W. Javier. University of San Diego.

Whether you need to develop your knowledge for clinical practice purchase kemadrin 5 mg line, or refresh that knowledge in the run up to examinations kemadrin 5 mg amex, Clinical Medicine Lecture Notes will help foster a systematic approach John Bradley to the clinical situation for all medical students and hospital doctors 5 mg kemadrin sale. Mark Gurnell For information on all the titles in the Lecture Notes series, please visit: www. This means that 9781444335118 our books are always published with you, the student, in mind. The Hands-on Guide for Junior Doctors, Fourth Edition Anna Donald, Mike Stein and Ciaran Hill 2011 If you would like to be one 9781444334661 of our student reviewers, go to www. Blackwells publishing programme has been merged with Wileys global Scientic, Technical and Medical business to form Wiley-Blackwell. Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. The seventh edition follows the format of Mark Gurnell previous editions of this book with two sections: Diana Wood Clinical Examination and Clinical Medicine. Each section has been updated to reect the increased Acknowledgements evidence upon which clinical practice is based and the more objective methods of assessment that are We would like to thank Dr Ellie Gurnell, Dr Mark now used. Lillicrap and Dr Narayanan Kandasamy for their con- It is rewarding to discover how many readers have tributions, help and advice during the preparation of found the text useful for study, for revision and for the the manuscript. P reface to th e irst ditio This book is intended primarily for the junior hospital working knowledge in a clinical situation. It should doctor in the period between qualication and the not be forgotten that some rare diseases are of great examination for Membership of the Royal Colleges importance in practice because they are treatable or of Physicians. Some for higher specialist qualications in surgery and conditions are important to examination candidates anaesthetics. The experienced phy- We have not attempted to cover the whole of sician has acquired some clinical perspective through medicine, but by cross-referencing between the two practice: we hope that this book imparts some of this sections of the book and giving information in sum- to the relatively inexperienced. A short account of psychiatry is given in the section The book as a whole is not suitable as a rst reader on neurology since many patients with mental illness for the undergraduate because it assumes much basic attendgeneralclinicsanditishopedthatreadersmaybe knowledge and considerable detailed information has warned of gaps in their knowledge of this important had to be omitted. The section on dermatology is incomplete but textbook of medicine and the information it contains should serve for quick revision of common skin must be supplemented by further reading. In are most commonly seen and where possible have the rst part we have considered the situation which a listed them in order of importance. The frequency candidate meets in the clinical part of an examination with which a disease is encountered by any individual or a physician in the clinic. This part of the book thus physician will depend upon its prevalence in the resembles a manual on techniques of physical exam- district from which his cases are drawn and also on ination, though it is more specically intended to help his known special interests. Nevertheless, rare condi- the candidate carry out an examiners request to tions are rarely seen; at least in the clinic. Wehave We should like to thank all those who helped included most common diseases but not all, and we us with producing this book and, in particular, have tried to emphasise points which are under- Sir Edward Wayne and Sir Graham Bull who have stressed in many textbooks. Accounts are given of kindly allowed us to benet from their extensive many conditions which are relatively rare. It is neces- experience both in medicine and in examining for sary for the clinician to know about these and to be on the Colleges of Physicians. Supplementary reading is essential to un- derstandtheirbasicpathology,buttheinformationwe David Rubenstein give is probably all that need be remembered by David Wayne the non-specialist reader and will provide adequate November 1975 1 T h e m edical in terview Good communication between doctor and patient forms the basis for excellent patient care and the clinical consultation lies at the heart of medical prac- Effective consultation tice. Good communication skills encompass more Effective consultations are patient-centred and ef- than the personality traits of individual doctors they cient, taking place within the time and other practical forman essentialcorecompetencefor medicalpracti- constraints that exist in everyday medical practice. In essence, good communication skills pro- Theuseofspeciccommunicationskillstogetherwith duce more effective consultations and, together with a structured approach to the medical interview can medical knowledge and physical examination skills, enhance this process. Important communication lead to better diagnostic reasoning and therapeutic skills can be considered in three categories: content, intervention. These skills are evidence-base shows that health outcomes for pa- closely interrelated so that, for example, effective tients and both patient and doctor satisfaction within use of process skills can improve the accuracy of the therapeutic relationship are enhanced by good information gathered from the patient, thus enhan- communication skills. Providing structure to the consultation is one of the There are a number of different models for most important features of effective consultation. They are generally similar and all em- that is responsive to the patient and exible for dif- phasise the importance of patient-centred inter- ferent consultations. Like all clinical skills, com- examination) munication skills can only be acquired by experien-. Before meeting a patient, the doctor should prepare by focusing him- or herself, Theinitialpartofaconsultationisessentialtoformthe tryingtoavoiddistractionsandreviewinganyavailable basis for relationship building and to set objectives for information such as previous notes or referral letters. Gathering information An accurate clinical history provides about 80% of the Explanation and planning information required to make a diagnosis. Tradition- ally, history-taking focused on questions related to the Explanationandplanningiscrucially importantto the biomedical aspects of the patients problems. Establishment of a manage- evidencesuggeststhatbetteroutcomesareobtainedby ment plan jointly between the doctor and the patient including the patients perspective of their illness and has important positive effects on patient recall, un- by taking this into account in subsequent parts of the derstanding of their condition, adherence to treat- consultation. Patient expectations should therefore include exploring the history from have changed and many wish to be more involved in boththebiomedicalandpatientperspectives,checking decision-making about investigation and treatment thattheinformationgatherediscompleteandensuring options. The goals of this part of the consultation are thatthepatientfeelsthatthedoctorislisteningtothem. Explanation and planning Gathering information Avoid jargon: use clear concise language; explain Ask the patient to tell their own story. Listen attentively: do not interrupt; leave the pa- Find out what the patient knows: establish prior tient time and space to think about what they are knowledge; nd out how much they wish to know saying. Encourage the patient to express their feelings: Involvethe patient:share thoughts; reveal rationale actively seek their ideas, concerns and expectations. The way in which these two are understand and which takes their perspectives into used is shown in Table 1. It encourages patient participation and collaboration and facilitates accurate information Closing the session gathering. Building a relationship with the patient in- Closing the interview allows the doctor to summarise volves a number of communication skills that enable and clarify the plans that have been made and what the doctor to establish rapport and trust between thenextstepswillbe. Itmaximisesthechances contingency plans are in place in case of unexpected of accurate information gathering, explanation and events and that the patient is clear about follow-up planning and can form part of the development of a arrangements. Itisvitaltopatient ent relationship in this way has positive effects on and doctor satisfaction with the consultation adherence to treatment and health outcomes. Closing the session Summarise:reviewtheconsultationandclarifythe Special circumstances plan of action; make a contract with the patient Certain circumstances demand a special approach to about the next steps. Sequencing Maintain a logical sequence to the Involve the Share your thoughts to interview; use exible but ordered patient encourage patient interaction; organisation by signposting and explain your rationale for doing summarising. The medical interview 5 Breaking bad news Approach to communication skills assessment Prepare: ensure you have all the clinical details and know the facts; set aside enough time; Past papers: the format of the examination should encourage the patient to bring a relative or be available for review; look at the communication friend. In some examinations spective; do not overwhelm with information in the clinical scenario is available in advance of the rst instance; check repeatedly that the pa- the examination to allow preparation of content tient understands. Make a plan: explain what will happen next; give Make a plan: before you enter the station, have a hope but be realistic; conrm your role as a clear plan as to how you will approach the partner in care. Complexsituationsrequirethedoctor present and discuss the case, listen carefully to to use basic skills to a higher level. Preparation and the examiner and present the salient features in planning, listening to the patient, delivering informa- a clear and logical manner. Closureisalsoimport- ant, ensuring the patient knows what is happening and is clear about the next steps. Communication skills are usually ments should have been through appropriate 6 The medical interview Concrete experience Consultation with a patient Interview a simulated patient Role play Reflection Active experimentation Think about the consultation Try a different approach Observe a recorded consultation in a learning environment Give and receive feedback Abstract conceptualisation What will I do differently next time? Thecycleenablesthelearnertobuildonexistingknowledgeand skills, to take responsibility for their own progress and to use real life clinical and simulated encounters to promote further learning. Dyspnoea may be observed and outstretched abnormal movements, including tremor or paucity of T resting tremor of Parkinsons disease hands facial expression, should be noted. Many patients with ischaemic heart disease have few or no physical signs and a characteristic history of peripheral vascular disease may be elicited.

Instant electronic imaging systems are superior to Polaroid at Lancet 2007 order kemadrin 5 mg with mastercard;370(9600):1687-97 purchase kemadrin 5 mg on-line. Int of retinopathy in type 2 diabetes: identification of prognostic Ophthalmol 2008 order 5 mg kemadrin amex;28(1):7-17. Diabetic Retinopathy triamcinolone or laser alone for treating diabetic macular edema: Screening: Clinical Standards. Diabetic Retinopathy Clinical Research Network: provision: the effectiveness of a low vision clinic. Optom Vis Sci Three-year follow-up of a randomized trial comparing focal/ 1994;71(3):199-206. The provision of low vision two-year results of a double-masked, placebo-controlled, care. Simvastatin retards progression and economic aspects of foot problems in diabetes. Effectiveness of the diabetic foot risk atorvastatin as an adjunct in the management of diabetic macular classification system of the International Working Group on the edema. Diabetes vascular endothelial growth factor aptamer, for diabetic macular Care 1999;22(7):1029-35. Graefes Arch Clin Exp patients at high risk for lower-extremity amputation in a primary Ophthalmol 2008;246(4):483-9. Bevacizumab-augmented retinal laser photocoagulation in patients with diabetes: A systematic review and meta-analysis. Intravitreal bevacizumab (avastin) program to reduce amputations and hospitalizations. Diabetes injection alone or combined with triamcinolone versus macular Res Clin Pract 2005;70(1):31-7. Effect of lisinopril on progression of retinopathy pressures and arterial calcification in diabetic occlusive vascular in normotensive people with type 1 diabetes. Effect of ruboxistaurin on the visual acuity decline associated preventing diabetic foot ulceration (Cochrane Review). Antibiotic therapy padded hosiery to reduce abnormal foot pressures in diabetic for diabetic foot infections: comparison of two parenteral-to-oral neuropathy. Good practice guidance for the use of antibiotics in patients Res Clin Pract 1995;28(1):29-34. Improved survival of the diabetic foot: the role of a negative pressure wound therapy using vacuum-assisted closure specialized foot clinic. Diabetic patients compliance with bespoke footwear negative pressure wound therapy in the management of diabetes after healing of neuropathic foot ulcers. Microscope-aided pedal bypass is an effective the feet after revascularization for gangrene. Impact of increasing comorbidity on infrainguinal diabetic foot care during the 1980s: prognostic determinants for reconstruction: a 20-year perspective. Trends in the care of the diabetic incidence of major amputation in diabetic patients: a consequence foot. Total contact casting in treatment of diabetic plantar by quantitative techniques. A randomized trial of two irremovable off- A systematic review of antidepressants in neuropathic pain. Pain loading devices in the management of plantar neuropathic diabetic 1996;68(2-3):217-27. Effects of management of diabetic foot ulcers: a randomized prospective trial venlafaxine and carbamazepine for painful peripheral diabetic versus traditional fiberglass cast. Diabetes Care 2007;30(3):586- neuropathy: A randomized, double-blind and double-dummy, 90. Effect of initial weight-bearing in a total contact release in the treatment of painful diabetic neuropathy: a double- cast on healing of diabetic foot ulcers. Gabapentin for the symptomatic treatment of painful relation to patient compliance. Diabet Med Antiepileptic drugs in treatment of pain caused by diabetic 1996;13(2):156-9. Use of ampicillin/sulbactam Pregabalin as a Treatment for Painful Diabetic Peripheral Neuropathy: versus imipenem/cilastatin in the treatment of limb-threatening A Meta-Analysis. Stratification of foot ulcer risk in patients with diabetes: a population-based study. It was frst reported in Egyptian manuscript about countries of the world with the number of people afected expected 3000 years ago. Studies insulin was licensed for use in 2006 but has been withdrawn from examining data trends within Africa point to evidence of a the market because of low patronage. Olokoba decades and much of the increase will occur in developing countries Department of Ophthalmology, University of Ilorin Teaching Hospital, where the majority of patients are aged between 45 and 64 years. However, practicing As a result of this dysfunction, glucagon and hepatic glucose physicians frequently employ other measures in addition to those levels that rise during fasting are not suppressed with a meal. In July 2009, the International Expert Committee Oman Medical Specialty Board Oman Medical Journal (2012) Vol. Pre- emphasizes specifcity, commenting that this balanced the stigma prandial administration allows fexibility in case a meal is missed and cost of mistakenly identifying individuals as diabetic against without increased risk of hypoglycemia. Pioglitazone nutrition evaluation; lifestyle recommendations should be tailored use is not associated with hypoglycemia and can be used in cases according to physical and functional ability. Due to the concern of development T eir use is usually limited due to high rates of side-efects such of lactic acidosis, metformin should be used with caution in elderly as diarrhoea and fatulence. It has a low incidence 39 drugs, has been shown in a study to signifcantly improve glucose of hypoglycemia compared to sulfonylureas. T ey dehydrogenase 1, which reduce the glucocorticoid efects in liver are efective as monotherapy in patients inadequately controlled and fat. Insulin-releasing glucokinase activators and pancreatic- with diet and exercise and as add-on therapy in combination with G-protein-coupled fatty-acid-receptor agonists, glucagon-receptor metformin, thiazolidinediones, and insulin. Education of the populace is still key to the control of this some beta cell function remains. Novel drugs are being developed, yet no cure insulin is necessary if beta cell exhaustion occurs. Rescue therapy is available in sight for the disease, despite new insight into the using replacement is necessary in cases of glucose toxicity which pathophysiology of the disease. T e long acting forms are less likely to cause hypoglycemia compared to the short acting 1. T e worldwide epidemiology of the new insulin analogues are distinct from those of the regular type 2 diabetes mellitus: present and future perspectives. Diabetic atlas in 2006,55 after it was approved by both the European Medicines ffth edition 2011, Brussels. National diabetes fact sheet: national estimates obesity and type 2 diabetes in Asia. Rates of hypoglycemia in users of United States, 1988-1994 and 1999-2000"Centers for Disease Control and sulfonylureas. Drug interactions of clinical importance with antihyperglycaemic and adolescent overweight and obesity: Summary report. Association of urinary bisphenol A concentration with medical disorders common and distinct processes. Genetics of obesity and the prediction tolbutamide-plus-acarbose in non-insulin-dependent diabetes mellitus. Voglibose for prevention of type 2 diabetes insulin resistance on resting and glucose-induced thermogenesis in man. Int J mellitus: a randomised, double-blind trial in Japanese individuals with Obes Relat Metab Disord 1999 Dec;23(12):1307-1313. Cost-efectiveness of insulin analogues for science, and the multiplier hypothesis. Prandial inhaled insulin plus basal insulin glargine versus twice daily hormones and beta-cell dysfunction. Clin and cost-efectiveness of inhaled insulin in diabetes mellitus: a systematic Diabetes 2009;4(27):132-138.

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If a change occurs in your life that requires a change in goals buy kemadrin 5mg visa, then maybe youll have to: o Enjoy activities in new ways o Develop new interests buy discount kemadrin 5 mg, abilities and activities order kemadrin 5mg with amex. Promote a discussion about the pictures and how different perceptions can be had of each one. The purpose is to illustrate the difference between the objective and the subjective world, and how our perceptions about the same thing or event can be different from that of other people. The key to feeling emotionally healthy is: To learn how to manage these two parts of our reality. You can also find a friend to talk to, think that your parents are adults and 49 they must know why they made that decision, and try to do pleasant activities that can help make you feel better. You can see the possible positive side to this, which could be that they are happier and there is more peace at home. When people are depressed, the often perceive their subjective world as the only reality. If you dont change your negative thoughts, you might think they are the only reality and that will continue to make you feel depressed. It can also happen that we feel we dont have any alternatives when things dont happen the way we want them to. On these occasions it helps to consider all the alternatives and not to focus on that fact that you dont have what you really wanted. If the adolescent doesnt provide an example, you can present him/her with one of the following situations, asking them to provide alternatives to them: o A guy you dont have romantic feelings for invites you to a party, but you enjoy his company as a friend. They can also think that their depression wont go away unless something in the objective world changes. If you see the world as little chunks of time that you decide what to do with, you can feel more in control and take action to overcome your depression. For example, if you tell yourself: o I cant enjoy life until my depression goes away, consider thinking I can feel better every day if I do the things I have been learning. Mention two alternatives (concrete actions) that you have to manage the outside world. You can ask the adolescent whether there are still negative thoughts that he/she has often, and work with these thought in alternatives and time (below). Mention two alternatives (concrete actions) that you have to manage your internal world. Do you spend a lot of time thinking you want to change the past or anticipating the future? When your time becomes more satisfactory, your life will also and you will feel better. If pleasant activities help you overcome your depression, they can also help you feel healthier emotionally. In this module (the last 4 sessions) we will be working with your relationships and how they affect how you feel. Severe depression is associated with: Having less contact with others Feeling uncomfortable, shy or mad at others Being less assertive (not saying what you like/dislike or not knowing how to express your feelings and preferences) Being more prone to feeling rejected, ignored, or criticized 2. The answer is probably that depression and lack of contact with other people influence one another. If when you feel sad you dont make an effort at making new friends, your sadness can become depression. Feeling depressed may make you feel less sociable, which will make you even more depressed because youre spending a lot of time sad and lonely. The contacts we have with our family and friends create a kind of protective social network or "social support network". In general, the stronger the social support we receive, the more we are able to confront difficult situations. Exercise: Recreate your social support network using the diagram on the My Social Support Network worksheet. The adolescent should his/her name in the center circle and in each shape write the name of someone in their network. In discussing this exercise, evaluate the quality and quantity of his/her network and whether it should be expanded or strengthened. Your network is too small if there is no one you trust to talk about your personal matters, if you have no one to go to if you need help, or if you have no friends or acquaintances to do things with. If there were people you want to get to know better, its more probable that theyll have things in common with you. Promote a discussion or list places and ways you can meet new people and make friends. You dont always have to say what you think, but its important to feel that you have that option. You can say things in a nice way that can help resolve situations and maintain the relationship healthy. Use the Weekly Activities Schedule to write down the types of contacts you had with people each day. Write a plus sign (+) if they were positive and a minus sign (-) if they were negative. Before talking about how these three areas are affected by your relationships, its important to evaluate first how they are when you are alone. Also, if you expect little from people, youre not giving them the chance to show you what they can really offer. Present the following information and discuss by relating to the adolescents experience. This is way its important to be able to identify and manage our feelings in a healthy way. For this, its important to: o Recognize how your feel and why youre feeling that way o Communicate in an assertive or appropriate way what you feel o The difference between being passive, assertive or aggressive: Assertiveness = is being able to share positive and negative feelings clearly and comfortably (even if you think the other person wont like what youre saying). Changing your point of view can help you to be more assertive instead of being passive. Examine the adolescents thoughts, feelings and actions in relation to a person with whom he/she has identified interpersonal difficulties. Learning to be assertive and practicing in your mind Exercise: Ask the adolescent to think about a situation with a person with whom he/she has difficulty in being assertive. Provide the following instructions: o Image the situation as if it were a photograph. This exercise is a useful way to rehearse being assertive before actually putting it into practice. Apply the following communication skills the situation discussed in the previous exercise. Active listening When you are talking to someone, listen to what they are saying instead of thinking about you are going to say back or respond. If youre thinking about what youre going to answer, you might miss part of what the person is telling 62 you. People often argue about what somebody said without knowing if that was what the person really wanted to say or express. To improve your active listening and communication skills: Repeat what the other person said in your own words so you can be sure you understood him/her correctly. Instead of saying You (are/always/never) Its better to say I feel /I think. The best times arent when the person is doing something, or there isnt enough time to talk or if youre in the middle of an argument. You can decide to change Before being with other people Thinking differently: To change your feelings towards others, you can decide beforehand the kind of thoughts you want to have when youre with them. After being with other people Learn from your experiences: think about the feelings you had while you were with them. If you use the strategies youve learned here, its less likely that you become depressed again or that you remain depressed for a long time. Contact with others is important for you mood because they can: Share pleasant experiences with you Help you reach your goals Provide you with company and a sense of security Provide you with valuable information about yourself, your strengths and areas to improve 2. When relationships dont work out, it doesnt necessarily mean that something is wrong with you or with the other person. Its helpful to consider the following questions: Do you both want the same thing from the relationship? Remember you always have the option to end a relationship that is not good for you. People can help you feel like a good person, as valuable and with good self-esteem.

There is a picture communications book in the communications aids boxes on the wards discount kemadrin 5 mg line. If a patient has swallowing difficulties cheap kemadrin 5 mg on line, again 5mg kemadrin otc, an appropriate route of administration needs to be identified. This information will be available on the patient passport if the patient has one. Yes X No Explain your response: Dosage adjustments of doses may be necessary due to declining renal or hepatic function as recommended in standard texts. Yes No X Explain your response: No adverse impact identified as a result of this policy. All staff can access training on equality and diversity and the Trust has participated in the Stonewall Healthcare equality index. Yes No X Explain your response: If the patient follows a religion or belief where certain substances are not allowed the prescriber should always check that the antibiotic does not contain these products. Yes No X Explain your response: Support may be required from the carer if the patient is to continue the antibiotic at home, particularly if the patient has a disability. Also paid carers may need more support and information if the patient is to continue the antibiotic when discharged to a care or nursing home. From the evidence available does the policy, procedure, proposal, strategy or service affect, or have the potential to affect any other groups differently? Yes X No Explain your response: Choice of antibiotics specifically as appropriate for pregnancy-related infections. If yes please describe the nature and level of the impact (consideration to be given to all children; children in a specific group or area, or individual children. As well as consideration of impact now or in the future; competing / conflicting impact between different groups of children and young people: c. If no please describe why there is considered to be no impact / significant impact on children Policy applies to adult patients 5. Relevant consultation Having identified key groups, how have you consulted with them to find out their views and that the made sure that the policy, procedure, proposal, strategy or service will affect them in the way that you intend? Consulted with: Consultants, Clinical Pharmacists, Antimicrobial Stewardship Group, Medicines Management Group 6. Any actions identified: Have you identified any work which you will need to do in the future to ensure that the document has no adverse impact? Approval At this point, you should forward the template to the Trust Equality and Diversity Lead lynbailey@nhs. Yet misuse and overuse of these drugs have contributed to a phenomenon known as antibiotic resistance. This resistance develops when harmful bacteria change in a way that reduces or eliminates the effectiveness of antibiotics. Antibiotic resistance is one of the most challenging public health issues of our times as antibiotics might no longer cure bacterial infections and common infections such as strep throat could once again prove fatal. Consequently it is necessary to curb all antibiotic uses as antimicrobial use in one environment will drive selection and 2 impact microbial diversity in another. In recent years consumer organisations have decided to address the antibiotic resistance issue from a food safety perspective after several years devoted to the fight against antibiotic resistance from the patient side only. After a series of tests on meat products, it emerged that the presence of antibiotic resistant bacteria is widespread. Multiresistant bacteria, which are of particular concern as they exhibit resistance to several classes of antibiotics, were also discovered in some products. Consumer organisations are particularly concerned of the growing presence of antibiotic resistant bacteria in food products and the associated consumers exposure and we believe policy-makers urgently need to protect consumers from this growing threat. Indeed this issue can only be addressed if strong policies to curb antibiotic overuse are in place. The option of banning the use of antibiotics in medicated feed should be thoroughly examined. Those antibiotics should be banned for species where a high risk of resistance transmission has been identified, as well as for therapeutic group treatment and eventually for metaphylaxis. When other treatment options are available we believe their use should be phased out. Carbapanems should also continue to be banned in veterinary medicine while tough controls are necessary to ensure the drug is not used for livestock production. At the same time concrete and ambitious reduction targets should be set to achieve a significant reduction in the use of antibiotics. Collecting data on the use of antibiotics at farm level proved to be an efficient way to compare practices and to align with the best performers. More and more bacteria strains are becoming resistant to several kinds of antibiotics, limiting treatment options, while few new antibiotics are available. Without antibiotics, therapies such as stem cell transplants, bone marrow transplantation, cancer chemotherapy as well as therapies weakening the immune system (e. Scientific and medical authorities have warned that if measures are not urgently taken we might return to the pre-antibiotic era, where people had no medicines and simple infections could kill. Arjun Srinivasan: Weve reached The End of Antibiotics, Period, Hunting the Nightmare Bacteria, Frontline. Contamination causing foodborne can occur by consumption of meat and dairy infections, such as products but also through spread of faeces and Salmonella, are manure which can end up on fruits and vegetables, becoming more well as in soil and rivers. Direct contact with animals and more can also be of significance depending on the type of resistant to bacteria. If we acknowledge the fact that it is difficult to quantify transmission potential between antibiotic resistant bacteria in livestock and antibiotic resistant bacteria in humans, it is now recognised that the intensive use of antibiotics in food animals adds to the burden of antibiotic resistance in humans. More and more scientific studies demonstrate a stronger link between the two than previously thought and a recent study showed genetic similarities between resistant isolates found in chicken 9 meat and humans. If the risk posed to humans by resistant organisms from farms and livestock cannot be precisely quantified the link between antibiotic use in food- producing animals and the occurrence of antibiotic-resistant infections in humans is 10 now undeniable. For instance in Germany, according to data collected by the Federal Office of Consumer Protection and Food Safety in 2011, 1. The relationship between antibiotic use in animal antibiotics are husbandry and the increase in resistance in bacteria pathogenic used in to humans is of particular concern because the same classes of livestock than antibiotics are used in both animal and human medicine and for human similar resistance mechanisms have emerged in both sectors. Therefore it is urgent to combat this growing threat by adopting measures to regulate the use of antibiotics at farm level and decrease the prevalence of these bacteria in food-producing animals and eventually in food products. The products, ranging from chicken fillets to pork chops, were bought in supermarkets but also in retail stores and butchers. Overall 16 member tests showed a high prevalence of antibiotic-resistant bacteria. In addition, members found some samples were contaminated with bacteria strains resistant to several antibiotics 18 belonging to different chemical classes, the so-called multiresistant bacteria. Yet this is the first initiative launched on such a scale which depicts how serious the situation actually is. After the Council and the European Parliament both called for immediate measures the European Commission issued an action plan listing twelve areas of actions. Such plan included the promotion of the appropriate use of antimicrobials and the need to consider this issue via the review of veterinary medicines and 19 medicated feed legislations. It has found that significant differences exist in the sales of antimicrobials between Member States, and that it cannot be explained by the animal husbandry practices. At the same time some countries are more affected by 21 antimicrobial resistance than others. Indeed the high prevalence of antibiotic resistant bacteria found in food products highlights the risk of contamination via the food chain. Indeed if consumers organisations will continue to Full test products and to provide advice to consumers on responsibility ways to avoid contamination, such as thorough cooking should not fall of the meat, careful handling of raw products to avoid on consumers cross-contamination and frequent hand washing, full who should be responsibility should not fall on consumers who should be provided with provided with safe food products. In six countries more than 70% of the products tested were contaminated with antibiotic resistant bacteria while eight countries reported that 22 half of the samples contained these harmful bacteria. Consequently the quantity of bacteria found is critical, as it increases contamination risks, but the profile of the bacteria is also a major criteria to take into account when analysing the results. It aims to demonstrate the high prevalence of antibiotic resistant bacteria in meat products in each country. On the one hand, prophylaxis consists in giving healthy animals antibiotics to prevent infection.

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