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By T. Denpok. Holy Family College. 2019.

The most common manifestations of secondary syphilis are mucocutaneous lesions that are macular 10 mg vardenafil, maculopapular 20 mg vardenafil, papulosquamous vardenafil 20mg, or pustular vardenafil 20 mg, can involve the palms and soles 20mg vardenafil, and are often accompanied by generalized lymphadenopathy vardenafil 10mg, fever 10mg vardenafil, malaise vardenafil 10 mg, anorexia , arthralgias , and headache. Lues maligna is a rare manifestation of secondary syphilis, characterized by papulopustular skin lesions that can evolve into ulcerative lesions with sharp borders and a dark central crust. Latent syphilis is defined as serologic reactivity without clinical signs and symptoms of infection. Tertiary syphilis includes cardiovascular syphilis and gummatous syphilis, a slowly progressive disease that can affect any organ system. Neurosyphilis can occur at any stage of syphilis with different clinical presentations, including cranial nerve dysfunction, auditory or ophthalmic abnormalities, meningitis, stroke, acute or chronic change in mental status, and loss of vibration sense. A presumptive serologic diagnosis of syphilis is possible based upon non-treponemal tests (i. Serologic diagnosis of syphilis traditionally has involved screening for non-treponemal antibodies with confirmation of reactive tests by treponemal-based assays. This latter strategy may identify those with previously treated syphilis infection, persons with untreated or incompletely treated syphilis, or those with a false positive result in persons with a low likelihood of infection. If a second treponemal test is positive, persons with a history of previous treatment appropriate for the stage of syphilis will require no further treatment unless sexual risk history suggests likelihood of re-exposure. In this instance, a repeat non-treponemal test 2 to 4 weeks after the most recent possible exposure is recommended to evaluate for early infection. Unless history or results of a physical examination suggest a recent infection (e. If the second treponemal test is negative and the risk of syphilis is low, no treatment is indicated. By definition, persons with latent syphilis have serological evidence of syphilis (nontreponemal and treponemal testing) in the absence of clinical manifestations. Early latent syphilis is defined by evidence of infection during the preceding year by 1. A documented seroconversion or four-fold or greater increase in nontreponemal titer; or 2 Symptoms of primary or secondary syphilis; or 3. Laboratory testing is helpful in supporting the diagnosis of neurosyphilis; however, no single test can be used to diagnose neurosyphilis. Treatment can prevent disease progression in the individual and transmission to a partner. Persons who have had sexual contact with a person who receives a diagnosis of primary, secondary, or early latent syphilis more than 90 days before the diagnosis should be treated presumptively for early syphilis if serologic test results are not immediately available and the opportunity for follow-up is uncertain. If serologic tests are positive, treatment should be based on clinical and serologic evaluation and stage of syphilis. Long- term sex partners of persons who have late latent syphilis should be evaluated clinically and serologically for syphilis and treated on the basis of the evaluation’s findings. Sexual partners of infected persons considered at risk of infection should be notified of their exposure and the importance of evaluation. The use of any alternative penicillin treatment regimen should be undertaken only with close clinical and serologic monitoring. Limited clinical studies and biologic and pharmacologic evidence suggest that ceftriaxone may be effective; however, the optimal dose and duration of therapy have not been determined. Although systemic steroids are used frequently as adjunctive therapy for otologic syphilis, such therapy has not been proven beneficial. Because neurosyphilis treatment regimens are of shorter duration than those used in late-latent syphilis, 2. Syphilis treatment recommendations are also available in the 2015 Centers for Disease Control and Prevention Sexually Transmitted Disease Treatment Guidelines. If clinical signs or symptoms recur or there is a sustained four-fold increase in non-treponemal titers of greater than 2 weeks, treatment failure or re-infection should be considered and managed per recommendations (see Managing Treatment Failure). The potential for re-infection should be based on the sexual history and risk assessment. Response to therapy for late latent syphilis should be monitored using non-treponemal serologic tests at 6, 12, 18, and 24 months to ensure at least a four-fold decline in titer, if initially high (≥1:32), within 12 to 24 months of therapy. However, data to define the precise time intervals for adequate serologic responses are limited. Most persons with low titers and late latent syphilis remain serofast after treatment often without a four-fold decline in the initial titer. If clinical symptoms develop or a four-fold increase in non- treponemal titers is sustained, then treatment failure or re-infection should be considered and managed per recommendations (see Managing Treatment Failure). The potential for reinfection should be based on the sexual history and risk assessment. Antipyretics can be used to manage symptoms but have not been proven to prevent this reaction. The Jarisch-Herxheimer reaction occurs most frequently in persons with early syphilis, high non-treponemal antibody titers, and prior penicillin treatment. Managing Possible Treatment Failure or Re-infection Re-treatment should be considered for persons with early-stage syphilis who have persistent or recurring clinical signs or symptoms of disease, or a sustained four-fold increase in serum non-treponemal titers after an initial four-fold decrease following treatment. The assessment for potential reinfection should be informed by a sexual history and syphilis risk assessment including information about a recent sexual partner with signs or symptoms or recent treatment for syphilis. However, assessing serologic response to treatment can be difficult, as definitive criteria for cure or failure have not been well established. Persons whose non-treponemal titers do not decrease four-fold with 12 to 24 months of therapy can also be managed as a possible treatment failure. Targeted mass treatment of high-risk populations with azithromycin has not been demonstrated to be effective. In communities and populations in which the prevalence of syphilis is high and in women at high risk of infection, serologic testing should also be performed twice in the third trimester (ideally at 28–32 weeks gestation) and at delivery. Pregnant women with reactive treponemal screening tests should have additional quantitative testing with non-treponemal tests because titers are essential for monitoring treatment response. If the non-treponemal test is negative and the prozone reaction is ruled out, then the results are discordant; a second treponemal test should be performed, preferably on the same specimen (see Diagnosis section above). Rates of transmission to the fetus and adverse pregnancy outcomes for untreated syphilis are highest with primary, secondary, and early-latent syphilis and decrease with increasing duration of infection. Pregnancy does not appear to alter the clinical course, manifestations, or diagnostic test results for syphilis infection in adults. In general, the risk of antepartum fetal infection or congenital syphilis at delivery is related to the quantitative maternal nontreponemal titer, especially if it ≥1:8. Serofast low antibody titers after documented treatment for the stage of infection might not require additional treatment; however, rising or persistently high antibody titers may indicate reinfection or treatment failure, and treatment should be considered. Treatment of syphilis during the second half of pregnancy may precipitate preterm labor or fetal distress if it is associated with a Jarisch-Herxheimer reaction. During the second half of pregnancy, syphilis management can be facilitated with sonographic fetal evaluation for congenital syphilis, but this evaluation should not delay therapy. Sonographic signs of fetal or placental syphilis indicate a greater risk of fetal treatment failure. After 20 weeks of gestation, fetal and contraction monitoring for 24 hours after initiation of treatment for early syphilis should be considered when sonographic findings indicate fetal infection. At a minimum, repeat serologic titers should be performed in the third trimester and at delivery for women treated for syphilis during pregnancy, appropriate for the stage of infection. Non-treponemal titers can be assessed monthly in women at high risk of re-infection. Clinical and non-treponemal antibody titer responses should be appropriate for the stage of disease, although most women will deliver before their serologic response can be definitively assessed. Maternal treatment is likely to be inadequate if delivery occurs within 30 days of therapy, if a woman has clinical signs of infection at delivery, or if the maternal antibody titer is four-fold higher than the pre-treatment titer. Recommendations for Treating Treponema pallidum Infections (Syphilis) to Prevent Disease (page 1 of 2) Empiric treatment of incubating syphilis is recommended to prevent the development of disease in those who are sexually exposed. It occurs more frequently in persons with early syphilis, high non-treponemal antibody titers, and prior penicillin treatment. Patients should be warned about this reaction and informed it is not an allergic reaction to penicillin. Azithromycin should be used with caution and only when treatment with penicillin, doxycycline or ceftriaxone is not feasible. For pregnant women with early syphilis, a second dose of benzathine penicillin G 2. Late-Latent (>1 year) or Latent of Unknown Duration Preferred Therapy: • Benzathine penicillin G 2. Repeat syphilis among men who have sex with men in California, 2002-2006: implications for syphilis elimination efforts. Unusual manifestations of secondary syphilis and abnormal humoral immune response to Treponema pallidum antigens in a homosexual man with asymptomatic human immunodeficiency virus infection. Its occurrence after clinical and serologic cure of secondary syphilis with penicillin G. Cerebrospinal fluid abnormalities in patients with syphilis: association with clinical and laboratory features. A Cluster of Ocular Syphilis Cases—Seattle, Washington, and San Francisco, California, 2014–2015. Laboratory methods of diagnosis of syphilis for the beginning of the third millennium. Discordant results from reverse sequence syphilis screening--five laboratories, United States, 2006-2010. Syphilis testing algorithms using treponemal tests for initial screening--four laboratories, New York City, 2005-2006. Screening for syphilis with the treponemal immunoassay: analysis of discordant serology results and implications for clinical management. Evaluation of an IgM/IgG sensitive enzyme immunoassay and the utility of index values for the screening of syphilis infection in a high-risk population. Association of biologic false-positive reactions for syphilis with human immunodeficiency virus infection. A randomized trial of enhanced therapy for early syphilis in patients with and without human immunodeficiency virus infection. Biological false-positive syphilis test results for women infected with human immunodeficiency virus. Seronegative secondary syphilis in 2 patients coinfected with human immunodeficiency virus. Invasion of the central nervous system by Treponema pallidum: implications for diagnosis and treatment. The performance of cerebrospinal fluid treponemal-specific antibody tests in neurosyphilis: a systematic review. The rapid plasma reagin test cannot replace the venereal disease research laboratory test for neurosyphilis diagnosis. Risk reduction counselling for prevention of sexually transmitted infections: how it works and how to make it work. Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: a randomized controlled trial. Using patient risk indicators to plan prevention strategies in the clinical care setting. Syphilis and neurosyphilis in a human immunodeficiency virus type-1 seropositive population: evidence for frequent serologic relapse after therapy. Doxycycline compared with benzathine penicillin for the treatment of early syphilis. Primary syphilis: serological treatment response to doxycycline/tetracycline versus benzathine penicillin. Effectiveness of syphilis treatment using azithromycin and/or benzathine penicillin in Rakai, Uganda. Azithromycin treatment failures in syphilis infections--San Francisco, California, 2002-2003. Evaluation of macrolide resistance and enhanced molecular typing of Treponema pallidum in patients with syphilis in Taiwan: a prospective multicenter study. Response of latent syphilis or neurosyphilis to ceftriaxone therapy in persons infected with human immunodeficiency virus. Normalization of serum rapid plasma reagin titer predicts normalization of cerebrospinal fluid and clinical abnormalities after treatment of neurosyphilis. Jarisch-Herxheimer reaction after penicillin therapy among patients with syphilis in the era of the hiv infection epidemic: incidence and risk factors. Discordant Syphilis Immunoassays in Pregnancy: Perinatal Outcomes and Implications for Clinical Management. Maternal syphilis and vertical perinatal transmission of human immunodeficiency virus type-1 infection. Apparent failure of one injection of benzathine penicillin G for syphilis during pregnancy in human immunodeficiency virus-seronegative African women. A study evaluating ceftriaxone as a treatment agent for primary and secondary syphilis in pregnancy. Fluconazole (or azole) resistance is predominantly the consequence of previous exposure to fluconazole (or other azoles), particularly repeated and long-term exposure. Less commonly, erythematous patches without white plaques can be seen on the anterior or posterior upper palate or diffusely on the tongue. Esophageal candidiasis generally presents with retrosternal burning pain or discomfort along with odynophagia; occasionally esophageal candidiasis can be asymptomatic. Endoscopic examination reveals whitish plaques similar to those observed with oropharyngeal disease. On occasion, the plaques may progress to superficial ulcerations of the esophageal mucosa with central or peripheral whitish exudates.

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Encouragingly vardenafil 20mg, in both benefts of difering cannabis policy approaches can be regions vardenafil 10mg, the most recent data show a decline in use of assessed 10mg vardenafil. Furthermore vardenafil 10 mg, the extent to which developments tobacco and 10 mg vardenafil, albeit to a lesser extent 20 mg vardenafil, alcohol 20mg vardenafil; though occurring elsewhere can be directly transferable to the trends in cannabis use appear more stable vardenafil 20 mg. Levels of alcohol consumption also medical conditions , of growing interest in some countries . It is possible that some of these relative infuence of the social, contextual and regulatory developments will impact on consumption patterns in factors on the choices made by young people. Europe, underlining the importance of behavioural Understanding, for example, what has led to the reductions monitoring in this area and the need to evaluate the in cigarette smoking observed in both the United States potential health implications of any changes in future and Europe may ofer insights for addressing the use of consumption patterns. It is also important to remember that diferences exist in how substances are Te European cannabis market has already changed consumed. In Europe, for example, in contrast to the considerably in recent years, in part driven by a move to United States, cannabis is often smoked in combination more domestic production. Te historically high overall with tobacco, and this is likely to have implications for potency levels of both resin and herbal cannabis available public health policies. Te drug also continues to be associated with health problems, and is responsible for the greatest share of reported new entrants to drug treatment in Europe. For all these reasons, understanding trends in cannabis use and related harms is important to the debate on what constitutes the most appropriate policy responses to this drug. Tis sector of the illicit drug market has l for public health policies grown in complexity, with the ready availability of new stimulants including cathinones and phenethylamines. Tis does not mean, however, that concerns have seizures, and price and purity data, suggest that the disappeared in this area. Tis drug has historically been the most two decades, this still represents a signifcant public health commonly used illicit stimulant in a number of countries, problem. Moreover, there have been recent outbreaks in mainly located in the south and west of Europe. New data some vulnerable populations and among users who are reported here supports this, with increasing seizures noted injecting stimulants and new psychoactive substances. In contrast, in northern Tere is also evidence that blood-borne infections are and central Europe, amphetamine and, to a lesser extent, often diagnosed relatively late among people who inject methamphetamine play a more signifcant role in the drug drugs, compared with other groups, thereby reducing the market than cocaine. Good clinical practice In the past few years, the possibilities for the treatment of together with an understanding of how prescription viral hepatitis have improved greatly, with the arrival of a opioids are diverted from their legitimate use, and how to new generation of medicines, which are highly efective. Highly potent synthetic opioids: a growing health l e changing nature of the opioid problem l threat Comparison with developments in North America is also In both Europe and North America, the recent emergence relevant to an analysis of Europe’s opioid drug problem. A of highly potent new synthetic opioids, mostly fentanyl review of the data presented in this report suggests that, derivatives, is causing considerable concern. Tese substances have been sold Te latest data show that heroin use still accounts for the on online markets, and also on the illicit market. Tey have majority, around 80 %, of new opioid-related treatment sometimes been sold as, or mixed with, heroin, other illicit demands in Europe. Highly potent treatment demand related to heroin, observed since 2007, synthetic opioids present serious health risks, not only to is no longer evident. Of particular concern is the increasing those who use them, but also to those involved in their European estimate for drug overdose deaths, which has manufacture, as well as postal workers and law now risen for the third consecutive year; heroin is enforcement ofcers. Tis poses a considerable North America has also experienced considerable challenge for drug control agencies. At the same time, they morbidity and mortality associated with the misuse of present a potentially attractive and proftable commodity prescription opioids, rising levels of heroin use and, most for organised crime. One diference between the two regions is that in Europe, very few clients presenting for specialised drug treatment do so for addiction to opioid pain medicines. Tis probably refects the diferent regulatory frameworks and approaches to marketing and prescribing that exist between Europe and the North America. However, the possibility of under- reporting cannot be dismissed, as Europeans experiencing problems with prescription medicines may access diferent services than those used by illicit drug users. Medicines used for opioid substitution treatment, however, now play a more signifcant role in treatment demands and health harms in a number of European countries. Overall, non-heroin opioids account for around a ffth of all opioid- related demands to specialised drug services. Reducing the misuse of medicines, including those used for opioid substitution treatment, is a growing challenge for many European healthcare providers. In this context, the legal status of new substances, substances are being considered for control at European especially when they are sold alongside illicit drugs, may level, and a number of other drugs in this category are be less important and, correspondingly, be a less powerful currently under scrutiny. Prevention, substances phenomenon continues to represent a harm reduction and the reporting of adverse considerable public health challenge. Tis may be a this, however, among more chronic and marginalised user positive sign, especially if this decline is sustained. Moreover, even if the pace at Problematic use of new psychoactive substances is which new substances are being introduced may be becoming more apparent in certain settings and among slowing, the overall number of substances available on the some vulnerable populations. Tere are also signs that some example, among current and former opioid users, has been classes of new psychoactive substances, notably synthetic associated with increased levels of both physical and cathinones and synthetic cannabinoids, are now mental health problems. Tere are a number of reasons that may explain why the Despite some pharmacological similarities, these drugs pace of new substances appearing on the market may be should not be confused with cannabis products. Some European countries have introduced cannabinoids are often highly potent substances, which blanket bans, generic and analogue based legislation and can have serious, potentially lethal, consequences. Tere is other measures to target the producers and retailers of evidence to suggest that in parts of Europe, synthetic new psychoactive substances. Tis has created a more cannabinoids are now being consumed as cheap and restrictive legal environment, in which there may be less powerful intoxicants by marginalised groups such as the incentive for producers to engage in a ‘cat and mouse homeless. Difculties in detection mean that synthetic game’ with regulators, in which innovation is used to keep cannabinoids have become a particular problem in some ahead of legal controls. European prisons, resulting in serious implications for prisoner health and security. In addition, much of the supply of new psychoactive substances to Europe originates in China, and new controls there may also have had some impact on availability in the European Union. South America, West Asia and production facilities, drug laws, drug law ofences, retail drug prices, purity and potency. In some cases, North Africa are important source areas the absence of seizure data from key countries for illicit drugs entering Europe, while makes the analysis of trends difcult. A range of China is a source country for new factors can infuence trends, including user preferences, changes in production and trafcking, psychoactive substances. In addition, law enforcement activity levels and priorities and the some drugs and precursors are efectiveness of interdiction measures. Full data sets transited through Europe en route to and methodological notes can be found in the online Statistical Bulletin. As this some of the synthetic drugs are information is drawn from case reports rather than manufactured for export to other parts routine monitoring systems, seizure estimates of the world. Sizeable markets for cannabis, heroin and amphetamines have existed in many European countries since the 1970s and 1980s. Tese complex systems generate drug market, largely linked to globalisation and new large sums of money at all levels of the market. Some online vendors utilise the surface web, typically retailing non-controlled precursor chemicals, new psychoactive substances or medicines, which may be falsifed or counterfeit. Other vendors work on the deep Amphetamines web, through darknet markets, supported by technologies 5 % that hide buyer and seller identities. Tese markets share characteristics with legitimate online marketplaces such Heroin as eBay and Amazon, and customers can search for and 5 % compare products and vendors. Tese include anonymisation services, Other such as Tor and I2P, that hide a computer’s internet substances protocol address; cryptocurrencies, such as bitcoin and 8 % litecoin, for making relatively untraceable payments; and encrypted communication between market participants. Cannabis plants 2 % Reputation systems also play a role in regulating vendors on the markets. A recent study, exploring sales on 16 major darknet markets between 2011 and 2015, estimated that drug sales were responsible for more than 90 % of the total economic revenue of global darknet marketplaces. Cannabis is the most commonly seized drug, accounting for over 70 % of seizures in Europe (Figure 1. Most sales on darknet markets are drug-related 20 Chapter 1 I Drug supply and the market In 2015, more than 60 % of all drug seizures in the Recent decline in quantity of herbal cannabis European Union were reported by just 3 countries, Spain, l seized France and the United Kingdom; considerable numbers of seizures were also reported by Belgium, Denmark, Herbal cannabis (marijuana) and cannabis resin (hashish) Germany, Greece, Italy and Sweden. It should also be are the two main cannabis products found on the noted that recent data on the number of seizures are not European drugs market, while cannabis oil is available for the Netherlands or for Poland and Finland. Cannabis products account for the Tese gaps in the data add uncertainty to the analysis. Herbal cannabis refects both its signifcant consumer market and its consumed in Europe is both cultivated domestically and position on drug trafcking routes between the European trafcked from external countries. Price and potency of cannabis products: national mean values — minimum, maximum and interquartile range. Quantity of cannabis resin seized (tonnes) Quantity of herbal cannabis seized (tonnes) Spain Turkey Other countries Other countries 0 50 100 150 200 250 300 350 400 0 25 50 75 100 125 150 those countries. In addition, evidence suggests that Libya Te number of seizures of herbal cannabis in Europe has has become a major hub for the trafcking of resin to exceeded that of cannabis resin since 2009, with relatively various destinations including Europe. An estimated In 2015, 732 000 seizures of cannabis products were 135 tonnes of herbal cannabis was seized in Europe in reported in the European Union including 404 000 of 2015, a decrease of 38 % compared with the 217 tonnes herbal cannabis, 288 000 of cannabis resin and 19 000 of seized in 2014. A similar decrease in the quantity of however, is more than 6 times that of herbal cannabis herbal cannabis seized in Turkey is also evident from 2013. Tis is partially a A number of factors may be behind this overall drop in consequence of cannabis resin being trafcked in volume Europe. Tese may include initiatives to tackle large-scale over large distances and across national borders, making it production in countries outside the European Union, such more vulnerable to interdiction. In the analysis of the as Albania; increased focus on domestic cultivation rather quantity of cannabis seized, a small number of countries than trafcking; changes in the way seizures are registered, are particularly important due to their location on major and changing law enforcement priorities in some cannabis trafcking routes. In the latest data, the quantity of cannabis resin point of entry for cannabis resin produced in Morocco, seized in the European Union has remained relatively reported more than 70 % of the total quantity seized in stable since 2009. Te most recent data suggest that may refect changes in law enforcement priorities, with resin and herb have similar prices, whereas on average, cannabis cultivation more intensively targeted. In 2015, 335 seizures of cannabis oil were reported, with Greece and Turkey seizing the largest quantities. Historically, diverted from legitimate pharmaceutical supplies, while imported heroin has been available in Europe in two forms, others such as the 27 kilograms of morphine powder the more common of which is brown heroin (its chemical seized in 2015, are illicitly manufactured. Far less common is white heroin (a salt form), which in the past Afghanistan remains the world’s largest illicit producer of came from South-East Asia, but now may also be opium, and most heroin found in Europe is thought to be produced in Afghanistan or neighbouring countries. Price and purity of ‘brown heroin’: national mean values — minimum, maximum and interquartile range. However, the discovery of two combined — while the number of seizures rose during the laboratories converting morphine to heroin in Spain and same period (Figure 1. Among those countries reporting one in the Czech Republic in recent years suggests that a consistently, indexed trends suggest that heroin purity small amount of heroin is manufactured in Europe. In addition to heroin, other opioid products are seized in Te two most important are the ‘Balkan route’ and the European countries, but these represent a small fraction of ‘southern route’. Te other opioids most commonly Balkan countries (Bulgaria, Romania or Greece) and on to seized are the medicinal opioids buprenorphine, tramadol central, southern and western Europe. Te southern route, where shipments from Iran and Pakistan enter Europe by air or sea, either directly or transiting through African countries, has gained importance in recent years. Other routes include the ‘northern route’ and a route through the southern Caucasus and across the Black Sea. Following a decade of relative stability, markets in a number of European countries experienced reduced heroin availability in 2010/11. Tis is evident in the number of heroin seizures reported, which declined in the European Union from 2009 to 2014, before stabilising in 2015. Between 2002 and 2013, the quantity of heroin seized within the European Union halved, from 10 to 5 tonnes. Tere are marked regional diferences regarding which stimulant is most commonly seized (Figure 1. Cocaine is the most frequently seized stimulant in many western and southern countries, closely refecting where the drug enters Europe. Amphetamines seizures are predominant in northern and central Europe, with methamphetamine the most commonly seized stimulant in the Czech Republic, Latvia, Lithuania and Slovakia. Cocaine is transported to Europe by various means, including passenger fights, air freight, postal services, private aircraft, yachts and maritime containers. Price and purity of cocaine: national mean values — minimum, maximum and interquartile range. In total, around 87 000 seizures of cocaine were reported in the European Union in 2015. Together, Belgium, Spain, Other coca products were seized in Europe in 2015, France, Italy and Portugal account for 78 % of the including 76 kilograms of coca leaves and 377 kilograms estimated 69. Seizures of coca paste suggest the has remained relatively stable since 2007, although both existence of illicit laboratories producing cocaine the number of seizures and the quantity seized increased hydrochloride in Europe. While Spain date, most of the cocaine laboratories found in Europe (22 tonnes) continues to be the country seizing the most have been ‘secondary extraction facilities’, where cocaine cocaine, Belgium (17 tonnes) and France (11 tonnes) is recovered from materials in which it had been seized very large amounts in 2015, and notable increases incorporated (such as wines, clothes, plastics). However, this control Drug precursors are essential chemicals needed to measure appears to have prompted some innovative manufacture illicit drugs. Tis practice, resumed, with the Netherlands reporting 622 kilograms in however, increases the risk of detection, as more 2015 compared to zero in 2014. Over the last decade, seizures indicate 2015, with Polish authorities seizing 7 000 kilograms in a that the availability of methamphetamine has increased, single shipment linked to production in the Netherlands. Tere are indications that amphetamine mainly from the precursors ephedrine and production mainly takes place in Belgium, the Netherlands pseudoephedrine, which are extracted from medicinal and Poland, and to a lesser extent in the Baltic States, products smuggled chiefy from Poland. In 2015, of the 291 illegal fnal stage of production, the conversion of amphetamine methamphetamine laboratories reported in the European base oil to amphetamine sulphate, is carried out in Europe. Production in that country has shifted from small-scale operations, Some amphetamine is also manufactured for export, involving users making quantities for personal use or local principally to the Middle East, the Far East and Oceania. Te Czech Republic, and more recently, the border areas of neighbouring countries, has long been the source of much of Europe’s methamphetamine. Price and purity of amphetamines: national mean values — minimum, maximum and interquartile range.

Reference to “dollars” ($) means United States dollars 10mg vardenafil, unless otherwise indicated vardenafil 10mg. Annual rates of growth or change 10 mg vardenafil, unless otherwise stated vardenafil 10 mg, refer to annual compound rates vardenafil 20mg. Details and percentages in tables do not necessarily add to totals because of rounding vardenafil 20 mg. The material contained in this study may be freely quoted with appropriate acknowledgement 20mg vardenafil. It aimed at assisting developing countries to participate as effectively as possible in international investment rulemaking at the bilateral 20 mg vardenafil, regional , plurilateral and multilateral levels . Issues of transparency, predictability and policy space have come to the forefront of the debate. It is the purpose of the sequels to consider how the issues described in the first-generation Pink Series have evolved, particularly focusing on treaty practice and the process of arbitral interpretation. Compared to the first generation, the sequels will offer a greater level of detail and move beyond a merely informative role. The sequels are finalized through a rigorous process of peer reviews, which benefits from collective learning and sharing of experiences. Attention is placed on ensuring involvement of a broad set of stakeholders, aiming to capture ideas and concerns from society at large. The sequels are edited by Anna Joubin-Bret, and produced by a team under the direction of Jörg Weber and the overall guidance of James Zhan. The members of the team include Bekele Amare, Suzanne Garner, Hamed El-Kady, Jan Knörich, Sergey Ripinsky, Diana Rosert, Claudia Salgado, Ileana Tejada, Diana Ruiz Truque and Elisabeth Tuerk. It has to be interpreted in the light of general principles of treaty interpretation. Comparing treatment: treatment “in like circumstances”, identifying better treatment. It is therefore, a relative standard and must be applied to similar objective situations. It also reviews arbitral awards against the background of the cases that have followed the Maffezini v. With some notable exceptions, arbitral tribunals have generally been cautious in importing substantive provisions from other treaties, particularly when absent from the basic treaty or when altering the specifically negotiated scope of application of the treaty. Spain itself, focused on the elimination of a preliminary requirement to arbitration. Such awards have further strengthened the debate, particularly given the fact that tribunals have been rather inconsistent in their reasoning and conclusions. Consequently, States began reacting or expressing concern about the growing uncertainty. So far, arbitral tribunals have taken different and sometimes inconsistent approaches. This would allow States to: • Make better-informed decisions for drafting and negotiating purposes (more precise scope, wording, exceptions, etc. This benefit granted to foreign investors is of extraordinary legal nature insofar as it derogates from customary international law, which requires that any acts or measures taken by the State must be challenged before the national jurisdictions of the State. Only after the investor has exhausted local remedies can the State from which it derives its nationality file an action against the host State, but never the investor himself. It may not be within the role of investment tribunals to enforce commitments or secure their compliance. International and national frameworks for investment have generally evolved towards more certainty and predictability in the conditions relating to the entry and operation of foreign investors in host countries. In the context of arbitration, both States and investors would have reason for concern when seeing that the same argument may succeed one day and fail the next. It will also look into arbitral awards against the background of the cases that have followed the Maffezini v. The early clauses were quite broad, applying to a wide range of issues such as “rights, privileges, immunities and exceptions” with respect to trade, commerce and navigation, or to “duties and prohibitions” with respect to vessels, importation or exportation of goods, as illustrated by the examples in box 1. Amity, Navigation and Commerce Treaty (the Jay’s Treaty) between the United States and Great Britain (1794) Article 15 It is agreed, that no other or higher Duties shall be paid by the Ships or Merchandize of the one Party in the Ports of the other, than such as are paid by the like vessels or Merchandize of all other Nations. Nor shall any other or higher Duty be imposed in one Country on the importation of any articles, the growth, produce, or manufacture of the other, than are or shall be payable on the importation of the like articles being of the growth, produce or manufacture of any other Foreign Country. Nor shall any prohibition be imposed, on the exportation or importation of any articles to or from the Territories of the Two Parties respectively which shall not equally extend to all other Nations […]. These early clauses were often conditional, meaning that the benefits granted by one State were dependant on the granting of the same concessions by the beneficiary State. The unconditional approach emerged during the second half of the eighteen century. The Treaty of Commerce signed in 1869 between Great Britain and France (the Chevalier-Cobden Treaty) is a prominent example. The draft articles explore, inter alia, matters concerning definitions, scope of application, effects deriving from the conditional or unconditional character of the clause, source of treatment and termination or 2 suspension. Foreign investors seek sufficient assurance that there will not be adverse discrimination which puts them at a competitive disadvantage. Such discrimination includes situations in which competitors from other foreign countries receive more favourable treatment. It prevents competition between investors from being distorted by discrimination based on nationality considerations. The Parties list, in particular: unequal treatment in the case of restrictions on the purchase of raw or auxiliary materials, of energy or fuel or of means of production or operation of any kind, unequal treatment in the case of impeding the marketing of products inside or outside the country, as well as any other measures having similar effects. States interfere or affect investors by means of “measures” or the absence thereof, which include the enactment and implementation of any laws and regulations, practice and any form of regulatory conduct. The treatment refers to all measures applying specifically to foreign investors (investment- specific measures) or to measures of general application that regulate the economic and business activity of the investor and his investment throughout the duration of the investment. Examples of measures of general application include: • Starting/closing a business; • Corporate and commercial regulation; • Taxation; • Labour, social security and employing workers; • Acquisition/registration of property; • Finance, securities and access to credit; • Government procurement rules; • Intellectual property rights; • Competition; • Immigration; • Customs and exporting/importing goods or services; • Environmental and consumer’s protection; • Enforcement of contracts and obligations through local courts; • Concessions, licenses and permits; and • Sectoral regulation such as telecommunications, energy, transport and financial services. Substantive coverage is generally established by the text itself by defining the covered beneficiaries, the covered phases of investment and any applicable exceptions. And whether it covers: • The post-establishment phase; or • Both the pre/post-establishment phases. Moreover, this basic construction may include: • Generic exceptions; or/and • Country-specific exceptions. The host State shall accord the covered foreign investor treatment which is no less favourable than that it accords to any third foreign investor of different nationality as regards any such entry conditions (for instance, access to given sectors of the economy or limits of foreign equity participation in specific activities). The obligation applies across the board, which means that no existing or future measures may discriminate the covered investor vis-à-vis another foreigner, unless specific reservations are taken by the Contracting Parties. Therefore, the protection covers the life-cycle of the investment after entry (which is governed by domestic law, regulations, policies and other domestic measures), from start-up to the liquidation or disposition of investments. However, these are not meant to limit the scope of application per se but constitute mere guidance and clarification on how the clause is supposed to be applied. In other occasions the qualification may be placed separately “for greater certainty” purposes. The clause may take the form of a specific provision or a combination of various provisions of the treaty. It is a conventional obligation and not a principle of international law which applies to States as a matter of general legal obligation independent of specific treaty commitments. The fact that States have the sovereign right to discriminate and regulate the entry and operation of aliens within their territory does not mean that such discretion is unlimited and not subject to international law. It requires a comparison between two foreign investors in like circumstances, being therefore a comparative test not contingent to any arbitrariness or seriousness threshold. Non- discrimination under international law, by contrast, constitutes an absolute standard (it is due no matter how other investors are treated) and refers to gross misconduct, or arbitrary conduct that impairs the operation of the investment. It may involve, for instance, discrimination based on arbitrariness, sexual or racial prejudice, denial of justice or unlawful expropriation. Conversely, absolute standards require treatment no matter how other investors are treated by the host State. Any assessment of an alleged breach calls not only for the finding of an objective difference in treatment between two foreign investors, but also for a competitive disadvantage directly stemming from this difference in the treatment. In the area of investment, the principle has been highlighted by the Maffezini decision and not challenged by the many other cases that followed suit. Depending on the scope of the treaty, the subject matter can be investment promotion, investment protection, investment liberalization and/or a combination thereof. Under a most-favoured-nation clause the beneficiary State acquires, for itself or for the benefit of persons or things in a determined relationship with it, only those rights which fall within the limits of the subject-matter of the clause. The beneficiary State acquires the rights under paragraph 1 only in respect of persons or things which are specified in the clause or implied from its subject-matter. Under a most-favoured-nation clause the beneficiary State acquires the right to most-favoured-nation treatment only if the granting State extends to a third State treatment within the limits of the subject-matter of the clause. The beneficiary State acquires rights under paragraph 1 in respect of persons or things in a determined relationship with it only if they: (a) belong to the same category of persons or things as those in a determined relationship with a third State which benefit from the treatment extended to them by the granting State and (b) have the same relationship with the beneficiary State as the persons and things referred to in subparagraph (a) have with that third State. Different treatment is justified amongst investors who are not legitimate comparators, e. Other delegations considered it necessary to specifically include the formula “in like circumstances”. Irrespective of the precise wording, the proper interpretation of a relative standard requires that the treatment afforded by a host State to foreign investors can only be appropriately compared if they are in objectively similar situations. There is therefore little guidance to be found in arbitral awards on how the comparison should be made. Tribunals have used a variety of criteria for comparison depending on the specific facts and the applicable law of each case. Flexibility has prevailed, with the aim of comparing what is reasonably comparable and considering all the relevant factors. After a reasonable comparison has been made amongst appropriate comparators, there are factors that may justify differential treatment on the part of the State among foreign investors, such as legitimate measures that do not distinguish, 18 (neither de jure nor de facto) between nationals and foreigners. It requires a finding of less favourable treatment With the exception of foreign-investment-specific laws and regulations, the domestic legal framework of the host State applies to all economic actors and operators in the same manner, whether foreign or national. It therefore applies to the investor and its investment, irrespective of his nationality. States do not differentiate treatment granted to foreign investors of different nationalities once established and operating in the host State’s economy. However, in the pre-establishment phase, difference in the treatment afforded to investors of different nationalities is likely, depending on the treaty commitments made with the home State of these investors. Treatment is primarily materialized through “measures”, that is, State laws, regulation and conduct. The universe here is vast: basically, all measures that may affect the course of business – e. Similarly, even though the investor may prefer to submit a claim to arbitration directly than having to resort to domestic courts as a preliminary step for 6 or 18 months, one cannot presuppose without rigorous analysis that such direct access is more beneficial in and by itself, the amount of compensation the investor would potentially receive being based on the date the damage occurred. Different treatment does not necessarily mean less favourable treatment, and less favourable treatment rests on objective premises, not on perception. The reason is that a host country cannot be obliged to enter into an individual investment contract. Furthermore, the foreign investor that did not enter into a contract is not in “like circumstances” with the third foreign investor that did conclude the contractual arrangement with the host State. Regulation of goods and services is more specific, targeted and measurable, while investors and investments are subject to a much greater regulatory universe behind the border. In general, the barriers to entry and after entry of goods and investments tend to be of a different nature. Hence any analogy in the application and the identification of a violation of the commitment must be handled with care. It has to be interpreted in the light of general principles of treaty interpretation Treaty provisions have to be interpreted pursuant to the Vienna Convention on the Law of Treaties (the Vienna Convention), whether required by the instrument itself or by (customary) international law on treaty interpretation. Article 31 of the Vienna Convention (see box 5) contains one general rule of interpretation. Vienna Convention on the Law of Treaties Article 31 General rule of interpretation 1. A treaty shall be interpreted in good faith in accordance with the ordinary meaning to be given to the terms of the treaty in their context and in the light of its object and purpose. The context for the purpose of the interpretation of a treaty shall comprise, in addition to the text, including its preamble and annexes: (a) any agreement relating to the treaty which was made between all the parties in connection with the conclusion of the treaty; (b) any instrument which was made by one or more parties in connection with the conclusion of the treaty and accepted by the other parties as an instrument related to the treaty. There shall be taken into account, together with the context: (a) any subsequent agreement between the parties regarding the interpretation of the treaty or the application of its provisions; (b) any subsequent practice in the application of the treaty which establishes the agreement of the parties regarding its interpretation; (c) any relevant rules of international law applicable in the relations between the parties. A special meaning shall be given to a term if it is established that the parties so intended. Under this rule the “ordinary meaning” is not constructed in a vacuum, rather it has to be seen in the context of the treaty and in light of its object and purpose. Even if the words are clear, if applying them leads to a manifestly unreasonable result, 20 another interpretation must be sought. At the same time, “object and purpose” do not constitute an independent basis for interpretation, but are linked to the text set forth in the treaty. This comprehensive approach is particularly helpful when the text is unclear or admits different interpretations. Given that text, object and purpose are interlinked (Koskenniemi 1989), as the latter rest on subjective premises, recurring to the Contracting Parties’ intent constitutes a valid (sometimes necessary) tool, especially when it comes to economic bilateral arrangements and party-driven 21 commitments. However, the exercise should be confined to the premises of the text itself so as to establish but not to create content.

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When serum potassium levels are elevated vardenafil 20 mg, ~12 to 15% of the total kcal/day 20mg vardenafil, but the total amount of potassium intake (including salt substitutes) should be lim- protein varies greatly with the level of total caloric intake ited to 2 10 mg vardenafil,000 to 3 20 mg vardenafil,000 mg/day (40 to 70 mEq/day) 10mg vardenafil. Potassium should still be limited meal plan provides ~13% of kcal/day at the 1 vardenafil 10mg,200 kcal/ if blood tests show phosphate or potassium levels above day level but only ~8% of kcal at the 2 vardenafil 10 mg,400 kcal/day level vardenafil 20mg. Energy-intake requirements have been studied Vitamin D in hemodialysis patients considered to be under metabolic Supplemental vitamin D should be given to treat balance conditions . The study showed that the necessary energy treatment with an activated form of vitamin D (calcitriol , intake of 35 kcal/kg body weight/day was enough to main- alfacalcidol, paracalcitol, or doxercalciferol) is indicated. Iron should be administered to maintain the transferrin Nutrient Recommendation saturation >20% and serum ferritin level >100 ng/mL. For stable hemodialysis patients, the recom- Patients on peritoneal dialysis experience decreased appe- mended protein intake is 1. The Evaluation of A1c should include assessment of home following are recommended doses, often found in renal blood sugar records showing pre- and postprandial blood vitamins: vitamin C, 60 mg (not to exceed 200 mg daily); sugar excursions, as well as frequency and severity of folic acid, 1 mg; thiamine, 1. What Nutritional Recommendations are Patients on peritoneal dialysis should have a total daily Appropriate for Bone Health? Although causes of malnutrition 50% less absorption after menopause, as compared with in peritoneal dialysis are similar to those in hemodialy- adolescence. This decreased calcium absorption is due at sis patients, there is an increased loss of protein into the least in part to vitamin D insuffciency. In fact, protein losses average about 5 fciency is common in older patients with decreased to 15 g/24 hours. Calcium absorption decreases with studies indicate that the amount of calcium intake needed higher calcium intake, higher fber intake, and increased to maintain a positive calcium balance is over 1,000 mg/ alcohol use. Calcium ingestion slows age-related bone loss and Adequate amounts of calcium can be obtained from reduces osteoporosis fracture risk. Calcium-fortifed orange juice, soy milk, and soft pausal women and 1,690 late-menopausal women) studied drinks are becoming more popular as sources of calcium. In the early postmeno- fculty with calcium-fortifed beverages is that the calcium pausal women, bone loss was not prevented at the spine by may settle out of solution, thus decreasing the actual intake 500 mg of supplemental calcium. Calcium absorption is dependent on many factors A meta-analysis of 15 clinical trials randomized to (Table 27). There is both passive and active absorption in calcium supplements or usual calcium ingestion over 2 the small bowel. Absorption is decreased in the setting of years showed increased bone density and a trend towards low vitamin D, advanced age, low or absent stomach acid, reduced vertebral fractures with calcium supplementation and high fber intake. In women with low calcium intake absorption is about 35% but varies between 17 and 58% and pre-existing fractures, supplemental calcium of 600 Table 27 Medication and Food Interactions for Calcium Medication or food Interaction Calcium reduces absorption. Calcium supplements and calcium rich foods should be Thyroid hormone taken 4 hours or more after dosing of thyroid hormone. Bisphosphonates should be taken with plain water at least 30-60 minutes (depending on Bisphosphonates the particular drug) before taking anything else except water. Calcium decreases absorption and should be taken several hours before or after the Quinolone antibiotics medication. Glucocorticoids Even low doses can be associated with bone loss and decreased calcium absorption. Hypercalcemia can cause cardiac toxicity and calcium dosing and levels should be Digoxin carefully monitored. Decrease renal loss of calcium and may predispose to hypercalcemia in mild primary hyperparathyroidism. Thiazides may have therapeutic value in idiopathic hypercalciuria, especially when Thiazide diuretics associated with renal stones. Can be measured in a 24-hour urine Sodium sample along with creatinine and calcium. Calcium carbonate requires stom- tions, including about one-half who were taking hormone ach acid for absorption, so it is best dosed in the presence therapy. The risk of hip fracture 500 mg at a time since absorption decreases as the dose was not statistically different in the treated versus placebo increases above this level. However, the Calcium citrate does not require stomach acidity for subset analysis of only those patients who adhered to treat- absorption, and absorption is probably similar if taken with ment (those taking more than 80% of their supplements) meals. This suggests that the elderly may beneft from increased protein intake in addition to suffcient cal- Calcium Supplements cium, vitamin D, and physical activity. If calcium intake from meals is insuffcient and cannot be corrected, then calcium supplementation should be con- Potential Side-effects of Calcium Supplementation sidered. Lactose intolerant patients, vegans, chronic glu- Gastrointestinal Symptoms cocorticoid users, and those with a history of stomach sur- Gastrointestinal symptoms (bloating, gas, constipa- gery or malabsorptive bariatric procedures, celiac disease, tion) can be a problem in some patients. Adequate Evaluation for lactose intolerance, celiac disease, or lack vitamin D levels are also necessary to optimize absorption. Since these women citrate are the most common forms available, but other were permitted to use additional supplements on their forms may also be found, including lactate and gluconate. They are much more expensive and offer low calcium intake increases the risk of calcium oxalate no added health beneft. Calcium carbonate is about 40% kidney stones, probably due to binding of ingested calcium calcium. Calcium lactate is only 13% elemental by about 50% in patients receiving a normal calcium calcium, and calcium gluconate is 9% calcium. What Nutritional Recommendations are increased risk of kidney stones with calcium supplementa- Appropriate for Pregnancy and Lactation? Healthy eating in pregnancy and lactation has a sig- Prostate Cancer nifcant effect on both the mother and the child and can Prostate cancer risk was increased in 3,612 men fol- have a tremendous impact on their health, morbidity, and lowed prospectively who had an increased amount of dairy even mortality. Developing healthy eating behaviors requires active participation by the pregnant woman, as 4. Low levels of vitamin D result in decreased intestinal nutrition counseling and education. Meal plans including calcium absorption and cause secondary hyperparathyroid- optimal caloric intake and weight gain should be tailored ism and bone loss. Physicians should perform a thorough history and In addition to bone loss, vitamin D defciency has physical examination prior to conception. For example, the physical fnding of acanthosis cle tone and balance and reduces fall risk. Physicians should pay particular tation often delay diagnosis until 30- to 34-weeks gesta- attention to stopping any medications that could be poten- tion, well after the effects of hyperglycemia have begun to tially harmful to the fetus. Patient Education During Pregnancy A prenatal nutrition questionnaire helps the practitio- Pregnant women are more susceptible to food-borne ner to identify pregnancy-related problems affecting appe- illnesses and should practice safe food handling. Patients should also be queried on personal unpasteurized dairy products; thoroughly wash fresh pro- nutritional habits, including vegetarian, vegan, lactose-free duce before consuming it; and ensure that meats, poultry, and gluten-free diets, as well as cravings and aversions. All patients would beneft from referral to a dietician who Caffeine during pregnancy can increase the incidence specializes in nutrition in pregnancy and can evaluate the of miscarriage and stillbirth when consumed in large quan- patient’s individual habits, create an individualized meal tities. Generally, consuming less than 300 mg of caffeine plan, and address any special needs. Many women incorrectly estimate their daily weight gain for pregnant women who are obese. However, experts believe that it may be safe to gain little or no weight in pregnant women who are obese, additional calories may in this special population. Healthcare profes- Physical activity is also an important aspect of a sionals should determine the appropriate caloric intake for healthy pregnancy. Simple carbohydrates and Table 30 Dietary Reference Intakes for Womena,b Adult Lactation Nutrient woman Pregnancy (0-6 mo) Energy (kcal) 2,403 2,743 , 2,855c d 2,698 Protein (g/kg/day) 0. Protein is essential for the expansion Trans fatty acids may cross the placenta and may have of plasma volume; the generation of amniotic fuid; and to adverse effects on fetal development. Pregnant women who are vegetarian or Micronutrient Needs During Pregnancy vegan must be referred to a dietician specialized in preg- Pregnant women require specifc micronutrients to nancy to assist in specialized meal planning and recom- meet their gestational needs. Women should pay simplest way to assure that a woman is getting adequate close attention to the type of fat being consumed. Public Health Service recommends that all women in women are falling signifcantly short of recommended lev- their childbearing years consume 400 µg/day of folic acid. Women should be Women should maintain a daily iodine intake of 250 encouraged to eat 12 ounces of fsh per week. Maternal milk is also at the is needed for fetal erythropoiesis and an increase in mater- appropriate temperature, and breastfeeding creates a bond- nal red blood cell mass. Vitamin D requirements also do not change eral requirements all increase during lactation. Caloric intake exceeds prepregnancy demands by Vitamin A is imperative for fetal eye development and approximately 650 kcal/day in average sized women has been known to be defcient in developing countries. Anemic women on iron supplementa- lactation or eat a carbohydrate-containing snack prior to tion should take supplemental zinc. The recom- Exclusive breastfeeding is extremely benefcial for the mended rate of weight loss of 0. Nutrients that should myriad of educators and support groups such as lactation be repleted during lactation include calcium, magnesium, consultants, nurse educators and the La Leche League, all zinc, thiamin, vitamin B6, iodine, and folate. Their infants will beneft from a nutritional take 60 to 120 mg/day of ferrous sulfate. Iron supplementa- source with the appropriate nutrients and antibodies that tion should be continued until anemia is resolved. Some experts recommend Toward an Ideal Body Weight that bovine-based infant formula be completely avoided To achieve and maintain an ideal body weight is advis- during the frst year of life. If formula is required, parents able for all age groups because both over- and underweight should use soy-based products. However, both overweight and under- weight are present more frequently in older adults. Aging is Introduction: Why the Need for associated with unfavorable changes in body composition Healthy Eating for the Elderly? Older people are also prone to underweight and vidual’s physiological age (functional age) or true aging cachexia because malnourishment associated with aging status. We consider “healthy eating for the elderly” appli- and undernutrition associated with chronic diseases are cable even to those in their “middle age,” insofar as modi- more prevalent in the elderly. Both overweight and under- fying eating behaviors is more effective when it is started weight are predictors of functional impairment, chronic early. Many people start Defciency in Older Adults to gain weight, particularly fat mass, when they get older. Prevention of micronutrient defciency may be chal- In part, this is because their caloric intake is not adjusted to lenging for the elderly for 2 reasons. Additionally, there is the need for caloric and, hence, retards aging processes in this regard. To constrain caloric overconsumption while ensuring tional weight loss in the elderly. Aging is associated with micronutrient adequacy, foods low in calories and rich in gradual declines in appetite, taste and smell sensitivity, micronutrients should be ingested routinely. For carbohydrates, older adults are encour- the priority in achieving healthy eating objectives in this aged to consume more nutrient-dense whole grain foods subgroup of the elderly should be very different from peo- (high nutrient-to-calorie ratio), such as brown rice, whole ple who are overweight and/or obese. Consumption of refned together with supplementation of essential micronutrients, starch-based foods poor in other micronutrients, such as should be the focus of the healthy eating strategy and take processed potato, white bread, pasta, and other commercial precedent over the usual recommendation of “balanced products made of refned wheat four, should be decreased. In general, however, body weight is the ulti- and processed food intake should be minimal in order to mate measure for energy balance in the absence of edema- meet the guidelines for cardiovascular health. Gaining weight means a positive essential component of nutrition that must receive atten- energy balance, which results either from too little physical tion. Adequate and habitual fuid intake is encouraged for activity, too much food intake, or both. On the other hand, the elderly, as the thirst mechanism may become impaired weight loss means negative energy balance resulting from with aging. Dehydration proves to be a prevalent condi- more energy expenditure than caloric intake. A variety of colored vegetables and fruits (both bright- and deep-colored) are excellent sources of miner- 3. Special or Frail elderly who are nutritionally vulnerable require restrictive meal plans should be limited to individuals with special attention. These are individuals who are under- specifc diseases, where there is a need for limiting certain weight or at great risk for unintentional weight loss. With a nutritional priority for these individuals is to increase good meal plan, both energy and macro-/micronutrient caloric intake and achieve energy balance. However, a high risk for def- of healthy eating for other older adults should still apply to ciency of several micronutrients (calcium and vitamins D the greatest extent possible. Successful strategies to increase caloric and fruit juice (such as orange juice) need be consumed daily. The requirement for vitamin B12 supplemen- holds true whether at home or in a long-term care facility. Many of these problems are important to highlight that these chronic endocrine and potentially reversible and should be screened for and cor- metabolic diseases are more prevalent in the elderly, and rected if present. Also, attention should be paid to selecting more often than not co-exist in the same individual. Age-related reduction in appetite may be common thoughtful comments strengthened this document. Social isolation, phys- ical disability, inability to shop or prepare tasty meals, and Co-Chairs depression can all lead to poor appetite and undernutrition Dr. Importantly, many medical conditions are does not have any relevant fnancial relationships with any directly, and indirectly through polypharmacy, associated commercial interests. Jeor reports that she has received lant for potentially reversible causes of anorexia. Ayesha Ebrahim reports that she does not have function, resulting in poor perception of otherwise palat- any relevant fnancial relationships with any commercial able foods. Chronic laxative use salary as an employee from OmegaQuant and research in the elderly may also impair nutrient absorption or cause grant support for graduate studies from General Mills Inc. Dan Hurley reports that he does not have any rele- nutrient interactions may affect the absorption and metabo- vant fnancial relationships with any commercial interests.

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