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By B. Kaelin. Lutheran Bible Institute.

Many of produced when the procedure set forth these names consist of several words order amantadine 100 mg with visa hiv throat infection symptoms. In the past it has been the practice of It contains not more than 45 percent of some manufacturers to subordinate the moisture discount amantadine 100 mg with visa hiv infection rate in uae, and its solids contain not words "pasteurized purchase amantadine 100mg fast delivery four stages hiv infection," "blended discount 100 mg amantadine mastercard hiv infection rate miami," less than 50 percent of milkfat, as de- "process," "food," and "spread" to termined by the methods prescribed in give undue prominence to the word §133. Harmless artificial blue or (d) Safe and suitable antimycotic green coloring in a quantity which neu- agent(s), the cumulative levels of tralizes any natural yellow coloring in which shall not exceed current good the curd may be added. Sufficient manufacturing practice, may be added rennet, or other safe and suitable milk- to the surface of the cheese. Each of the in- lent curd formation, or both, with or gredients used in the food shall be de- without purified calcium chloride in a clared on the label as required by the quantity not more than 0. The pressed curd is salted in the definition and standard of identity brine and cured in a well-ventilated and is subject to the requirements for room. During curing the surface of the label statement of ingredients pre- cheese is occasionally rubbed with a scribed by §133. A harmless preparation cheese, except that it contains not of enzymes of animal or plant origin more than 35 percent moisture, its sol- capable of aiding in the curing or de- ids contain not less than 45 percent of velopment of flavor of asiago fresh milkfat, and it is cured for not less cheese may be added during the proce- than 6 months. Asiago old cheese conforms to the (c)(1) For the purposes of this sec- definition and standard of identity and tion, the word "milk" means cow’s is subject to the requirements for label milk, which may be adjusted by sepa- statement of ingredients prescribed by rating part of the fat therefrom or by §133. The dairy ingredi- (iv) Antimycotic agents, applied to ents used may be pasteurized. The weight of the benzoyl per- clotting enzymes specified in para- oxide is not more than 0. The mass is cut into smaller por- calcium sulfate, and magnesium car- tions and allowed to stand for a time. If milk is bleached While the curd is being placed in forms, in this manner, vitamin A is added to the curd in such quantity as to com- spores of the mold Penicillium roque- pensate for the vitamin A or its precur- fortii are added. The forms are turned sors destroyed in the bleaching process, several times during drainage. Each of the in- midity, until the characteristic mold gredients used in the food shall be de- growth has developed. During storage clared on the label as required by the the surface of the cheese may be applicable sections of parts 101 and 130 scraped to remove surface growth of of this chapter, except that: undesirable microorganisms. One or zymes"; and more of the other optional ingredients (2) The dairy ingredients may be de- specified in paragraph (b)(3) of this sec- clared, in descending order of predomi- tion may be added during the proce- nance, by the use of the terms "milkfat dure. Rennet and/or food prepared from dairy ingredients other clotting enzymes of animal, and other ingredients specified in this plant, or microbial origin. The min- (ii) Calcium chloride in an amount imum milkfat content is 50 percent by not more than 0. If the dairy ingredi- (iii) Enzymes of animal, plant, or mi- ents used are not pasteurized, the crobial origin, used in curing or flavor cheese is cured at a temperature of not development. Each of the in- are used, the phenol equivalent value gredients used in the food shall be de- of 0. One or more of the clot- nance, by the use of the terms "milkfat ting enzymes specified in paragraph and nonfat milk" or "nonfat milk and (b)(2) of this section is added to set the milkfat", as appropriate. Part of the whey is then Brick cheese for manufacturing con- removed, and the mixture diluted with forms to the definition and standard of water or salt brine to control the acid- identity for brick cheese prescribed by ity. One or more of (a) Caciocavallo siciliano cheese is the other optional ingredients specified the food prepared from cow’s milk or in paragraph (b)(3) of this section may sheep’s milk or goat’s milk or mixtures be added during the procedure. The following ents specified in this section, by the safe and suitable ingredients may be procedure set forth in paragraph (b) of used: this section, or by another procedure (1) Dairy ingredients. Milk, nonfat which produces a finished cheese hav- milk, or cream, as defined in §133. Rennet and/or the procedure set forth in paragraph (b) other clotting enzymes of animal, of this section is used. It is cured for weight of the dairy ingredients, used as not less than 90 days at a temperature a coagulation aid. Harmless artificial blue or may be added to the surface of the green coloring in a quantity which neu- cheese. I (4–1–10 Edition) paste, or other safe and suitable milk- in this manner, sufficient vitamin A is clotting enzyme that produces equiva- added to the curd to compensate for lent curd formation, singly or in any the vitamin A or its precursors de- combination (with or without purified stroyed in the bleaching process, and calcium chloride in a quantity not artificial coloring is not used. The mass is manufacturing practice, may be added cut, stirred, and heated so as to pro- to the cheese during the kneading and mote and regulate the separation of stretching process and/or applied to the whey from curd. This whey is the name of such cheese is withdrawn, the curd is allowed to mat, "Caciocavallo siciliano cheese". These are made from sheep’s milk or goat’s milk washed in hot whey until the desired or mixtures of these, or one or both of elasticity is obtained. The curd is re- these with cow’s milk, the name is fol- moved from the vat, drained, pressed lowed by the words "made from into oblong forms, dried, and salted in lll", the blank being filled in with brine, and cured. Each of the in- ing in the curing or development of fla- gredients used in the food shall be de- vor of caciocavallo siciliano cheese clared on the label as required by the may be added during the procedure, in applicable sections of parts 101 and 130 such quantity that the weight of the of this chapter, except that enzymes of solids of such preparation is not more animal, plant, or microbial origin may than 0. If the (2) Such milk may be bleached by the dairy ingredients used are not pasteur- use of benzoyl peroxide or a mixture of ized, the cheese is cured at a tempera- benzoyl peroxide with potassium alum, ture of not less than 35 °F for at least calcium sulfate, and magnesium car- 60 days. The name of the subjected to the action of a lactic acid- food is "cheddar cheese". Each of the in- more of the clotting enzymes specified gredients used in the food shall be de- in paragraph (b)(2) of this section is clared on the label as required by the added to set the dairy ingredients to a applicable sections of parts 101 and 130 semisolid mass. The mass is so cut, of this chapter, except that: stirred, and heated with continued stir- (1) Enzymes of animal, plant, or mi- ring, as to promote and regulate the crobial origin may be declared as "en- separation of whey and curd. The whey zymes"; and is drained off, and the curd is matted (2) The dairy ingredients may be de- into a cohesive mass. The mass is cut clared, in descending order or predomi- into slabs, which are so piled and han- nance, by the use of the terms "milkfat dled as to promote the drainage of and nonfat milk" or "nonfat milk and whey and the development of acidity. The curd is salted, stirred, conforms to the definition and stand- further drained, and pressed into ard of identity prescribed for cheddar forms. Rennet and/or ents and in the same manner pre- other clotting enzymes of animal, scribed in §133. The letters in crobial orgin, used in curing or flavor the words "low sodium" shall be of the development. The weight of the hydrogen per- or names of the ingredient or ingredi- oxide shall not exceed 0. Colby cheese shall be deemed not dure set forth in paragraph (b) of this to have been made from pasteurized section is used. Sufficient rennet, or may contain an optional mold-inhib- other safe and suitable milk-clotting iting ingredient consisting of sorbic enzyme that produces equivalent curd acid, potassium sorbate, sodium sor- formation, or both, with or without pu- bate, or any combination of two or rified calcium chloride in a quantity more of these, in an amount not to ex- not more than 0. The mass is a clear aqueous solution prepared by so cut, stirred, and heated with contin- condensing or precipitating wood ued stirring, as to promote and regu- smoke in water as provided in para- late the separation of whey and curd. A graph (d)(1) of this section, the name of part of the whey is drained off, and the the food is immediately followed by curd is cooled by adding water, the the words "with added smoke fla- stirring being continued so as to pre- voring" with all words in this phrase of vent the pieces of curd from matting. Colby cheese for manufacturing con- (2) All cheeses used in a cold-pack forms to the definition and standard of cheese are made from pasteurized milk identity prescribed for colby cheese by or are held for not less than 60 days at §133. If there is no applicable and in the same manner prescribed in definition and standard of identity, or §133. Any safe and (ii) The fat content of the solids of a suitable ingredient or combination of cold-pack cheese made from a single ingredients that contains no sodium variety of cheese is not less than the and that is recognized as a salt sub- minimum prescribed by the definition stitute may be used. The letters in the the solids of cold-pack gruyere cheese words "low sodium" shall be of the is not less than 45 percent. I (4–1–10 Edition) pack cheese made from two or more of citric acid, acetic acid, and phosphoric the varieties cheddar cheese, washed acid, in such quantity that the pH of curd cheese, colby cheese, and granular the finished cold-pack cheese is not cheese is not more than 39 percent.

Insulin therapy Patients should be preferentially managed with protocol 1 (see below) in a high care ward cheap 100 mg amantadine mastercard hiv infection rates who, with appropriate monitoring cheap 100mg amantadine with mastercard anti virus ware for mac. Note: Ketonaemia takes longer to clear than hyperglycaemia and combined insulin + and glucose (and K ) are needed to ensure clearance of ketonaemia 100 mg amantadine otc symptoms of hiv infection. Progress management Continue protocols 1 or 2 until the acidosis has resolved and: o the patient is able to eat cheap amantadine 100 mg antiviral lip balm, and o subcutaneous insulin therapy is instituted either at previous doses or, for newly diagnosed diabetes at 0. Infusion must overlap with subcutaneous regimen for 1–2 hour to avoid reversion to keto-acidosis. They play an important role in the morbidity and mortality suffered by people with diabetes. There are three major categories: » peripheral neuropathy, » autonomic neuropathy, and » acute onset neuropathies. Surgical drainage as soon as possible with removal of necrotic or poorly vascularised tissue, including infected bone – refer urgently. Revascularisation, if necessary Local wound care Frequent wound debridement with scalpel, e. Antibiotic therapy For polymicrobial infection: Topical antibiotics are not indicated. Renal impairment rd Replace gentamicin plus cloxacillin with 3 generation cephalosporin, e. Many patients with mild or moderate dyslipidaemia will be able to achieve optimum lipid levels with lifestyle modification alone and may not require lifelong lipid modifying therapy. The goal of treatment should be explained clearly to the patient and the risks of untreated dyslipidaemia should be emphasised. Drug therapy should be considered when non- pharmacological means have failed to reduce the lipid levels to within the target range. When lipid-lowering drugs are used, this is always in conjunction with ongoing lifestyle modification. Non-cardiovascular The most serious non-cardiovascular complication of dyslipidaemia is the development of acute pancreatitis. This is seen in patients with severe hypertriglyceridaemia (fasting triglycerides >15 mmol/L). Aetiology » Ambulatory patients: hyperparathyroidism is the most common cause ( > 90% of cases). For hypoparathyroidism: • Calcium, elemental, oral, 500–1 500 mg daily in divided doses. Secondary hypothyroidism (less than 1% of cases) may be due to any cause of anterior hypopituitarism. Hypothyroidism in pregnancy About 60% of hypothyroid pregnant women need an increase in levothyroxine therapy in the second and third trimesters. Adequate dietary calcium intake (>1 g/day) particularly in the young, in breastfeeding mothers and in the elderly. Therefore, it is only recommended for use in the institutionalised frail elderly patients, where it may reduce the incidence of hip fractures. In institutionalised frail elderly patients: • Calcium, elemental, oral, 1 000 mg daily. Secondary prevention of osteoporotic fracture, including patients on long- term corticosteroids In severe osteoporosis, i. Avoid high calcium diet when immobile as hypercalcaemia may occur with immobilisation. Differentiate bone pain of Paget’s, especially at night, from arthritic pain in joints near deformed bone, e. Note: There are numerous causes of hyperprolactinaemia other than a prolactinoma, e. Radiotherapy may be required in selected patients A notification bracelet is needed. Hypogonadism Individualise dosage and need for replacement according to age, symptoms, etc. Acute management Post operatively: • Desmopressin, nasal spray, 10–20 mcg 12–24 hourly. Careful monitoring of electrolytes and exclusion of fluid overload while on therapy is essential to determine the appropriate dose. Clinical Always suspect in a patient with resistant hypertension or hypertension with hypokalaemia. Diagnosis Elevated serum aldosterone with a suppressed renin level or elevated aldosterone/renin ratio. Because of limited specificity, a positive screening test result should be followed by a confirmatory test. Other common causes are toxic single or multinodular goitre and sub-acute thyroiditis. Radioactive iodine In the setting of Graves’ disease radioactive iodine may be administered for failed medical therapy and may be indicated for patients with coexistent heart disease. It is contraindicated during pregnancy and lactation and in active thyroid associated ophthalmopathy, unless corticosteroid cover is given. Surgery Consider if the thyroid is very large or if there is failure of antithyroid drug therapy. Monitoring Patients with Graves’ disease who are treated with antithyroid drugs should be monitored every 6–8 weeks using a serum T4. Once in remission, patients may be monitored less frequently to determine signs and symptoms of recrudescence of thyrotoxicosis. Because there is a risk of neutropenia or agranulocytosis with carbimazole, therapy should be temporarily stopped and a white cell count (with differential) must be done in patients presenting with an infection or sore throat. Medical therapy is indicated initially for patients with underlying heart disease to achieve euthyroidism before radio-active iodine. Many anatomical sites can be involved and only the four most common will be discussed. It is essential to obtain specimens for culture and sensitivity testing in all cases before starting antibiotics, as multi-drug resistant organisms are common causes of hospital-acquired infections. Infections acquired in the intensive care unit are much more likely to be due to multi-drug resistant organisms. Close liaison with regional microbiologists and regular review of hospital antibiotic policy are essential. In some cases of infection with coagulase negative staphylococci the infection will resolve on removal of the catheter. Note: Candida isolated from blood culture should always be treated, even if the fever has settled after line removal. Switch to oral therapy according to antibiotic susceptibility after resolution of fever. Ventilator associated pneumonia Choice will depend on local susceptibility patterns. Risk Type of exposure Action Category 1 » touching or None if reliable history feeding animal » licking intact skin 2 » nibbling Wound treatment. Vaccine is ideally given as soon as possible after exposure, but should still be given if patient presents some time after the exposure. If vaccine administration is delayed > 48 hours, a double dose should be given initially. Immunoglobulin must be given as soon as possible after exposure, but may be administered up to 7 days after the first vaccine is given.

This can partly be explained by the precession geometry safe amantadine 100 mg antiviral y alcohol, which tends to excite whole systematic rows at once 100mg amantadine fast delivery hiv stages of infection. As demonstrated in Figures 5 to 7 generic amantadine 100 mg without prescription hiv infection skin rash, kinematically forbidden reflections discount 100 mg amantadine amex infection rates for hiv, for example, ± and or reflections of silicon, are frequently present in electron diffraction patterns as a result of multiple dynamical scattering. The ±(002) reflections in the [110] orientation of silicon arise mainly from the double scattering by the ±(111)¯ ¯ and ±(111)¯ reflections. Since these ±(111)¯ ¯ and ±(111)¯ reflections possess the largest net plane spacing, the effect of the geometri- cal part of the Lorentz factore on their intensities will be rather significant for low Structural Fingerprinting of Nanocrystals in the Transmission Electron Microscope 291 Zero precession 1. All diffraction patterns were recorded close to the amorphized edge region of the sample that borders on the vacuum region within the microscope. The concentric rings in all diffraction patterns arise from the above-mentioned amorphized edge region. The effect of the geometrical part of the Lorentz factore seems to dominate over its structure–thickness- dependent part for this thin crystal and may explain the initial absolute increase of the intensity of the kinematically forbidden ±(002) reflections with precession angle. One member of this pair of reflections is marked by an arrow in each diffraction pattern. Figure 8 provides a comparison of the effect of the precession angle on the intensity of the ±(002), ±(111), and ±(111) reflections for the 6-nm thin silicon nanocrystal of Figure 7 with the corresponding dependency of the thickest silicon nanocrystal of that range, that is, the 56-nm thick silicon nanocrystal of Figure 6. Principally different dependencies of the integrated intensities of kinematically for- bidden and “allowed” reflections on the precession angle for both thicknesses are revealed in Figure 8. While there is an exponential decay of the intensities for the ±(002) reflections of the thick crystal and an analogous decay with nearly the same slope between 1. These principally different dependencies may allow for a quite unambigu- ous identification of some of the kinematically forbidden reflections and could be utilized for advanced structural fingerprinting. The normalization was performed by dividing the maximal peak intensity of the reflections by the maximal peak intensity of the primary beam. The relative large difference in the intensities of members of the two Friedel pairs in (A) is due to the recording of the diffraction patterns close to the amorphized edge region of the sample, bordering on the vacuum region in the microscope (see caption of Fig. The program “Space Group Determinator” from the Calidris companyf supports such identifi- cations (82). This effect is also demonstrated by the integrated peak intensities of the ±(111) Friedel pair reflections in Figure 8(B). Dorset’s correction scheme (37) may, therefore, be developed on the basis of two experimental data sets that differ with respect to their “effec- tive curvature” of the Ewald sphere but are recorded successively from the same crystalline sample area. The extraction of information on the projected reciprocal lattice geometry is very similar for both sources of structural data. One of these parameters 294 Moeck and Rouvimov is the distance of the reflection to the reflection 000, in other words, the length of the reciprocal lattice vector of this reflection. The other parameter is the acute angle this reflection makes with another reflection. The remaining parameter is the length of the other reciprocal lattice vector that was used in order to define the (acute) “interfringe angle. Experimen- tal plots of projected reciprocal lattice geometry are thus independent of this orien- tation. Another advantage of this definition of the position parameters of reflections is connected to the ways in which lattice centering and space group symmetry ele- ments with glide component that result in kinematically forbidden reflections are dealt with in such plots. For now, it suffices to say that the experimental plots will represent the whole projected reciprocal lattice geometry in a consistent manner. The latter plots can be calculated “on the fly” over the Internet from our mainly inorganic subset (15) of the Crystallography Open Database (16–18) and contain all of the data points for all of the zone axes of a crystalline material up to a predefined resolution in reciprocal space. Identifying a crystal from its projected reciprocal lattice geometry is, thus, frequently equivalent to finding the 2D data points of the experimental plot within the theoretical lattice-fringe fingerprint plot. Figure 9 shows the theoretical lattice-fringe fingerprint plot for the mineral rutile for a 0. Screw axes and glide planes result in systematic absences of reflections in 2D projections of the reciprocal lattice geometry and are revealed in “kinematic lattice-fringe fingerprint plots” by missing rows [compare Figs. The so-called “Gjønnes and Moodie dynamically forbidden reflections” (83) are shown in dynamical lattice-fringe fingerprint plots [Fig. The other type of system- atic absences of reflections in 2D projections of reciprocal lattice geometries, which are due to 3D Bravais lattice centerings, results in systematic absences of entire rows in lattice-fringe fingerprint plots independent of the “kinematic” or “dynamic” type of these plots. While there are two data points in lattice-fringe fingerprint plots for reflections with different spacings, the crossing of two symmetrically reflections results in just one data point (because the latter possess by symmetry the same spacing). All of the resolvable lattice fringes and reflections up to the appropriate resolution will be included for a certain crystal Structural Fingerprinting of Nanocrystals in the Transmission Electron Microscope 295 Lattice-fringe fingerprint plot for rutile; Ti O2 90 85 80 75 70 65 60 55 50 45 40 35 30 25 20 15 0 3. Note the (Gjønnes and Moodie) dynamically forbidden reflections, for example, in the case of rutile in the exact [001] orientation, are included in the (two-beam) dynamic diffraction limit plot. Note the characteristically different distribution of the two-dimensional data points in both plots and that the abscissas are on different length scales. Structural Fingerprinting of Nanocrystals in the Transmission Electron Microscope 297 structure into these plots. The appearance of lattice-fringe fingerprint plots is, thus, both crystalline material and reciprocal space resolution specific (Figs. Figure 10(A) shows a theoretical lattice-fringe fingerprint plot that has been calculated for vanadium oxide nanotubes, a crystalline material that did not give a characteristic X-ray powder diffraction fingerprint (Fig. Due to the rather large unit cell dimensions of the vanadium oxide nanotubes (29), an older transmission electron microscope with a very modest Scherzerb resolution of 0. A modern analytical transmission electron microscope with a Scherzerb resolution of 0. Figure 10(B) shows a theoretical lattice-fringe fingerprint plot for the min- eral pseudo-brookite, for which a characteristic X-ray powder diffraction fingerprint was shown as Figure 1. From the comparison of Figures 10(A) and 10(B), one can conclude that lattice-fringe fingerprinting works for both types of crystalline mate- rials, those that do not (Fig. An initial search in a database of theoretical lattice-fringe fingerprints that is based on the 2D positions of data points in lattice-fringe fingerprint plots alone may result in several candidate structures. In the following steps, the search can be made more discriminatory both by trying to match crystallographic indices to the 2D positions and by determining the projected symmetry. Because one will always project along one zone axis, all indices of the reflec- tions must be consistent with a certain family of zone axes. As far as the lattice- fringe fingerprint plots are concerned, this follow-up search is equivalent to assign- ing crystallographic indices to the 2D data points. Each (vertical) column of data points in a lattice-fringe fingerprint plot corresponds to one family of reflections (net planes). Discrete points on a second x-axis in a lattice-fringe fingerprint plot can, therefore, be labeled with the respective Miller indices, , of a family of reflections. Each (horizontal) row of data points in a plot such as Figures 9 and 10, on the other hand, belongs to a family of zone axes. Discrete points on a second y-axis of such a plot can, thus, be labeled with the respective Miller indices, , of a family of zone axes. The cross product of the Miller indices of two data points from two different columns (representing two different reciprocal spacings) that are also located within the same row (representing one interfringe angle) gives the zone axis symbol, = × . While each family of reflections will show up only once on such a second x-axis, the same family of zone axis symbols may be showing up multiple times on such a second y-axis. Guided by the added 298 Moeck and Rouvimov Miller indices for columns and rows on such a lattice-fringe fingerprint plot, kine- matically forbidden reflections can be easily identified (in kinematical diffraction limit plots). Higher orders of a family of net planes {nh,nk,nl} possess an (n times) integral multiple of the spatial frequency of that family. Such higher orders of families are also easily spotted in a lattice-fringe fingerprint plot because their “columns” look identical. This is because the respective higher order net planes will intersect other net planes at precisely the same interfringe angles as those net planes from a lower order. Within the error bars and especially in lattice-fringe fingerprint plots for a very high microscope resolution, it is possible that families of net planes or zone axes coincide on the second x-ory-axis.

Surveys of medical schools’ curricula from the mid-1980s onwards have all indicated that the education of medical students about drug use is typically patchy and uncoordinated amantadine 100 mg overnight delivery hiv infection timeline. While ‘The orange guidelines’ have no specific statutory status cheap amantadine 100mg free shipping hiv infection ukraine, the standards and quality of care set out in the guidelines are taken into account in any formal assessment of clinical performance in this area buy amantadine 100 mg lowest price hiv infection rates by gender. There are also separate defined legal obligations in relation to the prescribing of controlled drugs published in both ‘The orange guidelines’11 and the British National Formulary amantadine 100mg free shipping hiv transmission statistics heterosexual. They include ensuring that prescribers act within Home Office licensing arrangements for the prescription of restricted medications such as diamorphine for the management of illicit drug use. Chapter 9 details how patients may present to either primary or secondary care in states of acute withdrawal. In these instances, healthcare professionals have a responsibility to manage the clinical emergency, stabilise the individual, and slow the rate of change so that their physiology can adapt and the distressing and uncomfortable symptoms of withdrawal are reduced. Doctors are also responsible for addressing the individual healthcare needs of patients who use drugs. In addition to harm-reduction measures, an essential part of managing this aspect of drug use should include offering immunisation against hepatitis to patients who want it. Harm reduction focuses on the safe use of drugs, and includes provision of clean injecting equipment and education on how to use drugs safely. There have been arguments over the ethics of harm reduction,28 and there is a perception among some healthcare professionals that harm-reduction techniques may lead to an increase in drug use by individuals who would otherwise be deterred. Those who support harm reduction assert that, rather than encouraging drug use, it offers a realistic way to help keep drug users safe, as well as respecting their choice and individual freedoms. Maintaining patients in high-quality treatment is the most effective preventative measure for these risks. Clinicians can also prevent the risk of drug overdose by providing education to drug users on the risks of overdose, the dangers of combining drugs, and how to respond effectively if overdose takes place. In the event of an overdose at a healthcare facility, all services working with drug users should have an emergency protocol in place that covers the management of drug overdoses (see Section 8. The drug debate, both nationally and internationally, has been influenced by emotions and ideologies, when, in reality, a subject as important as the use of drugs should be based on rationality and scientific evidence. What is needed is a solid and pragmatic approach to drug use, which is informed by the best available evidence and puts health at the centre of any decisions. There is a widely held view within the drugs field that the prohibition of production and supply of certain drugs has not only failed to deliver its intended goals, but has been counterproductive. Before this can occur, rational debate is needed to inform an understanding of what is, and what may not be, working with the current approach to drug use, and options for change. An essential component of this will be ensuring that all relevant parties, including health professionals, and the organisations that represent them, are consulted, so that a clear, unbiased and effective approach is achieved. The report recommends establishment of a Royal Commission – to be set up immediately and report in 2015 – to ‘consider the best ways of reducing the harm caused by drugs’ and ‘instigate a public debate on all of the alternatives to the current drug policy’. It presents strong arguments for focusing on problem drug users, with interventions that are ‘tailored to the individual’, and calls for the setting of measurable targets that are based on evidence of what works. Recognising the lack of reliable data in some areas, it further recommends allocation of ring-fenced funding to drugs policy research. Dependent drug users have the same rights to medical treatment as any other individuals with a chronic disorder, and effective medical management is likely to include harm reduction, maintenance treatment and support to eventually abstain from drug use. An effective drug policy must take account of the complex biological, psychological and social factors involved in illicit drug use and aim to distinguish the harms associated with drug use from the unintended adverse consequences of attempts to minimise drug use. An effective policy that significantly reduces the harms associated with illicit drug use would have enormous benefit for individuals and generate large savings to society in terms of the cost of medical treatment and the financial and social costs of associated crime. There is a widely held view within the drugs field that the current legal framework has failed to deliver its intended goals of reducing illicit drug use. There are strong views on both sides of this debate, but it should be informed by the best evidence. While it must be accepted that international consensus dictates that supply and possession of illicit drugs must remain a criminal offence, this framework deserves to be re-examined in a way that takes account of all the evidence available. Doctors are ideally placed to play a key role in refocusing debate and influencing global drug policy, so that it is based on public health principles, and founded on rigorous scientific evidence. Dr James Bell Professor Bailey was dual trained in child Consultant in Addictions Medicine, and adolescent psychiatry and forensic South London and Maudsley psychiatry. Dr Bell has been complex mental health needs who present active in the development of training as high risk of harm to others and programmes for health professionals, and themselves. She has worked in specialist was a leading figure in establishing the inpatient and community services, and has Chapter of Addiction Medicine within the interests in human rights in practice, and Royal Australasian College of Physicians. His mental health and social care policy in major research interest is the treatment of national and international contexts. Through opioid dependence but he has also recently various roles in the Royal College of developed a ‘party drugs’ clinic in South Psychiatrists, Professor Bailey has worked London, and has been involved in to support stronger partnerships between developing a new clinical pathway for users, carers and families. She has sought to management of acute alcohol withdrawal increase recognition of the importance of presenting to emergency departments. He has been Declaration of interests: funded to attend conferences and seminars Professor Bailey declares no support from by Reckittbenckiser, Schering-Plough any organisation for the submitted work and Corporation and Titan Pharmaceuticals. The Foundation has organised Addiction Psychiatry at the Chelsea and nine influential international drug policy Westminster Hospital and Honorary Senior seminars, hosted mainly at the House of Lecturer at Imperial College. He oversees Lords, and has commissioned over 35 books, three teams providing treatment for alcohol, drug policy reports and proceedings drugs and mental health problems. Dr Bowden-Jones is the drugs conventions that would give individual Chair of the Faculty of Addictions, Royal signatory countries more freedom to College of Psychiatrists. In this role he sits on experiment with alternative drug policies; a number of working groups. The position and (2) A cost/benefit analysis of a regulated also requires regular meetings with and taxed cannabis market in England and Government and other professional groups. Declaration of interests: Amanda Feilding declares that she has no conflicts of interests. Emily is Clinical Director for the Addictions Clinical Professor Sir Ian Gilmore Academic Group, with responsibility for Immediate Past President, addiction services across Lambeth, Royal College of Physicians Southwark, Bexley, Greenwich and Croydon, Professor Sir Ian Gilmore is a Professor of and inpatient services based at the Maudsley Medicine at the University of Liverpool and Hospital. From 2004 to 2007, Emily was the was a consultant physician at the Royal Clinical Team Leader at the National Liverpool University Hospitals until April Treatment Agency, where she took a lead in 2011. He has particular interest secretariat for the 2007 joint publication of in harms related to alcohol misuse and the the Department of Health (England), the role of regulation in reducing this. A blueprint guidelines on clinical management, and a for a coherent alcohol strategy. Emily is also a member of the also been appointed as Chair of the Addictions Executive of the Royal College of European Alcohol and Health Forum Science Psychiatrists. He received a Knighthood in National Institute for Health and Clinical the Queen’s Birthday Honours in 2010. He Alcohol and Public Health to the Royal appears before all levels of the domestic College of Physicians. In 2010 Ms Arsha Gosine he was the Chairman of the Bar Council of Policy Adviser, Crown Prosecution England and Wales. In his capacity as Service Chairman of the Bar he was involved in Arsha is a Policy Adviser with the Crown leading negotiations with Government on Prosecution Service and is their policy lead behalf of the profession on all issues from for drugs. Arsha holds a Masters in reform of criminal and civil justice systems to International Law and has presented on legal aid reform. Prior to provides legal guidance and updates for becoming Chairman he had been a member prosecutors nationally. He of the Association of Chief Police Officers has subsequently been appointed as the Drugs Committee. Chairman of the Advocacy Training Council, a body that facilitates and coordinates the Declaration of interests: training of and professional support for the Arsha Gosine has no competing interests Bar. He has held a long-term interest in the that might be perceived as posing a conflict impact of drugs policy upon the or bias. Declaration of interests: Nicholas Green has no interests that conflict or compete with the issues being considered in the report and that would affect his views.

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