Ceftin

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Thomas Myron Coffman, MD

• Professor of Medicine
• James R. Clapp Distinguished Professor of Medicine, in the School of Medicine
• Professor in Cell Biology
• Professor in Immunology

https://medicine.duke.edu/faculty/thomas-myron-coffman-md

The proportion obese in 2014 the global target of halting the risk of people who are overweight in diabetes antibiotic resistance is ancient order 250 mg ceftin overnight delivery. High and middle However antibiotic x 14547a buy generic ceftin 250mg line, the prevalence of income countries have more physical inactivity globally is of than double the overweight and increasing concern virus or bacteria generic 500 mg ceftin fast delivery. In 2010 antibiotic zyvox generic 250 mg ceftin with amex, the obesity prevalence of low-income latest year for which data are countries (see Figure 5b) bacterial transformation purchase ceftin overnight delivery. However chapter 46 antimicrobial agents discount 500mg ceftin with visa, retinopathy than the reduction in the non rates are higher among: people diabetic population. Rates caused by diabetes, hypertension of amputation in populations with or a combination of the two diagnosed diabetes are typically (18). Encouragingly several is growing most rapidly in low and studies show a 40% to 60% middle-income countries. No and higher-than-optimal blood such data estimates exist for low glucose together are responsible or middle-income countries. The complications have contributed to this increase, of diabetes have significant but are not solely responsible for it. Global prevalence doubled from Diabetes is a serious threat to 1980 to 2014, mirroring a rise in population health. The age-specifc quantitative effects of metabolic risk factors on cardiovascular diseases and diabetes: a pooled analysis. Global and regional mortality from ischaemic heart disease and stroke attributable to higher-than-optimum blood glucose concentration: comparative risk assessment. Management of diabetes and associated cardiovascular risk factors in seven countries: a comparison of data from national health examination surveys. Gestational diabetes mellitus: results from a survey of country prevalence and practices. Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: a collaborative meta-analysis of 102 prospective studies. The diabetes-cardiovascular risk paradox: results from a Finnish population-based prospective study. A combination of fscal policies, legislation, changes to the environment and raising awareness of health risks works best for promoting healthier diets and physical activity. Population-based data from such as being overweight or Cuba show a fall in type 2 diabetes obese, unhealthy diet, insuffcient during a period of economic crisis physical activity and smoking are when the population experienced modifiable through behavioural a reduction in calorie intake and a and environmental changes. At the individual level, intensive interventions to Actions to address overweight and improve diet and physical activity obesity are critical to preventing can prevent or delay the onset type 2 diabetes. Reducing to prevention of type 2 diabetes, population exposure to tobacco given emerging evidence of a may also reduce diabetes-related link between smoking and type 2 complications, in part through diabetes risk. These actions must be aimed at improving No single policy or intervention can maternal health and nutritional achieve changes of this magnitude. Early in life, when continue until babies are 2 years eating and physical activity of age or more); promoting habits are formed and when the growth in height; preventing the long-term regulation of energy consumption of foods that are balance may be programmed high in energy, fats, sugars and (7), there is a critical window for sodium; and facilitating physical intervention to mitigate the risk activity (10). The physical environment focuses on improving both diet can also provide sports, recreation and physical activity can be very and leisure facilities, and ensure effective in improving dietary there are adequate safe spaces patterns both inside and outside for active living for both children school (13). The poorest physical activity interventions Policies that groups in society, especially should result in consistent women, may have less time and improvements in the knowledge, increase the price fewer resources to participate in attitudes and behaviour of children of foods high in leisure-time activity, making policy and, when tested, in physical and fat, sugar and salt interventions that target active clinical outcomes (14). Workplace interventions addressing diet and physical the sports sector can encourage activity can be effective in regular structured activities, changing behaviours and health especially among children and related outcomes (16). Healthy adolescents, and can strengthen eating messages in cafes and the link between physical activity, restaurants have been shown to sports and health. Partnerships stimulate consumption of healthy with communities, the private food provided that healthy food sector and nongovernmental items are made available as part organizations can also contribute of the intervention (17). Workplaces to developing facilities for can help develop environments physical activity. Workplaces may offer their Settings-based interventions employees free or discounted can support diabetes prevention vouchers for physical activity and control. Price is often be comprehensive, make use reported as a barrier to people of existing programmes when buying and consuming healthy possible and focus on actions foods. Likewise, policy action to that do not require additional increase the price of foods high resources. There is ample evidence Trade and agricultural policies that the marketing of foods that promote healthy diets. For example, in 2000 of recommendations and an Fiji banned the supply of high-fat implementation framework on mutton faps under the Trading the marketing of foods and non Standards Act. Changes in Nutrition labelling is a regulatory agricultural subsidies to encourage tool that can guide consumers fruit and vegetable production can towards healthier food choices. In January 2014 Mexico implemented a nationwide tax on drinks containing added sugar (bebidas azucaradas) that increased their price by over 10%. While it is too early to draw far-reaching conclusions, one analysis estimated that the 10% increase in the price of added-sugar drinks was associated with an 11. During the frst year of the tax, purchases of taxed sugar-sweetened beverages decreased by an average of 6% compared to what would have been expected without implementation of the tax (25), with higher reductions found in households of low socioeconomic status. There is showed that active intervention, at high risk evidence that simple, front-of-pack lasting 2 to 6 years, could have labels on packaged foods, or point extended benefts for glycaemic of-purchase information in grocery and cardiovascular outcomes that stores, cafes or restaurants, can last for 10 to 20 years (32). These delayed or prevented, but turning campaigns have greater impact this knowledge into large and are more cost-effective when scale impact brings significant used within multicomponent challenges. For example, a programmes depends on the social marketing campaign in feasibility of identifying, assessing Tonga using netball to promote and successfully involving high physical activity among women as risk groups (see Box 4). Its scoring includes questions based on age, sex, ethnicity, family history of diabetes, history of abnormal glucose metabolism, smoking status, current hypertensive treatment, physical activity, fruit and vegetable consumption, and waist circumference (36). It has the potential to will depend, at least in part, on overwhelm primary care services, the numbers likely to be identifed where the responsibility for and the resources available to intervention usually lies. Assessment of interventions are made available, diabetes risk should not be and whether or not systematic confused with the total risk assessment of risk is undertaken, approach to cardiovascular disease primary health-care services must risk in which diabetes is included be equipped to manage people as one component. These people diabetes results should receive (as a minimum) Much type 2 diabetes results from from risk factors repeat counselling on weight loss, modifable risk factors that can that can be reduced diet, physical activity and smoking. Creating of approaches at preventable, the causes and risk supportive policy, social and population and factors for type 1 diabetes remain physical environments for healthy unknown and prevention strategies lifestyles is a key aspect of type 2 individual levels. Healthy food and opportunities for physical activity must be available and affordable. As a result, hope has emerged that analogous interventions in humans might prevent type 1 diabetes or signifcantly slow the decline in beta cell function that characterizes the condition. Effective intervention of this nature could signifcantly reduce the incidence of type 1 diabetes and its long-term complications, greatly enhancing quality of life for people living with it. Primary prevention trials involving dietary modifcation have been conducted with infants identifed through genetic screening as being at highest risk of developing type 1 diabetes. Two large randomized clinical trials have explored the use of vitamin B6 supplementation in adults and children who are related to people with type 1 diabetes and are pancreatic islet antibody-positive, with negative results. Injected insulin and oral insulin have also been explored as preventive interventions in children with antibodies to insulin. The overall results were negative but a subgroup with the highest concentration of anti-insulin antibodies at the start of the trial showed some delay in onset. Other approaches, as yet unsuccessful, have been treatment of people at high risk with nasal insulin, low-dose cyclosporine and with a monoclonal antibody. Action is required implementation of these should both to increase physical activity reduce the occurrence of type 2 and healthy diet, and to reduce diabetes. Achieving the global sedentary behaviours and intake voluntary target to halt the rising of unhealthy foods and beverages. Trade measures and regulatory policies such as taxes on foods and beverages; restriction of marketing of unhealthy foods and non-alcoholic beverages; and implementing effective front of-package labelling frequently face opposition from industry. Interference by food and beverage companies in policy-making and conflicts of interest can lead to the adoption of industry self regulatory schemes that tend to be less effective than government regulation. A whole-of-government approach, and even a whole-of-society approach, is essential to the success of most of these strategies. Without support from the highest level of government, it may be diffcult to engage effectively with other key sectors, such as trade, industry, agriculture and education. Defnition, diagnosis and classifcation of diabetes mellitus and its complications. Population-wide weight loss and regain in relation to diabetes burden and cardiovascular mortality in Cuba 1980-2010: repeated cross sectional surveys and ecological comparison of secular trends. Population approaches to improve diet, physical activity, and smoking habits: a scientifc statement from the American Heart Association. A recommendation to improve employee weight status through worksite health promotion programs targeting nutrition, physical activity or both. Preventing noncommunicable diseases in the workplace through diet and physical activity. Fall in total cholesterol concentration over 5 years in association with changes in fatty acid composition of cooking oil in Mauritius: cross sectional survey. Agricultural policy and childhood obesity: a food systems and public health commentary. Price elasticity of the demand for sugar-sweetened beverages and soft drinks in Mexico. Beverage purchases from stores in Mexico under the excise tax on sugar sweetened beverages: observational study. Set of recommendations on the marketing of foods and non-alcoholic beverages to children. Tackling of unhealthy diets, physical inactivity, and obesity: health effects and cost-effectiveness. Using rapid assessment and response to operationalise physical activity strategic health communication campaigns in Tonga. Uusitupa M, Peltonen M, Lindstrom J, Aunola S, Ilanne-Parikka P, Keinanen-Kiukaanniemi, et al. The long-term effect of lifestyle interventions to prevent diabetes in the China Da Qing Diabetes Prevention Study: a 20-year follow-up study. Prevention of type 2 diabetes; a systematic review and meta analysis of different intervention strategies. Good management using a standardized protocol can potentially prevent complications and premature death from diabetes using: a small set of generic medicines; interventions to promote healthy lifestyles; patient education to facilitate self-care; regular screening for early detection and treatment of complications through a multidisciplinary team. Facilities for diabetes diagnosis and management should be available in primary health-care settings, with an established referral and back-referral system. Access to essential medicines (including life-saving insulin) and technologies is worryingly limited in low and middle-income countries. Well-structured health services end-stage renal disease) have been can provide the key interventions observed in countries that have and regular follow-up necessary adequate data to examine trends to help people with diabetes over time (4). Where reductions in live long and relatively healthy complications have been observed lives, even though it is a chronic, at population level they are likely progressive disease. Many of these to be the result of improvements in interventions are known to be the management of key risk factors cost-effective or cost-saving, and such as smoking, blood pressure are feasible even in low-resource and lipid levels, and blood glucose, settings (1, 2, 3). Controlling blood along with improvements in the glucose levels and cardiovascular organization and quality of care. Type 2 diabetes often undiagnosed and shows no symptoms, and some Whether people should be untreated diabetes, patients contact health services screened or not for type 2 diabetes because of a complication such is a much-debated question and the worse their as vision loss, heart attack or currently there is no definitive health outcomes limb gangrene. Type 2 diabetes evidence from randomized trials are likely to be develops slowly and there is to answer it. Some evidence often a very long period of time suggests there are benefits to in which the disease is present but early detection and treatment, undetected. Diabetes can also be the decision to put in place (or diagnosed by measuring glycated not put in place) systems for haemoglobin (HbA1c), even if the early detection is a strategic one patient is not in a fasting state that depends on a number of (5). Screening programmes blood glucose concentration over will increase the number of the past few weeks, rather than clinically diagnosed cases of the blood glucose concentration type 2 diabetes and as such will at that moment (reflected by increase the health-care system the fasting and 2-hour blood workload, not only in dealing with glucose measurements mentioned the process of early detection above). However, the test is but, more importantly, in dealing more costly than blood glucose with the increased number of measurement (5). No system should be Blood glucose measurement to established without consideration diagnose diabetes should be of whether local health-care available at the primary health resources are suffcient to cope care level.

Medication tracking begins three months after enrollment month to account for gaps between enrollment and first prescription refill antibiotics for dogs chest infection ceftin 250mg for sale. Completed surveys were received from the nephrologist for 12 of the 14 identified patients virus attack purchase 250mg ceftin overnight delivery, with at least one survey from each of the five identified nephrologists infection process purchase ceftin with american express. There is no proven benefit of these medications on mortality in dialysis patients with uncontrolled hypertension antibiotics for acne south africa purchase ceftin 500mg without a prescription. Nevertheless antibiotics for acne safe during pregnancy order ceftin 250 mg amex, the observed prevalence of hypertension by study criteria was extremely high ure 8 infection high blood pressure buy generic ceftin on-line. First, the small patient sample size generally limits the extent of the inference we can draw from our analyses. Additional study is needed to evaluate the impact of interventions to improve medication management and related quality indicators among dialysis patients with hypertension. Prescription patterns of pharmacological agents for left ventricular systolicdysfunction among hemodialysis patients. In 2007, the program was expanded to include Connecticut, Alabama, Tennessee, and California. Patients with a functioning transplant at enrollment were excluded from these analyses. Supplements were discontinued as soon as the three month average serum albumin exceeded 3. Patients were provided 24 cans per month of the standard oral supplement Ensure Plus (Abbott Laboratories), and were advised to consume one can per day at home, with a certain number of days off per week. In 2007, Glucerna (Abbott Laboratories), a nutritional supplement designed for patients with diabetes mellitus (diabetes), was used for patients with diabetes. In this Project, serum albumin was recorded in October, November, and December of 2006. Although both patient groups experienced an increase in mean serum albumin within the first three months of enrollment, the increase in albumin was more robust among patients with a lower initial serum albumin. Impact of Oral Nutritional Supplements on Mortality We conducted an intent-to-treat analysis for one-year mortality similar to the hospitalization analysis. Hemodialysis patients are at a particularly increased risk of malnutrition for several reasons [2]. This is a more robust statistical methodology as this is not subject to treatment by indication bias as well as patient factors. One-year hospitalization rates were not significantly different from the comparison group in the intention-to-treat analysis. Department of Health and Human Services, Centers for Medicare & Medicaid Services, Office of Clinical Standards & Quality, Baltimore, Maryland, December 2008. Consensus Report: Expert working group on nutrition in adult patients with renal insufficiency (Part 2 of 2): Clinical Nutrition 2000; 19(4): 281-291. Cardiovascular-related hospitalizations were identified by the presence of a cardiovascular-related diagnosis code. We computed time-to-death beginning at enrollment, and ending at time of disenrollment, transplant, or the end of the enrollment period. Higher scores indicate poorer health (observed scores ranged from a minimum of 0 to a maximum of 101). These administrative changes may have resulted in differences in characteristics of the patient sample over time. Therefore, we performed separate analyses for 2006 enrollees and 2007/2008 enrollees, in addition to an overall analysis combining 2006-2008 patients. For each patient, all calendar weeks in which the patient was enrolled for the entire week were included. A 900 800 700 600 500 400 300 200 100 0 Jan-06 Jul-06 Jan-07 Jul-07 Jan-08 Jul-08 Jan-09 Calendar Time Figure 10. B 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 0 3 6 9 12 15 18 21 24 27 30 33 36 Months Since Patient Enrollment 1. Logistic regression was used to model the odds of having an extra dialysis session during all calendar weeks. The hazard ratios associated with all-cause mortality from adjusted Cox regression models predicting time to death are also shown in Table 10. For comparison, from 2005 to 2007 the unadjusted cardiovascular-related mortality rate for U. For dialysis sessions both two days apart and three days apart, there were significant interactions for black race (p < 0. However, issues of patient non-adherence/non-acceptance and technical challenges such as patient difficulties using and hooking up the scale made this impractical. However, few patients were able to utilize it due to the lack of a land line telephone. Often, extra sessions are provided in the hospital because they are required urgently, and these sessions were likely not captured in this dataset. Programmatic changes instituted during the evaluation period, as well as the large reduction in participation in the program during 2007-2008 compared to 2006, technical challenges, and patient non-adherence/acceptance issues may have contributed to the disparate findings noted between the 2006 and 2007-2008 enrollee cohorts. Available at: Health, National Institute of Diabetes and Digestive and. Unite d Sta tes Renal Health, National Institute of Diabetes and Digestive and Da ta Sys the m. Fluid Report: Atlas of Chronic Kidney Disease and End-Sta ge retention is associated with cardiovascular mortality in Renal Disease in the United States. Circulation Health, National Institute of Diabetes and Digestive and 2009; 119(5): 671-9. Though national trends in mortality rates are encouraging, hospitalization rates have shown little change since 1980 [3]. This chapter will describe findings for one and two year survival, all-cause and cardiovascular hospitalizations, and kidney transplantation outcomes. Populations and Data Sources Patients who enrolled in the Demonstration at any time from January 1, 2006 through December 31, 2008 and were receiving dialysis at the time of enrollment were included in these analyses. Patient time at risk ended at the first of Demonstration disenrollment, death, three days prior to transplant (so as not to include the hospitalization for transplantation), or December 31, 2008. In these instances a risk score based only on demographic information from the current year was used [4]. Data from the federally-funded national registry of wait-listing and Arbor Research Collaborative for Health 67 Final Report Chapter 11: Patient Outcomes transplantation, collected by the Organ Procurement and Transplantation Network and analyzed by the Scientific Registry of Transplant Recipients, were used to examine wait-listing rates and combined with Medicare data to examine transplantation rates for each program. Patients aged 70 years or older were excluded from the transplantation, wait-listing, and transplant referral analyses. To illustrate, if one of the groups had a higher percentage of patients with diabetes, then unadjusted differences in mortality rates may simply be due to the higher prevalence of diabetes in one group. Specifically, we calculated adjusted survival, hospitalization, and transplantation percentages using stratified Cox proportional hazards models, which is one of the most established methodologies in healthcare outcomes research [6-10]. To account for residual differences remaining after the propensity-score methodology, a second-stage multivariate regression adjustment was performed using a negative binomial regression model. We also examined Poisson regression models (with correction for over-dispersion) and found similar results. As described in further detail in the Technical Appendix, both methods are commonly used for count data such as Arbor Research Collaborative for Health 68 Final Report Chapter 11: Patient Outcomes service utilization. The negative binomial regression results are shown in this Report because these models generally fit the data better. Results There were 2, 364 dialysis patients in the Demonstration after excluding 14 patients with functioning transplants at enrollment. These differences in patient characteristics highlight the importance of statistical adjustment for the analyses presented in this chapter. Arbor Research Collaborative for Health 69 Final Report Chapter 11: Patient Outcomes a Figure 11. Arbor Research Collaborative for Health 70 Final Report Chapter 11: Patient Outcomes a Figure 11. In a separate analysis of the excluded patients who have Medicare as a secondary payer, we generally found comparable utilization of services including hospital admission rates. However, we excluded these patients as their utilization data may not be complete. Transplantation, Wait-listing, and Referral Transplant-related analyses were limited to patients under 70 years of age. Arbor Research Collaborative for Health 73 Final Report Chapter 11: Patient Outcomes a Figure 11. Wait-listing data for all patients were collected by the Organ Procurement and Transplantation Network and obtained through the Scientific Registry of Transplant Recipients. Arbor Research Collaborative for Health 74 Final Report Chapter 11: Patient Outcomes Table 11. In general, patients who were younger were more likely to be referred for transplant. The analysis of service utilization in this Demonstration found no evidence of a robust, systematic reduction in hospitalization rates. Possible explanations for the lack of clear improvement in clinical outcomes may relate to several factors. First, programmatic changes observed in Disease Management components because of operational reasons may have limited their potential impact. However, modification of this program removed the routine pharmacist evaluation of patient medications. A second potential explanation is that Disease Management which focuses on care coordination, modification of self-care behavior and prevention may be insufficient to effect change on clinical outcomes. Finally, differences in degree of interaction between patients and members of the health care team may influence the effectiveness of Disease Management. This is a promising finding and demonstrates the ability of care coordination at the dialysis facility to replace the need for utilization of additional services elsewhere. In particular, regular interaction during dialysis sessions may reduce the need for outpatient physician visits. Transplant-Related Outcomes We evaluated three transplant-related outcomes: transplantation, transplant wait-listing and referral for transplantation. Furthermore, the high frequency of patient refusal as a reason for non-referral for evaluation suggests the need to strengthen patient education efforts on the benefits of kidney transplantation. Finally, the high percentage of missing data accounting for reasons for non-referral suggests that this information is not routinely collected in dialysis facilities. Identifying reasons for non-referral of a patient for transplant evaluation is important in determining and addressing obstacles to kidney transplantation. It is plausible that social and cultural factors among Hispanics may lead to increased focus on health and well-being of sick relatives leading to improved clinical outcomes [13]. First, we analyzed several components of patient outcomes including survival, hospitalization and transplantation-related outcomes. Statistical adjustment allows for a more fair comparison, but relies upon measuring all variables that may differ between the populations and be causally associated with the outcomes of interest. We attempted to address this limitation by performing multivariate second-stage regression as described above. A third limitation of the propensity score method used for the utilization analysis is that longitudinal effects of the program on utilization and cost were not taken into account. Sensitivity analyses stratified by enrollment times revealed no substantive differences from the results reported here. This evaluation differs from prior Disease Management demonstrations because of three key aspects. In particular, emphasis on care coordination and modification of patient behavior as part of Disease Management may be insufficient and treatment interventions may be necessary to impact clinical outcomes significantly. In this current analysis, statistical adjustment and the use of matched control groups were critical given the observed differences in case-mix, though unobserved differences may persist. We observed promising survival benefits in this notably fragile and complex patient population. Applied disease management: Is $1billion a year a good Survival Analysis: Regression Modeling of Time to Event investment The Evaluation of disease-state management of dialysis Statistical Analysis of Failure Time Data. The United States: An Update from the United States Renal Analysis of Survival Data in Nephrology: Basic Concepts Data System. These two summary scores are composite scales based on four domains of mental health and four domains of physical health. A change of five percentage points (on a scale of 0-100) or more in sub-scales or composite scores was considered a clinically meaningful change, based on accepted norms in the literature [6].

Ceftin 250 mg cheap. Outsmarting Bacteria: Confronting Antibiotic Resistance.

Online social networks and security of their users: an exploratory study of students at the Faculty of humanities and social sciences Zagreb // Central European Conference on In formation and Intelligent Systems infection prevention week 2014 generic ceftin 500mg with amex, University of Zagreb Faculty of Organization and Infor matics treatment for dogs with fits discount ceftin 500 mg otc, 2013 antimicrobial over the counter purchase online ceftin, 214-221 virus 1980 buy discount ceftin online. The top spot holds information operations virus repair buy ceftin cheap, perception management and various types of cyber-at tacks ardis virus cheap ceftin 250mg otc. Cyber-attacks that can be carried out via critical infrastructure can disa ble the normal functioning and development of a society or state for a long time. Analyzing such threats and designing solutions to reduce or eliminate these threats is a challenge for current and upcoming generations of computer secu rity and legal experts. In this research paper, some examples of cyber-attacks on critical infrastructure from this decade are analyzed to see which attack vectors are the biggest threats and what can be done to avoid or minimize its impact. Key words: hybrid warfare, cyber-attacks, critical infrastructure, defence strat egies Introduction In the modern world, various states, centers of power, various activist groups and individuals are trying to spread their influence. The spread of influence can be done in two ways: through hard power and through soft power. Instead of pushing 1 someone to do something, the same goal is achieved through co-operation. But there is a gray zone, something that is neither purely conventional warfare, nor peaceful diplomatic and economic action. Apart from the problems that may arise in private and business networks, special problems can arise out of threats on critical infrastructure. Given the role critical infrastructure has, it can have seri ous consequences for the stability and integrity of states. There are many differ ent attack vectors like email attachments, insecure network connection, physical access to an insufficiently protected device, web pages, operating system ex 1 Joseph Nye: Soft Power: the Means of Success in World Politics, pp. The aim of this research paper is to analyze several examples of cyber-attacks on a critical infrastructure, to see which attack vector represents the greatest danger and what can be done to avoid or minimize the impact of certain cyber-attack. Today, all these resources are managed by means of information communication technology, which opens up a special attack vector. What makes it an advantage for easier management and control is at the same time a weakness subject to attacks. Domovic, Cyber-attacks as a threat to critical infrastructure Why can we consider that Schneier is right In the protection of information communication systems it is essential to keep its functionality, easy managea bility, scalability and supervision of the system. In the data security it is essen tial to stick to the classical principle of cryptography, i. Since the information and communication system consists of not only software and hardware, but also the people who manage it and protocols and procedures under which it is being operated, it is obvious that there are many points where an error or omission may occur. The attackers in front of them have a concrete system with concrete technologi cal solutions. They have advantage over defence which has to anticipate attacks, which is practically impossible because the attacks are enhanced by the devel opment of technology and knowledge. At the time of launching a system in operation, attacks on it or its parts may be completely unknown and impossible to predict. In addition, sharing knowledge in computer security is often hampered by business secrets and the secrecy of scientific discovery until its publication in a journal or at a conference. This benefits the group of attackers who unite resources in an at tempt to attack a newly discovered weak point in a system. In general, cyber-attacks can be divided into four categories according to the 7 type of the attack: a. By analyzing the cyber-attacks on critical infrastructure, it is possible to draw conclusions about which attack vectors are currently the most common and which critical points of the system within critical infrastructure are the most vulnerable. Threat analysis For the purpose of this paper five major cases of cyber-attacks on critical infra structure from this decade have been analyzed. Stuxnet Worm Impact on Industrial Cyber-Physical System Security, 2011, papers. The first phase of such attack is studying the targets and con ducting social engineering over the target by which it is fooled, causing it to install malware. The second phase is a breakthrough in the network and the search for the appropriate parts of the information system, such as a user with as many administrator access rights to servers as possible. The third phase is the ultimate activity such as data gathering, data modi fication, data deletion, etc. In this attack, the attacker sent two different phishing emails within two days to two small groups of employees, who at the first glance were not worth the effort, just doors to higher levels. The assumption is that the attacker had previously gathered information about these employees. In this case, the attack vector is also human error, an error made by the operator that works in the com pany, who opened infected file on a computer connected to the internal company network. In 2014 a hacker group known as Dragonfly or Energetic Bear attacked companies from energy sector in Europe and United States. Havex is known to be distributed to targeted users through three arrival vectors: spam emails, exploit kits and trojan ized installers planted on compromised vendor sites. The collected data is then forwarded to compromised websites, which surreptitiously 13 serve as remote Command and Control (C&C) servers. Consequently, the operators were unable to adequately reg ulate and immediately turn off a blast furnace. In this case, the attack vector is also human error, an error made by certain employees who have activated backdoor and released malware into the network. On December 23, 2015 an event that according to gathered evidence points to a cyber-attack at three regional electric power distribution com panies, called Oblenergos, has caused a power outage in Ukraine and made impact on approximately 225, 000 customers. According to company personnel, the cyber-attacks at each com pany occurred within 30 minutes of each other and impacted multiple 13 F-Secure. Report on Cybersecurity and Critical Infrastructure in the Americas, 2015, (Access date 29. Domovic, Cyber-attacks as a threat to critical infrastructure central and regional facilities. The companies believe that the ac tors acquired legitimate credentials prior to the cyber-attack to facilitate remote access. Companies also reported that they had been infected with BlackEnergy malware which was delivered via spear-phishing emails with malicious Microsoft Office attachments. It is suspected that it may have been used as an initial attack vector to acquire legitimate cre 16 dentials. In this case, the attack vector is also human error, an error made by cer tain employees who have activated backdoor and released malware into the network. Based on the performance of the attacks and the spotted defects in defense it can be analyzed which scenarios should occur so that the attacks are unsuccessful and without or with less dam age. Unfortunately, all essential attacks detail and countermeasures needed for thorough in-depth analysis are not available. Therefore, after the analysis car ried out on the basis of available information, a synthesis of the necessary de fense countermeasures can be made. Particularly interesting case is a Stuxnet breach into the uranium enrichment plant in a desert outside Natanz in central Iran. Its wall and roof are reinforced with con 19 crete and covered with layers of earth and it is heavily guarded. This prevents unwanted surveillance over the facility, physical entry into the facility and par tially protects it from missiles and different kinds of armed attacks. Regarding to cyber-attacks, it prevents side channel attacks on the internal electronic de vices and communication. It means that they are isolated from the internet or any other external network, which prevents di rect intrusion by remote attackers. It looks like all the necessary protection measures have been taken so that any type of cyber-attack taken from the out side is not possible. Since it is impossible to access internal devices from the outside because of the air-gap, the air-gap needs to somehow be bypassed. Whether it is updating of operating systems, software, hardware or firmware, whether it is adding new components to a fa cility that should be connected to others, these operations are usually conducted by outside contractors. Technicians who are employees of companies who as outside contractors collaborate with a nuclear facility, have the ability to enter the plant and perform upgrades of the system. For the upgrade, it is necessary to add new parts of the upgrade to the existing components. These companies were a gateway and its infected technicians were carriers which passed Stuxnet inside Natanz facility and bypassed the air-gap. So, a sce nario in which no air-gap bypass comes up includes a thorough check of every device entering the plant, conducted on separate pieces of equipment that are also air-gapped. It is time consuming and requires additional resources but re duces the possibility of breach. For such cases, an optimal solution should be found, but it cannot be presented in this paper because any such solution de pends on the specific situation in a specific environment. Domovic, Cyber-attacks as a threat to critical infrastructure In four other cases, there were procedures under which employees should not open suspicious files or click on suspicious links. Despite this, the breaches oc curred by phishing emails and compromised web sites which download pay loads to an access computer. A scenario in which such breaches cannot occur involves administrator procedure of blocking every incoming file on the email server, sending message to a recipient that there is a file for him and that it should be checked on the air-gapped machine before being delivered to a spe cific computer. But this procedure can create a massive queue on email check ing which can affect working efficiency and cause harm to operational capabili ties of certain critical infrastructure. There can be other solutions and again, an optimal solution depends on the specific situation in a specific environment. From all analyzed cases it is possible to extract elements of cyber-attacks that represent the greatest threat. The greatest threat that cannot be entirely resolved will remain the existence of zero-day exploits and carefully programmed mal ware which can remain undetected despite sophisticated digital-forensic equip ment, all-rounded procedures, staff knowledge and experience. If the precautionary measures are inten 21 sified, it may be significantly reduced. Also, it is possible to extract elements of cyber-attack countermeasures that are usually implemented, but must be improved. Critical infrastructure must be protected physically and procedurally from all known types of attack. In addition, as much as possible, new types of attacks must be foreseen and accordingly there has to be a modular defense strategy. Implementation of defensive strategies depends on certain type of critical infra structure, its business operation and cost/benefit analysis of cyber security in vestments. Due to the importance of critical infrastructure for the functioning of a society, defence strategies must be fully met. Cyber-attacks are being carried out fre quently and the consequences are very expensive. In all cases, such attacks began by gathering information about certain employees who are then manipulated and deceived by social engineering which forces them to un consciously install malware into the computer. That action allows attackers further penetration into the network and causing damage. Part of the package of solutions that provide resilient critical infrastructure, in addition to high-quality security specialists and technology solutions, must in clude a scenario in which vital part of information systems must be procedures that prevent air-gap bypassing as well as continuing education of personnel in terms of computer security and how to not become a victim of social engineer ing who makes fatal errors. For a thorough study on this topic, more examples should be analyzed with in depth look at targeting infrastructure and types of cyber-attack methods. The persuasion and security awareness experiment: reducing the success of social engineering attacks. Centre for International Govern ance Innovation, Chatham House, 2017. Report on Cybersecurity and Critical Infrastructure in the Americas, 2015. The patients are not satisfied only with the medical report and diagnosis made by a professional, they want to know more. Therefore digital technology is used to gain more information about the painful syndromes in the lower back. The pain that occurs in the lower back is called lumbago and it can have several causes. The hypothesis stated in the research: H1: Participants show interest and positive attitude in using infor mation technology in order to assist in the back pain treatment. This research carried out the result analysis of the E-back pain questionnaire about the usage of information technology and the digital communication capabilities in order to achieve new knowledge and to expand the already existing one related to the back pain.

Rather patient-specific epitope pattern might be relevant for birch-related soybean allergy bacteria 2 buy ceftin with american express. Therefore a thorough diagnosis by the combination of component-resolved diagnosis and profound epitope analysis might be mandatory in the future antibiotics for clearing acne buy generic ceftin canada. Using two misfolded variants of rBet v 1a and rGly m 4 the impact of unstructured allergens in rBet v 1a/rGly m 4 preparations was addressed with physico and immunological assays antibiotic name list cheap ceftin 500mg with mastercard. Correlation of rBet v 1a 5 Summary 141 content with secondary structure and IgE binding was suitable only at high rBet v 1aS112P/R145P levels in mixtures infection under crown discount ceftin 500mg on-line. In addition infection 2004 order ceftin online now, quantification of IgE-binding allergen was difficult for concentrations of rBet v 1a 10% in all assays bacteria organelles purchase cheap ceftin online. Results of both misfolded variants rBet v 1aS112P/R145P and rGly m 4S111P/L150P might be used within screening of hypoallergenic molecules with potential use in treatment of allergies or in quality assessment of recombinant allergen preparations. Grund ist eine Kreuzreaktion von IgE Antikorpern gerichtet gegen das Hauptallergen der Birke, Bet v 1, und dem strukturhomologen Allergen Gly m 4 der Sojabohne. Die klinischen Symptome konnen in der Birkenpollen-assoziierten Sojaallergie bis hin zu schweren Reaktionen, wie einem anaphylaktischen Schock, reichen. Patienten mit einer Birkenpollen assoziierten Sojaallergie weisen demnach sowohl IgE-Antikorper gegen Bet v 1 als auch Gly m 4 auf. Auffallig ist hierbei, dass Birkenpollenallergiker ohne assoziierte Sojaallergie oft auch diese beiden Allergen-spezifischen IgEs besitzen. Deshalb kann die Prasenz von Gly m 4-gerichteten IgEs an sich nicht als geeigneter Marker fur eine Sojaallergie eingesetzt werden. Um eine exakte Diagnose und wirkungsvolle Therapie zur Behandlung solcher Allergien zu ermoglichen, sind neben Patientendaten auch detaillierte Informationen uber die IgE-bindenden Bereiche, die sogenannte Epitope, auf Gly m 4 notig. Bis heute ist jedoch nur wenig uber IgE Epitope von Bet v 1 und seinem Homolog Gly m 4 bekannt. Aminosauren von Gly m 4, die als mogliche IgE-bindende Reste in Frage kommen, wurden mittels einer bioinformatischen Analyse von IgE-bindenden Peptiden einer Phagenbibliothek sowie durch das Mappen von Primarstrukturabschnitten von Gly m 4 auf dessen Proteinoberflache identifiziert. Auerdem wurden funf Varianten von rGly m 4, die insgesamt 18 potentiell IgE relevante Aminosaureaustausche zeigen, erzeugt und hinsichtlich ihrer Bindung an 6 Deutsche Zusammenfassung 143 Patienten-IgE untersucht. Zusatzlich wurden zwei ungefaltete Varianten von rBet v 1a und rGly m 4 hergestellt und in unterschiedlichen Mischungen mit korrekt gefaltetem rBet v 1a/rGly m 4 anhand diverser immunologischer und physiko chemischer Verfahren untersucht. Hinsichtlich ihrer mittleren Gly m 4-spezifischen IgE und IgG-Konzentrationen konnte kein Unterschied zwischen Patienten mit (IgE: 9. Weiterhin korrelierten diese spezifischen IgE-Konzentrationen nicht mit dem klinischen Phanotyp der Patienten. Insgesamt konnten aus 51 Gly m 4-spezifischen Aminosauren 46 potentiell funktionale IgE-Epitope identifiziert werden. Bei funktionalen Epitopen handelt es sich um einzelne Aminosauren, welche innerhalb eines strukturellen IgE-Epitops die Energetik der Allergen-IgE-Bindung dominieren. Das potentielle, funktionale IgE-Epitopprofil jedes Patienten war individuell und nicht charakteristisch fur die Unterscheidung zwischen Allergikern und Nicht-Allergikern. Alle 46 potentiell funktionalen IgE Epitope konnten in sechs mogliche Epitopbereiche auf Gly m 4 zusammengefasst werden. Eine densitometrische Analyse der IgE-Bindung in Patientenseren wurde mittels eines Dot Blots durchgefuhrt, jedoch konnte kein charakteristisches IgE-Epitopprofil ermittelt werden. Demnach sind die identifizierten potentiell funktionalen IgE-Epitope spezifisch fur die Bindung von IgE-Antikorpern in der Studiengruppe. Vielmehr scheint ein patientenspezifisches Epitopprofil Grundlage fur eine Birkenpollen assoziierte Sojaallergie zu sein. Somit konnte also eine Kombination aus rekombinant hergestellten Allergenen und der detaillierten Untersuchung mittels einer Epitopbibliothek zukunftig zu einer genaueren Diagnose fuhren. Mittels der beiden Allergenvarianten von rBet v 1a und rGly m 4 konnte der Einfluss von ungefaltetem Protein durch physikochemische und immunologische Methoden in Praparaten aus rBet v 1a bzw. Beide Varianten rBet v 1aS112P/R145P und rGly m 4S111P/L150P zeigten eine ungefaltete Proteinstruktur sowie eine reduzierte IgE-Bindung in den eingesetzten Patientenseren. Eine Korrelation von rBet v 1a-Konzentration mit der Sekundarstruktur des Allergens sowie der IgE-Bindung war nur bei hohen Konzentrationen an rBet v 1aS112P/R145P moglich. Bei letzteren waren groere Unterschiede zwischen nativem und ungefaltetem Allergen fur eine eindeutige Korrelation notig. Weiterhin war die Bestimmung an IgE-bindendem Allergen in allen Assays fur rBet v 1a-Konzentrationen 10% schwierig. Die Ergebnisse der beiden Faltungsvarianten rBet v 1aS112P/R145P und rGly m 4S111P/L150P konnten fur das Screening von hypoallergenen Molekulen zur moglichen Behandlung von Allergien oder in der Qualitatskontrolle von Allergenpraparaten eingesetzt werden. Relevance of IgE binding to short peptides for the allergenic activity of food allergens. Clinical characteristics of soybean allergy in Europe: a double-blind, placebo-controlled food challenge study. Component-resolved in vitro diagnosis of carrot allergy in three different regions of Europe. Celery allergy confirmed by double-blind, placebo-controlled food challenge: a clinical study in 32 subjects with a history of adverse reactions to celery root. Carrot allergy: double-blinded, placebo-controlled food challenge and 7 References 146 identification of allergens. Enlarging the toolbox for allergen epitope definition with an allergen-type model protein. IgE versus IgG4 epitopes of the peanut allergen Ara h 1 in patients with severe allergy. Cooking birch pollen-related food: divergent consequences for IgE and T cell-mediated reactivity in vitro and in vivo. Efficacy of birch-pollen immunotherapy on cross-reactive food allergy confirmed by skin tests and double-blind food challenges. Stepwise prediction of conformational discontinuous B-cell epitopes using the Mapitope algorithm. Effect of tree pollen specific, subcutaneous immunotherapy on the oral allergy syndrome to apple and hazelnut. MimoPro: a more efficient Web-based tool for epitope prediction using phage display libraries. Several distinct properties of the IgE repertoire determine effector cell degranulation in response to allergen challenge. Isoallergen variations contribute to the overall complexity of effector cell degranulation: effect mediated through differentiated IgE affinity. Purification and characterization of a soybean hull allergen responsible for the Barcelona asthma outbreaks. Characterization of a stress-induced, developmentally regulated gene family from soybean. A mutational analysis of binding interactions in an antigen-antibody protein-protein complex. Prediction of IgE-binding epitopes by means of allergen surface comparison and correlation to cross-reactivity. Secondary soy allergy in children with birch pollen allergy may cause both chronic and acute symptoms. Gly m 2S albumin is a major allergen with a high diagnostic value in soybean-allergic children. Sensitization profiles in birch pollen-allergic patients with and without oral allergy syndrome to apple: lessons from multiplexed component resolved allergy diagnosis. Pollen-food syndromes associated with weed pollinosis: an update from the molecular point of view. Anaphylaktische Reaktion nach Sojagenuss bei einem Patienten mit Birkenpollenallergie. Modulation of IgE reactivity of allergens by site-directed mutagenesis: potential use of hypoallergenic variants for immunotherapy. Ferreira, F, Rohlfs, A, Hoffmann-Sommergruber, K, Schenk, S, Ebner, C, Briza, P, Jilek, A, Kraft, D, Breitenbach, M, Scheiner, O. Modulation of IgE binding properties of tree pollen allergens by site-directed mutagenesis. Purification and characterization of recombinant Bet v I, the major birch pollen allergen. Focke-Tejkl, M, Weber, M, Niespodziana, K, Neubauer, A, Huber, H, Henning, R, Stegfellner, G, Maderegger, B, Hauer, M, Stolz, F, Niederberger, V, Marth, K, Eckl-Dorna, J, Weiss, R, Thalhamer, J, Blatt, K, Valent, P, Valenta, R. Development and characterization of a recombinant, hypoallergenic, peptide-based vaccine for grass pollen allergy. Franck, P, Moneret Vautrin, D A, Dousset, B, Kanny, G, Nabet, P, Guenard Bilbaut, L, Parisot, L. Bet v 1, the major birch pollen allergen, and Mal d 1, the major apple allergen, cross-react at the level of allergen-specific T helper cells. Ganglberger, E, Grunberger, K, Wiedermann, U, Vermes, M, Sponer, B, Breiteneder, H, Scheiner, O, Boltz, G, Jensen-Jarolim, E. Monitoring allergen immunotherapy of pollen-allergic patients: the ratio of allergen-specific IgG4 to IgG1 correlates with clinical outcome. Chimeras of Bet v 1 and Api g 1 reveal heterogeneous IgE responses in patients with birch pollen allergy. Birch pollen-related food allergy: clinical aspects and the role of allergen-specific IgE and IgG4 antibodies. Gieras, A, Cejka, P, Blatt, K, Focke-Tejkl, M, Linhart, B, Flicker, S, Stoecklinger, A, Marth, K, Drescher, A, Thalhamer, J, Valent, P, Majdic, O, Valenta, R. Mapping of conformational IgE epitopes with peptide-specific monoclonal antibodies reveals simultaneous binding of different IgE antibodies to a surface patch on the major birch pollen allergen, Bet v 1. Presentation of allergen in different food preparations affects the nature of the allergic reaction-a case series. IgE, IgG4 and IgA specific to Bet v 1-related food allergens do not predict oral allergy syndrome. Prediction of residues in discontinuous B-cell epitopes using protein 3D structures. Hecker, J, Diethers, A, Schulz, D, Sabri, A, Plum, M, Michel, Y, Mempel, M, Ollert, M, Jakob, T, Blank, S, Braren, I, Spillner, E. Epitope grafting, re-creating a conformational Bet v 1 antibody epitope on the surface of the homologous apple allergen Mal d 1. Allergy Vaccine Engineering: Epitope Modulation of Recombinant Bet v 1 Reduces IgE Binding but Retains Protein Folding Pattern for Induction of Protective Blocking-Antibody Responses. Soybean (Glycine max) allergy in Europe: Gly m 5 (beta-conglycinin) and Gly m 6 (glycinin) are potential diagnostic markers for severe allergic reactions to soy. Intralymphatic allergen-specific immunotherapy: an effective and safe alternative treatment route for pollen-induced allergic rhinitis. Ilari, A, Franceschini, S, Bonamore, A, Arenghi, F, Botta, B, Macone, A, Pasquo, A, Bellucci, L, Boffi, A. Ito, K, Sjolander, S, Sato, S, Moverare, R, Tanaka, A, Soderstrom, L, Borres, M, Poorafshar, M, Ebisawa, M. IgE to Gly m 5 and Gly m 6 is associated with severe allergic reactions to soybean in Japanese children. Jahn-Schmid, B, Radakovics, A, Luttkopf, D, Scheurer, S, Vieths, S, Ebner, C, Bohle, B. Bet v 1142-156 is the dominant T-cell epitope of the major birch pollen allergen and important for cross-reactivity with Bet v 1-related food allergens. Long-term tolerance after allergen immunotherapy is accompanied by selective persistence of blocking antibodies. Jensen-Jarolim, E, Leitner, A, Kalchhauser, H, Zurcher, A, Ganglberger, E, Bohle, B, Scheiner, O, Boltz-Nitulescu, G, Breiteneder, H. Peptide mimotopes displayed by phage inhibit antibody binding to bet v 1, the major birch pollen allergen, and induce specific IgG response in mice. Mechanisms of allergen-specific immunotherapy and novel ways for vaccine development. Kahlert, H, Suck, R, Weber, B, Nandy, A, Wald, M, Keller, W, Cromwell, O, Fiebig, H. Characterization of a hypoallergenic recombinant Bet v 1 variant as a candidate for allergen-specific immunotherapy. Prevention of allergy by a recombinant multi-allergen vaccine with reduced IgE binding and preserved T cell epitopes. Kazemi-Shirazi, L, Pauli, G, Purohit, A, Spitzauer, S, Froschlc, R, Hoffmann Sommergruber, K, Breiteneder, H, Scheiner, O, Kraft, D, Valenta, R. Quantitative IgE inhibition experiments with purified recombinant allergens indicate pollen-derived allergens as the sensitizing agents responsible for many forms of plant food allergy. Klinglmayr, E, Hauser, M, Zimmermann, F, Dissertori, O, Lackner, P, Wopfner, N, Ferreira, F, Wallner, M. Identification of B-cell epitopes of Bet v 1 involved in cross-reactivity with food allergens. Severe reactions after the intake of soy drink in birch pollen-allergic children sensitized to Gly m 4.

References

• Fink G, Krelbaum T, Yellin A, et al. Pulmonary carcinoid: presentation, diagnosis, and outcome in 142 cases in Israel and review of 640 cases from the literature. Chest 2001;119(6):1647-1651.
• Futterer, J.J., Heijmink, S.W., Scheenen, T.W. et al. Prostate cancer: local staging at 3-T endorectal MR imaging-early experience. Radiology 2006;238:184-191.
• Nam JE, Ryu YH, Cho SH, et al. Air-trapping zone surrounding sclerosing hemangioma of the lung. JComputAssistTomogr 2002;26:358-61.
• Coca SG, Krumholz HM, Garg AX, Parikh CR: Underrepresentation of renal disease in randomized controlled trials of cardiovascular disease. JAMA 2006;296:1377-1384.
• Robinson TN, Wallace JI, Wu DS, et al: Accumulated frailty characteristics predict postoperative discharge institutionalization in the geriatric patient, J Am Coll Surg 213:37n42, discussion 42n34, 2011.
• Avery RK, Ljungman P. Prophylactic measures in the solid-organ recipient before transplantation. Clin Infect Dis. 2001;33(suppl 1):S15-SMolrine DC, Hibberd PL. Vaccines for transplant recipients. Infect Dis Clin North Am. 2001;15(1):273-305, xii. Health Information for International Travel 2007-2008: The Yellow Book. Atlanta, Georgia: Centers for Disease Control and Prevention, Department of Health and Human Services; Rand EB, McCarthy CA, Whitington PF. Measles vaccination after orthotopic liver transplantation. J Pediatr. 1993;123(1): 87-89.