now browse information conveniently arranged in topics including Resource Library, Recipes and Menu Planning, Food Safety, Special Diets and Nutrient Standard Menu Planning. The Training Materials Database provides information on over 1100 curriculums and training materials. The site map includes a detailed list of all materials available on the site.

Nutrition educators and other users of the Food Stamp Nutrition Connection site will find information arranged in subjects such as Resource Library, Professional Development Tools, Recipes and Databases, National Food Stamp Nutrition Education (FSNE), State Gates, and Photo Gallery. The Resource Library connects users to educational resources, recipes, a referral index and an online Sharing Center where FSNE professionals can share ideas and resources. The Professional Development Tools section of the site contains resources and information to aid in the training and development of FSNE professionals including: Hot-Topics A-Z, Web-based Learning and background information on Evaluation and Social Marketing.

Heart Truth

The Heart Truth is a national awareness and prevention campaign about heart disease in women sponsored by the National Heart, Lung, and Blood Institute (NHLBI), part of the National Institutes of Health of the U.S. Department of Health and Human Services.

The Heart Truth Professional Education Website provides information for clinicians and educators about the prevention of heart disease in women including:

• Links to consumer information and patient education materials
• Links to evidence-based references for clinical decision making
• Educational materials suitable for medical and nursing students, physician assistant students, primary practice physicians, and other health care providers
• Links to web-based CME learning modules about heart disease and women

The Heart Truth campaign includes the following three components: professional education, patient education, and public awareness.

Professional Education

The U.S. DHHS Office on Women's Health has collaborated with the NHLBI to address the continuing education and training needs of health professionals about heart disease in women. A team of national experts from the National Centers of Excellence in Women's Health and the National Community Centers of Excellence in Women's Health developed an array of educational materials for use by educators, practicing health professionals and students. These materials include self study modules offering free CME/CEU credits and other resources which are available on this web site.

Patient Education

The Heart Truth campaign offers individuals and organizations many easy to use materials, resources, and tools to help women learn about their risk of heart disease, and to take action to lower that risk.

Public Awareness: The Red Dress Symbol

The Heart Truth first introduced the Red Dress as the national symbol for women and heart disease awareness at Fashion Week in 2003. Since its introduction, women around the country have rallied around the Red Dress and are celebrating the cause and taking ownership of the symbol.

National Vaccine Program Office

About NVPO

The National Vaccine Program Office (NVPO) has responsibility for coordinating and ensuring collaboration among the many federal agencies involved in vaccine and immunization activities. The NVPO provides leadership and coordination among Federal agencies, as they work together to carry out the goals of the National Vaccine Plan. The National Vaccine Plan provides a framework, including goals, objectives, and strategies, for pursuing the prevention of infectious diseases through immunizations.

NVPO functions

• Coordinate and integrate activities of all Federal agencies involved in immunization efforts
• Ensure that these agencies collaborate, so that immunization activities are carried out in an efficient, consistent, and timely manner
• Develop and implement strategies for achieving the highest possible level of prevention of human diseases through immunization and the highest possible level of prevention of adverse reactions to vaccines
• Ensure that minimal gaps occur in Federal planning of vaccine and immunization activities.

NVPO Partners

• Agencies within the Department of Health and Human Services (HHS); CDC, NIH, FDA, HRSA
• Other Federal agencies (e.g., Department of Defense (DoD), U.S. Agency for International Development (USAID))
• NVPO's Inter-Agency Vaccine Group (IAVG)
  • Inter-Agency Vaccine Communications Group (IAVCG)
• The National Vaccine Advisory Committee
• U.S. commercial vaccine industry
• Global organizations, including the World Health Organization (http://www.who.org/)
• Non-governmental organizations, the Gates Foundation, GAVI (http://www.gatesfoundation.org/default.htm)
• Consumer groups
• Academic institutions

Artificial Heart

In 2004, the United States Food and Drug Administration (FDA) approved the first implantable temporary artificial heart, which keeps heart failure patients alive until they can receive a transplant.

A direct descendant of the Jarvik-7, implanted into dentist Barney Clark in 1982, the CardioWest Total Artificial Heart takes over a patient’s failing ventricles, the heart’s lower two pumping chambers and all cardiac valves. Manufactured by Syncardia Systems Inc., of Tucson, Ariz., the device is a “bridge” for people waiting for a heart transplant who do not respond to other treatments and who are at risk of imminent death from non-reversible bi-ventricular failure (left and right side heart failure).

The FDA approval was based in large part on the results of a study of the artificial heart in 81 patients at high risk for death due to irreversible biventricular cardiac failure. The rate of survival to transplantation was 79 percent, compared with 46 percent in a group of control patients who did not receive the artificial heart. The one-year survival rate among patients who received the artificial heart was 70 percent, compared with 31 percent among the controls. The one and five year survival rates among transplant recipients were 86 percent and 64 percent.

In 2006, the FDA approved first totally implanted permanent artificial heart for patients with advanced heart failure involving both pumping chambers of the heart. According to the FDA, the "AbioCor Implantable Replacement Heart, made by Abiomed, Inc. (Danvers, Mass.), is intended for people who are not eligible for a heart transplant and who are unlikely to live more than a month without intervention."

Coronary artery disease

Coronary artery disease (CAD) is the most common type and is the leading cause of heart attacks. When you have CAD, your arteries become hard and narrow. Blood has a hard time getting to the heart, so the heart does not get all the blood it needs. CAD can lead to:

• Angina (an-JEYE-nuh). Angina is chest pain or discomfort that happens when the heart does not get enough blood. It may feel like a pressing or squeezing pain, often in the chest, but sometimes the pain is in the shoulders, arms, neck, jaw, or back. It can also feel like indigestion (upset stomach). Angina is not a heart attack, but having angina means you are more likely to have a heart attack.

• Heart attack. A heart attack occurs when an artery is severely or completely blocked, and the heart does not get the blood it needs for more than 20 minutes.

The ways zoonotic diseases are spread

Diseases can be spread through direct contact with animals, their bites and scratches, and their carcasses, or through indirect contact with their faeces, urine, saliva, blood, aerosols, birth products, or enclosures contaminated with these materials. Animals may carry a range of microorganisms harmful to humans without showing any signs of disease (sickness).

There are several ways that zoonotic diseases can be spread:

• Faecal-oral route - Animal faeces may pass directly from soiled hands to mouth or indirectly by way of objects, surfaces, water or food contaminated with faeces. In petting zoos this spread may occur after touching animals or their enclosures, neglecting to properly wash hands with soap and running water and so faeces are passed directly from soiled hands to mouth or indirectly by way of objects, food or water soiled with faeces. An example of a disease spread this way is Salmonella infection.

• Inhalation - Humans may breathe in droplets containing harmful organisms (aerosols) originating from an infected animal. Dust or dried matter may also contain harmful organisms and be inhaled.

Visitors should not be exposed to aerosols from birthing animals or animals that have just been born. An example of a disease spread this way is Q fever infection caused by the bacterium Coxiella burnetii.

• Ingestion – Consuming contaminated food or water may lead to illness. For example, consumption of unpasteurised milk from an infected animal or eating animal feed. An example of a disease spread this way is salmonellosis caused by the bacterium Salmonella.

• Skin or mucous membrane contact - Infections may be spread directly through animal bites and scratches or indirectly when broken skin or mucous membranes come in contact with contaminated animals or surfaces. An example of a disease spread this way is ringworm caused by fungi.

• Urine - Some infections may be spread when urine is transferred from soiled hands or objects to the mouth, mucous membranes or cuts and scratches. An example of a disease spread this way is leptospirosis caused by the bacterium Leptospira.

Cochlear Implants

Welcome to the Food and Drug Administration (FDA) website on cochlear implants. Cochlear implants are electronic hearing devices. Doctors implant cochlear implants into people with severe to profound hearing loss to produce useful hearing sensations.

The purpose of this website is to describe cochlear implants, link to FDA-approved implants, tell the benefits and risks of cochlear implants, and provide news about cochlear implant recalls and safety issues. You can find information here too on what educators of implant users need to know, what happens before, during and after surgery, and where to report problems.

The FDA regulates manufacturers of cochlear implants. For manufacturers to sell cochlear implants in the United States, they must first show the FDA that their implants are safe and effective. As a matter of policy, FDA does not rate or recommend brands of cochlear implants or medical facilities that implant them.

Mass Medical Care with Scarce Resources

About This Guide

Purpose of the Guide

The purpose of this guide is to provide community planners—as well as planners at the facility/community, State, and Federal levels—with valuable information and insights that will help them in their efforts to plan for and respond to a mass casualty event (MCE). This guide provides information on:

• The circumstances that communities likely would face as a result of an MCE.
• Key constructs, principles, and structures to be incorporated into the planning for an MCE.
• Approaches and strategies that could be used to provide the most appropriate standards of care possible under the circumstances.
• Examples of tools and resources available to help States and communities in their planning process.
• Illustrative examples of how certain health systems, communities, or States have approached certain issues as part of their MCE-related planning efforts.

This information will be useful in helping planners address the issues associated with preparing for and responding to an MCE in the context of broader emergency planning processes, such as those laid out in Standing Together: An Emergency Planning Guide for America's Communities, published by the Joint Commission on the Accreditation of Healthcare Organizations, 2005.

This document is intended not to reflect Department of Health and Human Services policy but to provide State and local planners with options to consider when planning their response to an MCE.

Development of the Guide

This guide builds and expands on an earlier document published by the Agency for Healthcare Research and Quality (AHRQ) that explored the issues and outlined the principles associated with the provision of medical care in the face of overwhelming numbers of casualties. It is the product of collaboration between the Office of the Assistant Secretary for Preparedness and Response (formerly the Office of Public Health Emergency Preparedness) and AHRQ, who coedited the guide.

Leading experts were identified and a series of papers was commissioned to address issues pertaining to six critical fields related to mass casualty care. Working individually or as parts of writing teams, the experts prepared drafts of their papers, which were presented for discussion among a broader group of experts at a meeting held in Washington, DC, on June 1-2, 2006. The writers incorporated much of the discussion and input from that meeting into their respective chapters.

Keep children and mercury apart

The Mecury is harm to children

• Eat a balanced diet but avoid fish with high levels of mercury.
• Replace mercury thermometers with digital thermometers.
• Don't let kids handle or play with mercury.
• Never heat or burn mercury.
• Contact your state or local health or environment department if mercury is spilled - never vacuum a spill.

An immunomodulatory polysaccharide from Fruit

The fruit juice of Morinda citrifolia (noni) contains a polysaccharide-rich substance (noni-ppt) with antitumour activity in the Lewis lung (LLC) peritoneal carcinomatosis model. Therapeutic administration of noni-ppt significantly enhanced the duration of survival of inbred syngeneic LLC tumour bearing mice. It did not exert significant cytotoxic effects in an adapted culture of LLC cells, LLC1, but could activate peritoneal exudate cells (PEC) to impart profound toxicity when co-cultured with the tumour cells. This suggested the possibility that noni-ppt may suppress tumour growth through activation of the host immune system. Concomitant treatment with the immunosuppressive agent, 2-chloroadenosine (C1-Ade) or cyclosporin (cys-A) diminished its activity, thereby substantiating an immunomodulatory mechanism. Noni-ppt was also capable of stimulating the release of several mediators from murine effector cells, including tumour necrosis factor-alpha (TNF-alpha), interleukin-1beta (IL-1beta), IL-10, IL-12 p70, interferon-gamma (IFN-gamma) and nitric oxide (NO), but had no effect on IL-2 and suppressed IL-4 release. Improved survival time and curative effects occurred when noni-ppt was combined with sub-optimal doses of the standard chemotherapeutic agents, adriamycin (Adria), cisplatin (CDDP), 5-fluorouracil (5-FU), and vincristine (VCR), suggesting important clinical applications of noni-ppt as a supplemental agent in cancer treatment.

Veteran Smokers

Despite the detrimental effects of smoking, approximately 33% of veterans continue to smoke compared to approximately 21% of the general population. While efficacious cessation interventions are available, implementation of cessation interventions remains a challenge and new intervention strategies are needed to reach veterans. VA cessation providers recently met in Atlanta and one recommendation was to develop a cessation website for veterans. The evidence-based Tobacco Tactics website will be designed, pre-tested, and pilot tested as an intervention to assist veteran smokers to quit smoking. The efficacy of the website will then be tested in a subsequent randomized control trial (RCT). If the website proves efficacious, it would decrease morbidity and mortality among veterans, decrease face-to-face cessation intervention time for providers, and reach veterans in areas all over the country, perhaps through the VA "My Healthy Vet" website. This is a Phase 1 behavioral clinical trial designed to develop and pilot test a web-based Tobacco Tactics intervention tailored to veteran smokers. First, we will outline the specific content areas to be addressed. Second, we will develop the Tobacco Tactics intervention with our web designer in accordance with VA Web Operations. Third, a member of the research team will go through the website with the 5 veteran smokers obtaining feedback and noting any problems that occur. Fourth, with human studies approval, we will pilot test the impact of the intervention with 9 veteran smokers recruited to quit smoking using the Tobacco Tactics website. A research nurse will:

1. be available by phone to answer any questions;
2. collect qualitative data on veterans use of the Tobacco Tactics website; and,
3. note the 30 day quit rate.

Formative evaluation during pre-testing will include qualitative feedback on the:

1. ability to accomplish tasks;
2. ability to accomplish goals with skill and speed;
3. ability to operate the system; and
4. satisfaction.

For the 9 veteran smokers that actually try to use the Tobacco Tactics website to quit smoking, we will be able to determine:

1. the number of times they signed onto the website;
2. the time spent on the website; and
3. the number of times each module was accessed.

Be Involved in Your Health Care

The Following Tips is useful to us:

1. The single most important way you can help to prevent errors is to be an active member of your health care team.

That means taking part in every decision about your health care. Research shows that patients who are more involved with their care tend to get better results. Some specific tips, based on the latest scientific evidence about what works best, follow.

Medicines

2. Make sure that all of your doctors know about everything you are taking. This includes prescription and over-the-counter medicines, and dietary supplements such as vitamins and herbs.

At least once a year, bring all of your medicines and supplements with you to your doctor. "Brown bagging" your medicines can help you and your doctor talk about them and find out if there are any problems. It can also help your doctor keep your records up to date, which can help you get better quality care.

3. Make sure your doctor knows about any allergies and adverse reactions you have had to medicines.

This can help you avoid getting a medicine that can harm you.

4. When your doctor writes you a prescription, make sure you can read it.

If you can't read your doctor's handwriting, your pharmacist might not be able to either.

5. Ask for information about your medicines in terms you can understand—both when your medicines are prescribed and when you receive them.

• What is the medicine for?
• How am I supposed to take it, and for how long?
• What side effects are likely? What do I do if they occur?
• Is this medicine safe to take with other medicines or dietary supplements I am taking?
• What food, drink, or activities should I avoid while taking this medicine?

6. When you pick up your medicine from the pharmacy, ask: Is this the medicine that my doctor prescribed?

A study by the Massachusetts College of Pharmacy and Allied Health Sciences found that 88 percent of medicine errors involved the wrong drug or the wrong dose.

7. If you have any questions about the directions on your medicine labels, ask.

Medicine labels can be hard to understand. For example, ask if "four doses daily" means taking a dose every 6 hours around the clock or just during regular waking hours.

8. Ask your pharmacist for the best device to measure your liquid medicine. Also, ask questions if you're not sure how to use it.

Research shows that many people do not understand the right way to measure liquid medicines. For example, many use household teaspoons, which often do not hold a true teaspoon of liquid. Special devices, like marked syringes, help people to measure the right dose. Being told how to use the devices helps even more.

9. Ask for written information about the side effects your medicine could cause.

If you know what might happen, you will be better prepared if it does—or, if something unexpected happens instead. That way, you can report the problem right away and get help before it gets worse. A study found that written information about medicines can help patients recognize problem side effects and then give that information to their doctor or pharmacist.

Hospital Stays

10. If you have a choice, choose a hospital at which many patients have the procedure or surgery you need.

Research shows that patients tend to have better results when they are treated in hospitals that have a great deal of experience with their condition.

11. If you are in a hospital, consider asking all health care workers who have direct contact with you whether they have washed their hands.

Handwashing is an important way to prevent the spread of infections in hospitals. Yet, it is not done regularly or thoroughly enough. A recent study found that when patients checked whether health care workers washed their hands, the workers washed their hands more often and used more soap.

12. When you are being discharged from the hospital, ask your doctor to explain the treatment plan you will use at home.

This includes learning about your medicines and finding out when you can get back to your regular activities. Research shows that at discharge time, doctors think their patients understand more than they really do about what they should or should not do when they return home.

Surgery

13. If you are having surgery, make sure that you, your doctor, and your surgeon all agree and are clear on exactly what will be done.

Doing surgery at the wrong site (for example, operating on the left knee instead of the right) is rare. But even once is too often. The good news is that wrong-site surgery is 100 percent preventable. The American Academy of Orthopaedic Surgeons urges its members to sign their initials directly on the site to be operated on before the surgery.

Other Steps You Can Take

14. Speak up if you have questions or concerns.

You have a right to question anyone who is involved with your care.

15. Make sure that someone, such as your personal doctor, is in charge of your care.

This is especially important if you have many health problems or are in a hospital.

16. Make sure that all health professionals involved in your care have important health information about you.

Do not assume that everyone knows everything they need to.

17. Ask a family member or friend to be there with you and to be your advocate (someone who can help get things done and speak up for you if you can't).

Even if you think you don't need help now, you might need it later.

18. Know that "more" is not always better.

It is a good idea to find out why a test or treatment is needed and how it can help you. You could be better off without it.

19. If you have a test, don't assume that no news is good news.

Ask about the results.

20. Learn about your condition and treatments by asking your doctor and nurse and by using other reliable sources.

For example, treatment recommendations based on the latest scientific evidence are available from the National Guidelines Clearinghouse at http://www.guideline.gov. Ask your doctor if your treatment is based on the latest evidence.

Aging

The United States is on the brink of a longevity revolution. By 2030, the proportion of the U.S. population aged 65 and older will double to about 71 million older adults, or one in every five Americans. The far-reaching implications of the increasing number of older Americans and their growing diversity will include unprecedented demands on public health, aging services, and the nation’s health care system.

Chronic diseases exact a particularly heavy health and economic burden on older adults due to associated long-term illness, diminished quality of life, and greatly increased health care costs. Although the risk of disease and disability clearly increases with advancing age, poor health is not an inevitable consequence of aging.

Much of the illness, disability, and death associated with chronic disease is avoidable through known prevention measures. Key measures include practicing a healthy lifestyle (e.g., regular physical activity, healthy eating, and avoiding tobacco use) and the use of early detection practices (e.g., screening for breast, cervical, and colorectal cancers, diabetes and its complications, and depression).

Critical knowledge gaps exist for responding to the health needs of older adults. For chronic diseases and conditions such as Alzheimer's disease, arthritis, depression, psychiatric disorders, osteoporosis, Parkinson's disease, and urinary incontinence, much remains to be learned about their distribution in the population, associated risk factors, and effective measures to prevent or delay their onset.

Japanese Encephalitis (JE)

Mode of Transmission

• JEV is transmitted to humans through the bite of an infected mosquito, primarily Culex species. Wading birds are the main animal reservoir for the virus, but the presence of pigs greatly amplifies the transmission of JEV.
• Humans are a dead-end host in the JEV transmission cycle.

Occurrence

• JEV is the most common cause of encephalitis in Asia, occurring throughout most of Asia and parts of the western Pacific (Map 2-5). JEV has not been locally transmitted in Africa, Europe, or the Americas.
• JEV transmission principally occurs in rural agricultural areas, often associated with rice production and flooding irrigation. In some areas of Asia, these ecologic conditions may occur near or occasionally within urban centers.
• In temperate areas of Asia, transmission is seasonal, and human disease usually peaks in summer and fall. In the subtropics and tropics, seasonal transmission varies with monsoon rains and irrigation practices and may be extended or even occur year-round.
• In endemic countries, JE is primarily a disease of children. However, travel-associated JE can occur among persons of any age.

Risk for Travelers

• The risk for JE for most travelers to Asia is extremely low but varies according to season, destination, duration, and activities. Fewer than 40 cases of confirmed JE have been reported in travelers in the last 40 years.
• The overall incidence of JE reported among people from nonendemic countries traveling to Asia is <1>
• Travelers on even brief trips are probably at increased risk if they have extensive outdoor or nighttime exposure in rural areas, including persons staying in resort areas or with family.
• Short-term travelers whose visits are restricted to major urban areas are at very minimal risk for JE.
• In endemic areas where there are few human cases among residents because of vaccination or natural immunity, JEV is often maintained in an enzootic cycle between animals and mosquitoes. Therefore, susceptible visitors still may be at risk for infection.

Clinical Presentation

• Most human infections with JEV are asymptomatic; <1%>
• Acute encephalitis is the most commonly recognized clinical manifestation of JEV infection. Milder forms of disease such as aseptic meningitis or undifferentiated febrile illness can also occur.
• The incubation period is 5–15 days. Illness usually begins with sudden onset of fever, headache, and vomiting. Mental status changes, focal neurologic deficits, generalized weakness, and movement disorders may develop over the next few days.
  • A parkinsonian syndrome resulting from extrapyramidal involvement is a very distinctive clinical presentation of JE.
  • Acute flaccid paralysis, with clinical and pathological features similar to poliomyelitis, has also been associated with JEV infection.
  • Seizures are very common, especially among children.
• Clinical laboratory findings include moderate leukocytosis, mild anemia, hyponatremia, and cerebrospinal fluid (CSF) pleocytosis with a lymphocytic predominance.
• Case–fatality ratio is approximately 20%–30%. Among survivors, 30%–50% may still have significant neurologic or psychiatric sequelae, even years after their acute illness.

Diagnosis

• JE should be suspected in a patient with evidence of a neurologic infection (e.g., encephalitis, meningitis, or acute flaccid paralysis) who has recently traveled or resided in an endemic country in Asia or the western Pacific.
• Laboratory diagnosis of JEV infection should be performed by using JE-specific IgM-capture enzyme-linked immunosorbent assay (ELISA) on CSF or serum. JE-specific IgM antibodies will be present in the CSF or blood of almost all patients by 7 days following onset of symptoms. A fourfold or greater rise in JEV-specific neutralizing antibodies between acute- and convalescent-phase serum specimens may be used to confirm the diagnosis.
• Vaccination history, date of onset of symptoms, and information regarding other flaviviruses known to circulate in the geographic area that may cross-react in serologic assays need to be considered when interpreting results.
• Humans have low levels of transient viremia and usually have neutralizing antibodies by the time distinctive clinical symptoms are recognized. Virus isolation and nucleic-acid amplification tests (NAATs) are insensitive for the detection of JEV or JE viral RNA in blood or CSF and should not be used for ruling out a diagnosis of JE.
• Health-care providers should contact their state or local health department or CDC’s Division of Vector Borne Infectious Diseases at 970-221-6400 for assistance with diagnostic testing.

Treatment

There is no specific antiviral treatment for JE; therapy consists of supportive care and management of complications.

Healthy Eating

Eating healthfully means getting the right balance of nutrients your body needs to perform every day. You can find out more about your nutritional needs by checking out the 2005 Dietary Guidelines for Americans. Published by the U.S. Government, this publication explains how much of each type of food you should eat, along with great information on nutrition and physical activity. The guidelines suggest the number of calories you should eat daily based on your gender, age, and activity level.

According to the guidelines, a healthy eating plan includes:

• fruits and vegetables
• fat-free or low-fat milk and milk products
• lean meats, poultry, fish, beans, eggs, and nuts
• whole grains

In addition, a healthy diet is low in saturated and trans fats, cholesterol, salt, and added sugars.

When it comes to food portions, the Dietary Guidelines use the word "servings" to describe a standard amount of food. Serving sizes are measured as "ounce-" or "cup-equivalents." Listed below are some tips based on the guidelines that can help you develop healthy eating habits for a lifetime.

Tips for making wise choices

* Include milk as a beverage at meals. Choose fat-free or low-fat milk.
* If you usually drink whole milk, switch gradually to fat-free milk, to lower saturated fat and calories. Try reduced fat (2%), then low-fat (1%), and finally fat-free (skim).
* If you drink cappuccinos or lattes—ask for them with fat-free (skim) milk.
* Add fat-free or low-fat milk instead of water to oatmeal and hot cereals
* Use milk products as dipUse fat-free or low-fat milk when making condensed cream soups (such as cream of tomato).
* Have fat-free or low-fat yogurt as a snack.
* Make a dip for fruits or vegetables from yogurt.
* Make fruit-yogurt smoothies in the blender.
* For dessert, make chocolate or butterscotch pudding with fat-free or low-fat milk.
* Top cut-up fruit with flavored yogurt for a quick dessert.
* Top casseroles, soups, stews, or vegetables with shredded low-fat cheese.
* Top a baked potato with fat-free or low-fat yogurt.