Jeffrey A Brinker, M.D.
- Professor of Medicine
- Joint Appointment in Radiology and Radiological Science
There is no cure for migraine purchase triamterene 75mg amex arteria spinalis anterior, and medications can only help reduce the frequency and severity of disorder (Bigal 2008) order triamterene without prescription blood pressure chart for elderly. It usually begins at the suboccipital region and spreads anteriorly to generic triamterene 75 mg overnight delivery blood pressure causes the ipsilateral orbital, frontal, and temporal areas. It is believed to be due to convergence of upper cervical and trigeminal sensory pathways allowing pain signals to refer from the neck to the trigeminal sensory fields of the head and face. Treatments with pain medication, physical therapy, manipulative treatment, and surgical interventions may provide only some inconsistent temporary relief of pain (Naja 2006). Various ablative surgical procedures targeting the trigeminal nerve, or the cranial parasympathetic outflow have been tried to treat these patients with intractable headaches. These include gamma knife surgery or root section of the trigeminal nerve, trigeminal tractotomy, microvascular decompression of the trigeminal nerve, glycerol injection of the Gasserain ganglion, and others. However, none of these procedures has a consistent effect, and many are associated with serious complications (Magis 2007). Electrical stimulation of the brain was first attempted late in the 19th century, but its application for pain control began in the 1960s with spinal cord stimulation. The neurostimulaton technique for ablating pain is based on the theory that peripheral nerve stimulation can produce specific focal analgesia and anesthesia. In addition, the technique may alter perception of pain by blocking cell membrane depolarization and axonal conduction with directly applied current (Shealy 1967, Lim 2007, Trentman 2008). In the early 2000s, neurostimulation therapy emerged as a potential treatment option for a variety of different intractable primary headache disorders. An incision is made over the occipital region at the level of the first cervical vertebra for the subcutaneous implantation of bilateral electrodes. These are tunneled in a cephalad direction so that they come to lie across the path of the greater occipital nerve on each side of the head. Confirmation of the electrode position by testing each separately by an external stimulator. The operator gradually increases the amplitude delivered to the electrodes from 0 to 4 v, and the patient is asked to locate and describe any sensation he /she feels. Correct placement is confirmed by the patient describing a vibrating sensation that radiates at least 4 cm cephalad from the base of the skull, on the side of the tested electrode, and Phase 3. Implantation of the stimulator battery in the pectoral, abdominal, or gluteal region, and connecting it to the electrodes via subcutaneously tunneled leads. The procedure is performed under sedation or general anesthesia, however during the second phase the patients are required to be awake and to be able to identify the position of the occipital electrodes when the electric stimulus is applied. Potential complications of the procedure include lead migration, infection, localized pain, muscle spasm, and lack or loss of effect (Lim 2007, Trentman 2008). It is typically implanted unilaterally on the side corresponding to the most severe symptoms. The use of bilateral stimulation using two electrodes has been investigated in patients with bilateral, severe symptoms. Initially, the electrode(s) is/are attached to a temporary transcutaneous cable to validate treatment effectiveness and, if effective, the patient returns to surgery several days later for permanent subcutaneous implantation of the cable and a radiofrequency-coupled or battery-powered programmable stimulator. After implantation, noninvasive programming of the neurostimulaton can be adjusted to control the © 2010 Kaiser Foundation Health Plan of Washington. Back to Top Date Sent: 3/24/2020 303 these criteria do not imply or guarantee approval. The procedures can be performed only by a highly experienced neurosurgeon and may be associated with a small risk of mortality due to intra-cerebral hemorrhage. Before implantation, all patients must undergo complete preoperative neuroimaging to exclude disorders associated with increased hemorrhagic risk (Leon 2006, Bartsch 2008). Neither the occipital nerve stimulation nor the deep brain stimulators are approved to date by the U. Food and Drug Administration for the treatment or prevention of primary headaches. There are no published randomized or nonrandomized controlled trials on the intervention to date. The empirical studies consist of a few very small case series with no comparison groups and a number of case reports. The outcome measures varied between studies as some reported change in pain and others reported on headache frequency intensity, disability and/or medication use. To date all published studies on hypothalamic deep brain stimulation are small case series and case reports with a combined total of 55 participants with refractory chronic cluster headache. Leone et al’s series had the largest size (N=16) and follow-up duration (mean 23 months). The results of this study and other case series indicate that this invasive procedure has potential serious complications and is not always effective. Deep brain stimulation was not compared to another treatment or intervention to determine that the benefit observed was no a placebo effect. The majority was review articles, opinion pieces, or dealt with technical aspects the procedure. The use of Deep brain stimulation for the treatment of primary headache does not meet the Kaiser Permanente Medical Technology Assessment Criteria. Back to Top Date Sent: 3/24/2020 304 these criteria do not imply or guarantee approval. Background Defecation is a highly complex physiologic process that requires normal colonic transit, ano-rectal sensation, expulsion force, and coordinated function of the pelvic floor for successful evacuation. Patients typically report symptoms such as excessive straining, sensation of blockage, and a feeling of incomplete evacuation. Some patients even report a need to use digital maneuvers to defecate, and frequent use of enemas or suppositories. Defecography, first described in 1952 by Wallden, was initially developed for the evaluation of outlet obstruction (Wallden 1952).
In adults: prophylaxis of acute organ rejection in renal transplantation using immunosuppressants like cyclosporin cheap triamterene 75 mg with mastercard arrhythmia getting worse, corticosteroid discount triamterene 75mg blood pressure classification, etc cheap triamterene 75mg on-line blood pressure medication types. In children: prophylaxis of acute organ rejection in renal transplantation using immunosuppressants like cyclosporin, corticosteroid, etc. Treatment of acute allograft rejection in renal transplant 7/20/1999 Becaplermin Regranex gel 0. Patients in whom surgery, radiotherapy or dopamine Sandostatin Lar agonist treatment is inappropriate or ineffective, or in the 9/18/1999 Octreotide 10mg, 20mg Novartis Korea Ltd. Alleviation of symptoms associated with gastro-entero pancreatic endocrine tumor carcinoid tumors with features of carcinoid syndrome. Treatment of patients with thrombocythemia, secondary to myeloproliferative disorders (Essential thrombocythaemia, Chronic myelogenous leukemia, Anagrelide Polycythaemia and other myeloproliferative disorders), to 10/18/1999 Agrylin capsule Yuhan Corp. Treatment of advanced breast cancer in women with natural or induced postmenopausal status whose disease 5/23/2000 Exemestane Aromasin tab 25mg has progressed following anti-oestrogen therapy and Pharmacia & Upjohn Ltd. Treatment of the following infections when caused by Quinupristin and Aventis Pharmaceutical Co. Reducing signs and symptoms and inducing and maintaining clinical remission in patients with moderately to severely active Crohn’s disease who have 10/21/2000 Infliximab Remicade had an inadequate response to conventional therapy. Treatment of patients with refractory anaplastic astrocytoma and refractory glioblastoma multiforme, i. Adjuvant therapy of severe bacterial infections additional IgM enriched Human 1/22/2001 Pentaglobin injection to antibiotic therapy; immunoglobulin substitution in Korean Drug Co. Thyroid globulin test or whole body scanning for recurrence possibility and/or metastasis of thyroid cancer, Sam-Oh Pharmaceutical Co. Treatment of hypercalcemia and osteolysis due to 9/17/2002 Disodium clodronate Bonefos capsule Schering-Plough Korea Ltd. Treatment of hypercalcemia and osteolysis due to 9/17/2002 Disodium clodronate Bonefos solution Schering-Plough Korea Ltd. The pharmaceutical market is valued at around $7 billion and offers advanced technology and a very high standard of care. While there are a number of Hong Kong-based drug manufacturers, more advanced drugs are generally imported. The Drug Office sector is responsible for drug registration and drug import/export control in Hong Kong. Separate applications should be submitted for variations in dosage form and strength; however, different package sizes do not require separate applications. This Committee only meets four times a year, so applicants should make an effort to submit their application several weeks prior to a Committee meeting in order to reduce processing time. The second option, registering under the “normal” registration process, takes 6-9 months to complete. Application forms should be turned into the Drug Registration and Import/Export Division. For detailed information for application requirements, refer to the guidelines posted on the Drug Office of the Department of Health website. In this case, a distributor can apply for importation of the orphan drug on behalf of supporting doctors in Hong Kong. Regarding sales, companies should keep in mind that in Hong Kong, pharmaceutical products, including orphan drugs, are not reimbursable unless a product is specifically listed on the hospital list of supplies. The best way to get an orphan drug on the hospital list of supplies is via very strong doctor support and active lobbying by the patients/parents. In addition, once an importer is importing an orphan drug, they will be the only importer that can sell the drug in Hong Kong. While a list of orphan drug approvals in Hong Kong is not available, a comprehensive and searchable database of all drug approvals in Hong Kong can be found at. Clinical papers in support of any new indications and claims that are not well documented in 7 pharmacopoeias and for unusual combination of drug ingredients 8 Method of analysis Three expert reports: Pharmaceutical Report, 9 Clinical Report and Pharmacological Report If product is an over-the One set of original (prototype) sales pack (outer counter medicine, sales pack 10 carton) and container label of each pack size of label must include dosage, product route, and frequency of use in both English and Chinese Real-time and accelerated 11 Stability test data to justify proposed shelf life conditions Certificate of analysis of representative batch of 12 product Reference standard with enough samples for ten 13 tests, including sterility testing Copyright © 2017 Pacific Bridge Medical. Foreign companies have centered their business expansion on large urban areas, such as Beijing, Shanghai and Guangzhou. In addition to huge principal areas, many “second tier” cities, such as Wuhan, Chengdu, and Dalian, are also quickly catching up in prosperity and becoming excellent markets. As the country’s citizens have begun to lead more affluent lifestyles due to the economic boom, their healthcare standards have increased. Additionally, pharmaceuticals are playing a much larger role in the Chinese lifestyle, especially in urban areas. However, the increased affluence and foreign influence on China has also led to changes in the country’s epidemiological profile. Now, chronic diseases, such as cardiovascular disease and cancer, are some of the leading causes of death. China is the world’s second largest drug market, and is expected to grow to $167 billion by 2020, representing an annual growth of 9. Foreign drug companies are significant players in China’s drug market, though there are thousands of domestic pharmaceutical companies throughout the country. The majority of these domestic pharmaceuticals companies produce generic drugs and they neither have the technology nor meet the quality requirements to compete with the foreign companies. Some of these domestic companies have paired up with foreign companies in Sino foreign joint ventures to be more competitive in the growing pharmaceutical market.
A significantly greater proportion of patients in the immediate treatment group perceived “less thinness” in the face buy generic triamterene online arrhythmia alliance. The study was limited by the short follow-up period buy generic triamterene 75 mg online heart attack feat thea austin, small sample size with no statistical power analysis and lack of clear primary outcomes order cheap triamterene on-line blood pressure chart 13 year old. The other empirical study reviewed was a case series with 50 patients (Valentin, 2003). Although there was no comparison group, advantages of the Valentin study were that there was objective measurement of changes in facial thickness and follow-up was longer, 96 weeks. There was a significant increase in the quality of life score compared to baseline at the 24 and 48 weeks follow-ups, but not at the 72 or 96-week follow-ups. The generalizability of Valentin study has been criticized because one dermatologist performed all of the injections; it is not known whether there would be similar results with other dermatologists. In summary, there is some evidence from an uncontrolled case series that treatment with Sculptra can reduce facial lipoatrophy for up to 96 weeks and has no serious adverse effects, when used by a trained dermatologist. The ideal study would have the following characteristics: Randomized controlled trial, Comparison of Sculptra to alternative treatment, or placebo, Long-term follow-up, sufficiently large sample size, Important outcomes include whether treatment with Sculptra is effective at increasing facial fat and reduces any adverse psychosocial effects. The third empirical study was a case report presenting data on 4 patients and was excluded from review. The following studies were critically appraised: Valantin M-A Aubron-Olivier C, Ghosn J et al. Back to Top Date Sent: 3/24/2020 565 these criteria do not imply or guarantee approval. Back to Top Date Sent: 3/24/2020 566 these criteria do not imply or guarantee approval. Background Fecal incontinence occurs when a person loses the ability to control his/her bowel movements and is unable to retain feces in the rectum. It can be caused by a wide variety of conditions that affect either the anatomy or function of the anal sphincter. Perineal injury during childbirth is a common cause of fecal incontinence in women. It can also be caused by neurological disorders such as spinal injury and multiple sclerosis, or it can result from anorectal surgery. In any case, fecal incontinence is common and, due to its association with considerable physical and social disability, is often under-reported (Tjandra, Chan et al. First line treatment for fecal incontinence is usually conservative and includes antidiarrheal medication and pelvic floor muscle training. In patients for whom conservative treatment fails, alternative treatments include surgery to tighten the anal sphincter, sacral nerve stimulation, creation of a new sphincter from other suitable muscles, implantation of an artificial sphincter or a permanent colostomy. Injectable bulking agents offer an additional, less invasive, second line treatment for fecal incontinence. The concept is to inject a biocompatible material to close © 2013 Kaiser Foundation Health Plan of Washington. Back to Top Date Sent: 3/24/2020 567 these criteria do not imply or guarantee approval. Criteria | Codes | Revision History the anal canal to avoid fecal incontinence (Siproudhis, Morcet et al. At least ten different materials have been used as bulking agents for fecal incontinence including autologous fat, Teflon, bovine glutaraldyhyde, cross-linked collagen, carbon coated zircomium beads, polydimethylsiloxane elastomer, dextranomer in nonanimal stabilized hyaluronic acid, hydrogel cross-linked with polyacrylamide, porcine dermal collagen, synthetic calcium hydroxylapatite ceramic microspheres and polyacrylonitrile in cylinder form (Maeda, Laurberg et al. The procedure may be performed under local, regional or general anesthesia and the injection may be guided by the surgeon’s finger in the anal canal or by ultrasound. This treatment is potentially attractive in its simplicity and minimal invasiveness and can be performed in an outpatient setting. Currently, the committee has been asked to review the literature on the safety and efficacy of injectable bulking agents for the treatment of fecal incontinence compared to standard treatment for fecal incontinence. This is the first time that bulking agents have been reviewed for this indication. Only two of the trials compared a bulking agent to sham treatment and none of the studies made a comparison of bulking agents versus other therapies. On the whole, the studies were of poor quality with only two providing adequate information to reliably assess bias. Two of the trials reported on the short-term benefit from injections as outcome measures improved with time but neither trial had follow up beyond 12 months (Siproudhis, Morcet et al. In addition, there appeared to be some short-term benefits from injections given with ultrasound guidance compared with digital guidance (Tjandra, Han et al. Two of the studies compared different types of bulking agents with the larger trial reporting that silicone material was better than the carbon coated beads in terms of fecal incontinence at six and 12 months (Tjandra, Chan et al. The smaller trial, which was not included in this critical appraisal, compared the injection of Bulkamid™ with Permacol™ and showed some improvement in outcomes in both groups but ultimately was too small to detect differences between groups (Maeda, Vaizey et al. Currently the literature addressing the efficacy of injectable bulking agents is limited for a variety of reasons. First and foremost, outcome measures and the definition of response to treatment are varied, and as a result, problematic for this indication. Furthermore, it is unclear how severity of incontinence at baseline affects outcomes data. Finally, there is a lack of information regarding the volume, the precise location where the agent should be placed, and the choice of guidance of the needle track. Several different techniques were employed with various bulking agents used across all studies making comparisons complicated. Overall, the observed adverse events were similar across all the studies with few complications reported and the most commonly reported complication being pain at injection site.
Iraq conducted research and development work on anthrax buy triamterene 75mg otc blood pressure medication diabetes, botulinum toxins purchase cheap triamterene online blood pressure chart jpg, Clostridium perfringens triamterene 75 mg with visa blood pressure wrist watch, aflatoxins, wheat cover smut, and ricin. Biological agents were tested in various delivery systems, including rockets, aerial bombs, and spray tanks. In all, Iraq produced 19,000 liters of concentrated botulinum toxin (nearly 10,000 liters filled into munitions), 8,500 liters of concentrated anthrax (6,500 liters filled into munitions) and 2,200 liters of aflatoxin (1,580 liters filled into munitions). Former Russian president Boris Yeltsin stated that he would put an end to further offensive biological research; however, the degree to which the program was scaled back is not known. There is intense concern in the west about the possibility of proliferation or enhancement of offensive programs in countries hostile to the western democracies, due to the potential hiring of expatriate Russian scientists. Iraq, Iran, and Syria have been identified as countries “aggressively seeking” nuclear, biological, and chemical weapons. Libya was also included; however, Libya has recently renounced further pursuit of offensive programs. The 1990s saw a well-placed increasing concern over the possibility of the terrorist use of biological agents to threaten either military or civilian populations. Extremist groups have tried to obtain microorganisms that could be used as biological weapons. Subsequent investigations revealed that, on several occasions, the Aum Shinrikyo had released botulinum toxin (1993 and 1995) and anthrax (1995) from trucks and rooftops. First responders, public health and medical personnel, and law enforcement agencies have dealt with the exponential increase in biological weapons hoaxes around the country over the past several years. Anthrax laden letters placed in the mail caused 23 probable or confirmed cases of anthrax-related illness and five deaths, mostly among postal workers and those handling mail. Ricin was also found in a South Carolina postal facility in October, 2003 and the Dirksen Senate Office Building in Washington, D. The National Strategy for Homeland Security and the Homeland Security Act of 2002 were developed in response to the terrorist attacks. The Public Health Security and Bioterrorism Response Act of 2002 requires drinking water facilities to conduct vulnerability assessments; all universities and laboratories that work with biological material that could pose a public-health threat have to be registered with the U. Department of Agriculture; and new steps were imposed to limit access to various biological threat agents. Smallpox preparedness was implemented, including a civilian vaccination program, vaccine injury compensation program, and aid to the States. Prior to the March 2003 invasion of Iraq, state and local health departments and hospitals nationwide conducted smallpox immunizations of healthcare workers and have since prepared statewide bioterrorism response plans. Therefore, awareness of and preparedness for this threat will require the education of our government officials, health-care providers, public health officials, and law enforcement personnel and is vital to our national security. With a covert attack, the most likely first indicator of an event will be an increased number of patients presenting to individual care providers or emergency departments with clinical features caused by the disseminated disease agent. The possibility exists that the recognizing authority for something unusual may be other medical professionals, such as pharmacists or laboratorians, who may receive more than the usual numbers of prescriptions or requests for laboratory tests from a number of different care providers. A sound epidemiologic investigation of a disease outbreak, whether natural or human-engineered, will assist medical personnel in identifying the pathogen and lead to the institution of appropriate medical interventions. Identifying the affected population, possible routes of exposure, signs and symptoms of disease, along with rapid laboratory identification of the causative agents, will greatly increase the ability to institute an appropriate medical and public health response. Good epidemiologic information can guide the appropriate follow-up of those potentially exposed, as well as assist in risk communication and responses to the media. Many diseases caused by weaponized biological agents present with nonspecific clinical features that may be difficult to diagnose and recognize as a biological attack. Features of the epidemic may be important in differentiating between a natural and a terrorist or warfare attack. Epidemiologic clues that may indicate an intentional attack are listed in Table 1. While a helpful guide, it is important to remember that naturally occurring epidemics may have one or more of these characteristics and a biological attack may have none. However, if many of the listed clues are recognized, one’s index of suspicion for an intentionally spread outbreak should increase. Although, the conduct of the investigation will not differ significantly whether the outbreak is intentional or not, there are some important differences. Because the use of a biological weapon is a criminal act, it will be very important for the evidence gathered to be able to stand up to scrutiny in court. Therefore, samples must be handled through a chain of custody and there must be good communication and information sharing between public health and law-enforcement authorities. In addition, because the attack is intentional, one must be prepared for the unexpected – there is the possibility of multiple outbreaks at different locations as well as the use of 7 multiple different agents, including mixed chemical and biological agents or multiple biological agents depending upon the intentions of the perpetrator. The first step in the investigation is to confirm that a disease outbreak has occurred. Because an outbreak generally means there is a higher rate of an illness than is normally seen in a specific population, then it is helpful to have background surveillance data to determine whether what is being seen constitutes a deviation from the norm. For example, in mid-winter, thousands of cases of influenza may not be considered an outbreak, whereas in the summer, it might be highly unusual. In addition, even a single case of a very unusual illness, such as inhalation anthrax, might constitute an outbreak and should be viewed with suspicion. The clinical features seen in the initial cases can be used to construct a case definition to determine the number of cases and the attack rate [the population that is ill or meets the case definition divided by the population at risk]. The case definition allows investigators who are separated geographically to use the same criteria when evaluating the outbreak.
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The development of spacecraft that can house three or more crewmembers has allowed investigators who have no professional piloting experience to buy cheapest triamterene and triamterene blood pressure young living participate in space exploration purchase 75mg triamterene with mastercard pulse pressure graph. Proposed Additions to order generic triamterene from india pulse pressure is quizlet or Improvements in Training Methods 57 Many suggestions have been made to expand or improve traditional means of crew training. One such proposal involved a nearly full-scale flight simulation, to be implemented with a ground-based training simulator linked via telemetry with a set of manual controls onboard the spacecraft and an information display system. This set-up creates a closed-loop system in which the cosmonaut, display, and controls are onboard a spacecraft, but the object of control (implemented through mathematical models and visual representations of the modeled environment) is on Earth. This system was first used to allow cosmonauts to practice docking with a space station, and significantly improved their performance and their psychological status within 4 or 5 practice trials. This method also is promising with regard to helping cosmonauts adapt psychologically to working conditions in space. Methods of biomedical training that model the combined effects of several space flight factors are thought to facilitate the development of more appropriate compensatory and adaptive reactions during actual flights. One such method involved the use of a complex vestibulometric test device that combines head-down hypokinesia with optokinetic stimulation and Coriolis acceleration by rotating the head in the sagittal plane while the body is rotated 14 V4 Ch 2 Cosmonaut Training Bugrov et al. Another method involves using an anti-g suit (to create excess pressure on the lower body and increase blood pressure in the upper body) in combination with exposure to 60 cumulative Coriolis acceleration every 3 hours in a Barany chair. This latter method is used in combination with a posthypnotic suggestion that he or she will experience the feeling of diminished weight. This combination of free fall and movement by the subject reportedly resembles actual space flight conditions. An experimental facility for simulating the dynamics of an entire space flight has been developed at the Yu. This facility combines a centrifuge with a cabin suspended on a gimbal mount and a device for creating excess pressure on the lower body. Headward redistribution of blood is simulated by the combination of lower-body pressure with horizontal-body orientation and cabin motion created by the centrifuge. A programmable control console is used to simulate the following sequence: the acceleration profile of orbital insertion; the transitional period between acceleration and weightlessness; the hemodynamic, sensory, and statokinetic effects of weightlessness; and the acceleration profile of descent. Cosmonauts perform spacecraft control operations and other functions during this process by using instruments located on an operator’s console in the centrifuge. Partial submersion in water (three submersions for 12 hours each during available free time) also has been proposed 64,65 as a way to foster preliminary adaptation to weightlessness. Alternating between submerged and nonsubmerged conditions is thought to be the best way of increasing adaptive capacity. Results from a 3-day 66,72 simulation experiment suggest that autogenic training was instrumental in eliminating unpleasant sensations like vertigo, nausea, and feelings of heaviness in the head during the acute phase of adaptation. Subjects using autogenic procedures experienced a sensation of unusual physical lightness and maintained a high level of performance for an extended period. Subjects who used autogenic-feedback techniques performed 6 to 12% better than control subjects on spacecraft control, had a 4 to 5% greater probability of detecting signals in the communication and navigation system, and were able to detect these signals 3. Yet another suggestion was to 69 speed autogenic training by using instrument-assisted biofeedback. Biofeedback can be combined with various autogenic-training exercises for conscious relaxation and training in both general and specialized self-regulation techniques. Mastery of conscious self-regulation skills as a defense against extreme environmental conditions is considered by 70 some to be one of the most important aspects of cosmonaut training. One such method includes taking active measures to counteract nervous tension; developing a specific strategy to regulate behavior described as “relative freedom from personal problems” and “deactualization of many nonexisting problems”; and mastering psychophysiological self-regulation techniques (voluntary control of breathing, muscular and vascular tonus, and the functioning of cardiovascular and other systems of the body). Preflight yoga exercises have been proposed as a way of improving coordination, promoting muscle relaxation 73 during the dynamic phase of flight, and supplying substantial [physical] loads during the static phase. Finally, ways of teaching self-treatment and first-aid techniques could be updated frequently to include the use of new methods as they become available. Training for Interplanetary Space Flights Because interplanetary missions will require long periods of weightlessness during which rapid return to Earth is not possible, the biomedical component of training for this type of mission should be expanded from its current form. The risks of psychological (anxiety, psychological disturbance) and somatic illnesses (cardiac arrhythmia, neurodermatitis, spastic colitis, ulcers, etc. It is difficult to imagine that crew safety and optimal performance—and thus successful completion of flight—could be ensured without a specially trained physician being part of the crew on such flights. Some specific countermeasures against psychological complications on long-term interplanetary flights could include the use of role-playing and simulations to enhance resolution of conflicts, or learning constructive methods of managing interpersonal relationships through training in social psychology. In addition to the medical and psychological risk factors associated with interplanetary flights, sensory deprivations. Optical conditions in the Martian atmosphere also could affect cosmonaut efficiency. These issues suggest the need for specialized training devices and methods of in-flight sensory conditioning as well as the development of technology to improve or augment the crewmembers’ sensory systems. In summary, the idea, first proposed during the earliest space flights, that space crewmembers require occupational and biomedical training is still applicable today, although the emphasis on occupational training has increased, particularly with regard to simulators. As flight duration lengthens, as the complexity of flight systems increases, and as the scope of scientific flight programs expands, the crew-training system should include both a general component, for skills needed by all crewmembers, and an individualized component, based on crewmember experience, previous training, and specialization. Although the present system of crew training has amply demonstrated the ability to produce competent crews that can tolerate space flight factors, further improvements to the system are always possible. Tsiolkovskiy and Their Development in Modern Cosmonautics, Nauka, Moscow, 1985, pp. Positive emotional relations Signs of negative attitudes of Multiple negative interrelations among the crew crew members to each other among the crew Willingness to work as a team; Signs of isolation & competition Persistent isolation & competition fast & efficient crew training among crew members; among crew members; no relatively inefficient, slow improvement during training crew training V 4 Ch 2 Cosmonaut Training Bugrov et al. Sargsyan, and Leonid Ivanovich Voronin V 4 Ch 3 Medical Monitoring Before and After Flight Billica et al. The continuing effort to provide appropriate health care for space crews has evolved into a robust program that encompasses all phases of crewed space missions, from the selection process through long-term follow-up after the completion of missions. Experience gained throughout the evolution of the crewed space program has verified that clinical medicine can be practiced in the space environment, given the availability of appropriate hardware, 1–3 supplies, procedures, crew training, and ground support.