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Typical plaque- like lesions disappear buy generic extra super cialis 100 mg line, the skin is universally red and scaly and the condition is known as erythrodermic psoriasis cheap generic extra super cialis canada. Patients who are seriously ill suffer from: ● heat loss buy extra super cialis 100 mg low price, and are in danger of hypothermia because of the increased blood supply to the skin ● water loss, leading to dehydration because of the disturbed barrier function of the abnormal stratum corneum ● a hyperdynamic circulation, because effectively there is a vascular shunt in the skin; when the patient’s myocardium is already compromised because of other factors, there is a danger of high output failure ● loss of protein, electrolytes and metabolites via the shed scales and exudates; patients may develop deficiency states. Pustular psoriasis Most dermatologists consider this to be a manifestation of psoriasis, although there are some who believe it is a separate disorder. It seems probable that pustu- lar psoriasis is indeed a type of psoriasis, with exaggeration of one particular com- ponent of the disease (see Pathology below). Palmoplantar pustulosis Patients with palmoplantar pustulosis develop yellowish white, sterile pustules on the central parts of the palms and soles (Figs 9. Older lesions take on a brownish appearance and are later shed in a scale at the surface. The affected area can become generally inflamed, scaly and fissured and, although relatively small areas of skin are affected, the condition can be very disabling. The disorder tends to be resistant to treatment (see below) and is subject to relapses and remission over many years. Generalized pustular psoriasis This is also known eponymously as Von Zumbusch disease, and is one of the most serious disorders dealt with by dermatologists. In its classical form, attacks occur suddenly and are characterized by severe systemic upset, a swinging pyrexia, arthralgia and a high polymorphonuclear leucocytosis accompanying the skin disorder. The skin first becomes erythrodermic and then develops sheets of sterile pus- tules over the trunk and limbs (Fig. Sometimes, the pustules become confluent so that ‘lakes of pus’ develop just beneath the skin surface. In other areas, there is a curious type of superficial peel- ing without pustules forming. They can usually be brought into remission by modern treatments (see below), but are subject to recurrent attacks. Other forms of pustular psoriasis Occasionally, pustules may develop after strong topical or systemic corticosteroids have been used and then abruptly withdrawn. Other rare variants of pustular psor- iasis include: ● acrodermatitis continua, in which there is a recalcitrant pustular erosive dis- order on the fingers and toes around the nails and occasionally elsewhere ● pustular bacterid, in which sterile pustules suddenly appear on the palms, soles and distal parts of the limbs after an infection. Arthropathic psoriasis There is a higher prevalence of a rheumatoid-like arthritis with symmetrical involvement of the small joints of the hands and feet, wrists and ankles in patients with psoriasis (5–6 per cent) compared to a matched control population (1–2 per cent). This ‘rheumatoid arthritis-like’ disorder differs in one important respect from ordinary rheumatoid arthritis – there is no circulating rheumatoid factor. In addition, there is a distinctive and destructive form of joint disease that seems specific to psoriasis. In this ‘psoriatic arthropathy’, the distal interphalangeal joints, the posterior zygohypophysial, the temporomandibular and the sacroiliac 135 Psoriasis and lichen planus Figure 9. Bony erosion and destruction take place, leading to ‘collapse’ of affected digits (Fig. Treatment may temporarily improve these joint complications of psoriasis, but they tend to run a progressive course subject to remissions and relapses. The main features may be subdivided into (1) the epidermal thickening, (2) the inflam- matory component, and (3) the vascular component, but of course all are closely interlinked. The epidermal thickening The epidermis shows marked exaggeration of the rete pattern and elongation of the epidermal downgrowths with bulbous, club-like enlargement of their ends (Fig. The average thickness is increased from about three to four cells in the normal skin to approximately 12–15 cells in the psoriatic lesion. Many mitotic fig- ures can be seen and the rate of epidermal cell production seems to be greatly enhanced. The turnover time of psoriatic epidermis and stratum corneum is con- sequently very much shortened. Normally, it takes some 28 days for new cells to ascend from the basal layer and travel through the epidermis and the stratum corneum and reach the surface. Epidermal nuclei are retained in the inefficient horny layer that results (parakeratosis). The inflammatory component Interspersed between the ‘parakeratotic’ horn cells are collections of desiccated polymorphonuclear leucocytes known as Munro microabscesses. The dermis immedi- ately below the epidermis also contains many inflammatory cells, mostly lym- phocytes. In pustular psoriasis, the epidermal component is much less in evidence and there are collections of inflammatory cells within the epidermis (Fig. The vascular component The papillary capillaries are greatly dilated and tortuous to a degree not seen in other inflammatory skin disorders. Ultrastructurally it can be seen that there are larger gaps than usual between the endothelial cells. One very obvious abnormality in psoriasis is the hyperplastic epidermis with increased mitotic activity, and one line of intense investigation was directed at the control of epidermal cell production in this disease. Attention has moved away from this possibility in recent years and focused more on the 137 Psoriasis and lichen planus inflammation and possible immunopathogenesis. The disorder often responds to immunosuppressive agents such as cyclosporin and methotrexate and currently psoriasis is thought of as a ‘lymphocyte-driven’ disease. Various potentially heritable biochemical abnormalities have been suggested and/or described that could explain both the increased epidermal proliferation and the inflammatory component. At different times, alterations in the skin content or activity of cyclic nucleotides, polyamines, eicosanoids, cytokines and growth fac- tors have been described, but in most cases these changes are secondary to the underlying and fundamental less well-characterized events. Infection has been considered as a cause and in recent years the involvement of retroviruses has been suggested. Case 8 Jessie’s mother and aunt had psoriasis and at the age of 19 Jessie thought that she was getting it too, as she had scaling patches on her knees and elbows and in her scalp. She also noticed some separation of the nail plates from the nail beds and pitting of three of her fingernails. The rash disappeared after 6 weeks, but unfortunately recurred the following year. In other patients, simple treatment with an emollient such as white soft paraffin, by itself or with 2 per cent salicylic acid, is sufficient when used once or twice daily. Tar-containing preparations are less popular than previously, but may suit some patients who can put up with the stinging, the unpleasant smell and the staining. Tar has anti-inflammatory and cytostatic activity and certainly has mild anti-psoriatic effect. Proprietary tar preparations have some advantages over the British National Formulary formulations. Used alongside medium-potency corticosteroids, the efficacy is increased and the skin imitation decreased. A preparation of calcipotriol formulated together with betamethasone-17-valerate is now available as ‘Dovobet’, and does appear quite effective. Tacalcitol is another vitamin D3 analogue, which, although effective when employed topically, is not as potent as calcipotriol.

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Correlation between quantitative and qualitative burn wound biopsy culture and surface alginate swab culture buy generic extra super cialis. Comparative evaluation of surface swab and quantitative full thickness wound biopsy culture in burn patients order extra super cialis online now. Use of burn wound biopsies in the diagnosis and treatment of burn wound infection best purchase for extra super cialis. Correlation of culture with histopathology in fungal burn wound colonisation and infection. Frozen section technique to evaluate early burn wound biopsy: comparison with the rapid section technique. The Incidence of bacteremia following burn wound manipulation in the early post-burn period. Evaluation of white blood cell count, neutrophil percentage, and elevated temperature as predictors of bloodstream infection in burn patients. Enteral feeding intolerance: an indicator of sepsis associated mortality in burned children. The risk factors and time course of sepsis and organ dysfunction after burn trauma. Incidence, outcome, and long-term consequences of herpes simplex-virus type 1 reactivation presenting as a facial rash in intubated adult burn patients treated with acyclovir. Pneumonia in patients with severe burns; a classification according to the carrier state. A prospective study of hospital acquired infections in burn patients at a tertiary care referral centre in North India. Association between the presence of the Panton- Valentine leukocidin-encoding gene and a lower rate of survival among hospitalized pulmonary patients with staphylococcal disease. Catheter infection risk related to the distance between insertion site and burned area. Infections Related to Steroids in 22 Immunosuppressive/Immunomodulating Agents in Critical Care Lesley Ann Saketkoo and Luis R. Espinoza Section of Rheumatology, Department of Medicine, Louisiana State University Health Sciences Center, New Orleans, Louisiana, U. Discussion will focus on complications of therapy in relation mainly to serious infections—defined as infection that is fatal, life threatening, or causing prolonged hospitalization. The use of biologic agents as they are newer therapies will be highlighted in the discussion. However, its use is fraught with a catalogue of damaging and disabling complications that will not be listed here. For this reason, it has been used as a bridge therapy during the time it takes for other less harmful therapeutics to take effect. The hospital-based physician needs to be aware of two potentially devastating complications in the management of the in-patient receiving exogenous corticosteroids: (i) hypothalamic suppression leading to adrenal insufficiency and (ii) risk of serious infection. Consensus in defining levels of immune suppression with glucocorticoid use is difficult to reach due to immunologic complexities inherent in underlying diseases being treated with corticosteroids as well as variances in patient sensitivity based on genetic make-up. But it is generally accepted that the degree of immune suppression increases with level of dosing and observation of physical changes such as cushingoid features, striae, and vascular friability. Level of dosing effecting immune response has been suggested through vaccine response studies and studies ascertaining infections as follows: l Daily prednisone of 10 mg (or its equivalent) or a greater or cumulative dose of 700 mg carried an increased relative risk of 1. Depending on the severity of the illness, glucocorticoids may indeed need to be supplemented to address hypothalamic stress caused by the illness itself. Decisions of hypothalamic support should be made on a case-by-case basis with decision-making between the critical care specialist, rheumatologist, infectious diseases specialist, and perhaps an endocrinologist. The effects of glucocorticoids on the immune system are several: l The appearance of increased white blood cell count is due to de-margination of leukocytes from the vascular endothelium. Nuclear factor kappa beta (key transcription factor) is prevented from attaching to the promoter regions of the genes expressing the above inflammatory agents. The risk of serious infection in the patient receiving exogenous corticosteroids is a real one. Due to steroid effects on innate and adaptive immunity, these patients may present in a very atypical manner with normal signals of the inflammatory response such as fever, itching, rash, or discrete pulmonary lesions, for example, being muted. Corticosteroids act further upstream in the body’s immune response and more widely than most of the biologics listed below. Therefore, patients receiving moderate-to-high–dose steroids have been reported to be vulnerable to each of the microbial entities that are listed in the following section for biologic therapy. It is important to maintain a high level of suspicion and conduct a thorough investigation for the unusual suspects and have a low threshold to begin empiric therapy. Further susceptibility to infection is likely conferred by concomitant use of other immunosuppressive therapies, such as glucocorticoids and disease-modifying agents such as methotrexate, coexistent morbidities (3), age (4), and underlying immune dysfunction inherent to many autoimmune diseases (5). It is important to recognize that the patient numbers reflected here are small in comparison to the vast number of patients receiving biologic therapy. Until we understand better infectious disease patterns with the use of these agents, it is important to maintain a high index of suspicion for serious infection with both the usual and the unusual suspects presenting in usual and unusual ways. Very importantly, with signs or symptoms of potentially serious infection, biologic agents must be discontinued. We also advocate that with the exceptions of hydroxychloroquine and the presence of transplantation, all other immunosuppressants, such as methotrexate, mycophenolate, cyclosporine etc. Interference of immune cell migration and entry into sites of inflammation (alefacept, natalizumab) 4. It is a protein secreted by T cells, natural killer cells, and mast cells but mainly from activated mononuclear phagocytes in response to antigen presentation. It is recognized as important in stimulating macrophages, fibroblasts, and hematopoiesis in bone marrow. It is secreted by T cells, macrophages, and fibroblasts in response to tissue damage and presence of antigenic material. This is in use and under investigation for inflammatory bowel diseases, multiple sclerosis, psoriasis, and psoriatic arthritis. This signaling lies upstream of major cytokine expression and adaptive immunity mechanisms such as T- and B-cell proliferation and signaling. Lymphocytes may show repletion three weeks after therapy; however, depletion may last as long as one year. T-Cell activation and migration are targeted under several therapies with very different mechanisms of action. This co-stimulatory binding is 380 Saketkoo and Espinoza necessary for activation of T cells that directly impacts cytokine activation and B-cell proliferation. Greater than 50% of these cases were disseminated extrapulmonary disease with involvement of bone, bladder, meninges, and lymphoid tissue (12–14).

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Identify additional cases Initial notification of an outbreak may come from a clinic or hospital; enquiries in health centres order generic extra super cialis from india, dispensaries and villages in the area may reveal other cases purchase extra super cialis 100 mg mastercard, sometimes with a range of additional symptoms order 100mg extra super cialis with visa. Overall or specific attack rates (age-specific village-specific) can then be calculated. These calculations may lead to new hypotheses requiring further investigation and development of study designs. Microbiological typing and susceptibility to antibiotics can then be used to develop appropriate control measures. Formulate a hypothesis as to source and spread of the outbreak Determine why the outbreak occurred when it did and what set the stage for its occurrence. Whenever possible the relevant conditions before the outbreak should be determined. For foodborne outbreaks it is neces- sary to determine source, vehicle, predisposing circumstances and portal of entry. All links in the process must be considered: i) disease-causing agent in the population and its characteristics; ii) existence of a reservoir; iii) mode of exit from this reservoir or source; iv) mode of transmission to the next host; v) mode of entry; vi) susceptibility of the host. Contain the outbreak The key to effective containment of an outbreak is a coordinated investigation and response involving health workers including clinicians, epidemiologists, microbiologists, health educators and the public health authority. The best way to ensure coordination may be to establish an outbreak containment committee early in the outbreak. Manage cases Health workers, including clinicians, must assume responsibility for treatment of diagnosed cases. In outbreaks of meningitis, plague or cholera, emergency accommodation may have to be found and additional staff may require rapid essential training. Outbreaks of diseases such as sleeping sickness and cholera may require special treatment and recourse to drugs not normally available. Outbreaks such as poliomyeli- tis may leave in their wake patients with an immediate need for physio- therapy and rehabilitation; timely organization of these services will lessen the impact of the outbreak. Implement control measures to prevent spread After the epidemiological characteristics of the outbreak have been better understood, it is possible to implement control measures to prevent further spread of the infectious agent. However, from the very beginning xxx of the investigation the investigative team must attempt to limit the spread and the occurrence of new cases. Immediate isolation of affected persons can prevent spread, and measures to prevent movement in or out of the affected area may be considered. Whatever the urgency of the control measures they must also be explained to the community at risk. Population willingness to report new cases, attend vaccination campaigns, improve standards of hygiene or other such activities is critical for successful containment. If supplies of vaccine or drugs are limited, it may be necessary to identify the groups at highest risk initial for control measures. Once these urgent measures have been put in place, it is necessary to initiate more perma- nent ones such as health education, improved water supply, vector control or improved food hygiene. It may be necessary to develop and implement long-term plans for continued vaccination after an initial campaign. Conduct ongoing disease surveillance During the acute phase of an outbreak it may be necessary to keep persons at risk (e. After the outbreak has initially been controlled, continued community surveillance may be needed in order to identify addi- tional cases and to complete containment. Sources of information for surveillance include: i) notifications of illness by health workers, community chiefs, employers, school teachers, heads of families; ii) certification of deaths by medical authorities; iii) data from other sources such as public health laboratories, entomological and veterinary services. It may be necessary to maintain estimates of the immune status of the population when immunization is part of control activities, by relating the amount of vaccine used to the estimated number of persons at risk, including newborns. Prepare a report A report should be prepared at intervals during containment if possible, and after the outbreak has been fully contained. Reports may be: i) a popular account for the general public so that they understand the nature of the outbreak and what is required of them to prevent spread or recurrence; ii) an account for planners in the Ministry of Health/local authority so as to ensure that the necessary administrative steps are taken to prevent recurrence: iii) a scientific report for publication in a medical journal or epidermiological bulletin (reports of recent outbreaks are valuable aids when teaching staff about outbreak control). For example, it may be necessary to show that sliced foodstuffs can be contaminated by an infected slicing machine if this has not been proven during the outbreak investigation. Such verification requires more laboratory facilities than are available in the field, and is often not completed until long after the outbreak has been contained. The response will of necessity involve the intelligence com- munity and law enforcement agencies as well as public health services, and possibly the Defence Ministry as well, especially if the event is considered of non-domestic origin. Difficulties in communication and approaches may arise, since these disciplines do not usually work to- gether. The public health response included identifying all those at risk of infection through the postal system, and prescribing antibiotics to over 32 000 persons identified as potentially in contact with envelopes contaminated with anthrax spores. The event and associated hoaxes caused unprecedented demands on public health laboratory services, and several nations had to recruit private laboratories to deal with the overflow. If the agent is widely dispersed and/or easily transmissible, a surge capacity may be required to accommodate large numbers of patients, and systems must be available for the rapid mobilization and distribution of medicines or vaccines according to the agent released. In the event that the agent is transmissible, additional capacity will be required for contact tracing and active surveillance. Some of the infectious agents of concern include bacteria and rickettsia (anthrax, brucellosis, melioidosis, plague, Q fever, tularemia, and typhus), fungi (coccidioidomycosis) and viruses (arboviruses, filoviruses and variola virus). International threat analysis xxxii considers that deliberate use of biological agents to cause harm is a real threat and that it can occur at any time; however, such risk analysis is not generally considered a public health function. According to national intelligence and defence services, there is evi- dence that national and international networks have engineered biological agents for use as weapons, in some instances with suggestions of attempts to increase pathogenicity and to develop delivery mechanisms for their deliberate use. Infection of humans may be a one-time occurrence, or may be repeated over a period of time after the initial occurrence. The agent used will determine whether there is a risk of person-to-person transmis- sion after the initial and subsequent attacks; information on this risk is covered in more detail under specific disease agents. Incubation period, period of communicability and susceptibility are agent-specific. Prevention of the deliberate use of biological agents presupposes accurate and up-to-date intelligence about terrorists and their activities. The agents may be manufactured using equipment necessary for the routine manufacture of drugs and vaccines, and the possibility of dual use of these facilities adds to the complexity of prevention. This has led some analysts to regard a strong public health infrastructure, with rapid and effective detection and response mechanisms for naturally occurring infectious diseases of outbreak potential, as the only reasonable means of responding to the threat of deliberately caused outbreaks of infectious disease. Adequate background information on the natural behaviour of infectious diseases will facilitate recognition of an unusual event and help determine whether suspicions of a deliberate use should be investigated. Preparedness for deliberate use also requires mechanisms that can be immediately called into action to enhance communication and collabora- tion among the public health authorities, the intelligence community, law enforcement agencies and national defence systems as need may arise. Preparedness should draw on existing plans for responding to large-scale natural disasters, such as earthquakes or industrial or transportation accidents, in which health care facilities are required to deal with a surge of casualties and emergency admissions. Most health workers will have little or no experience in managing illness arising from several of the potential infectious agents; training in clinical recognition and initial management may therefore be needed for first xxxiii responders. This training should include methods for infection control, safe handling of diagnostic specimens and body fluids, and decontamina- tion procedures. One of the most difficult issues for the public health system is to decide whether preparedness should include stockpiling of drugs, vaccines and equipment.

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Public health action to prevent the adverse consequences of inappropriate dietary patterns and physical inactivity is now urgently needed cheap extra super cialis 100 mg with amex. To this end order generic extra super cialis online, the Consultation discussed how nutrient/food intake and physical activity goals could be used by policy-makers to increase the proportion of people who make healthier choices about food and undertake sufficient physical activity to maintain appropriate body weights and adequate health status discount extra super cialis 100mg without a prescription. This chapter discusses ways to catalyse the long-term changes that are needed to place people in a better position to make healthy choices about diet and physical activity. Such processes require long-term changes in thinking and action at the individual and societal levels; demand concerted action by national governments, international bodies, civil society and private entities and will need insights and energies contributed by multiple sectors of society. New scientific information will be essential to permit adjustment not only of the policy levers, but also of the strategic processes to introduce change. This constitutes an important focus for applied research that should yield useful evidence to guide effective interventions. The first is the range of possible policy principles that would help people achieve and maintain healthy dietary and activity patterns in a simple and rewarding manner. The second is the prerequisites for possible strategies to introduce these policies in different settings. These include the need for leadership, effective communication of problems and possible solutions, function- ing alliances, and ways of encouraging enabling environments to facilitate change. The third is the possible strategic actions to promote healthy diets and physical activity. Strategies should be comprehensive and address all major dietary and physical activity risks for chronic diseases together, alongside other risks --- such as tobacco use --- from a multisectoral perspective. Each country should select what will constitute the optimal mix of actions that are in accord with national capabilities, laws and economic realities. Governments have a central steering role in developing strategies, ensuring that actions are implemented and monitoring their impact over the long term. Ministries of health have a crucial convening role --- bringing together other ministries needed for effective policy design and implementation. Governments need to work together with the private sector, health professional bodies, consumer groups, academics, the research community and other nongovernmental bodies if sustained progress is to occur. This starts with maternal and child health, nutrition and care practices, and carries through to school and workplace environments, access to preventive health and primary care, as well as community- based care for the elderly and disabled people. Strategies should explicitly address equality and diminish disparities; they should focus on the needs of the poorest communities and population groups --- this requires a strong role for government. Furthermore, since women generally make decisions about household nutrition, strategies should be gender sensitive. There are limits to what individual countries can do alone to promote optimal diets and healthy living. Strategies need to draw substantially on existing international standards that provide a reference in international trade. Member States may wish to see additional standards that address, for example, the marketing of unhealthy food (particularly those high in energy, saturated fat, salt and free sugars, and poor in essential nutrients) to children across national boundaries. Countries may also wish to consider means of ensuring the accessibility of healthier choices (such as fruits and vegetables) to all socioeconomic groups. These include leadership, effective communication, functioning alliances and an enabling environment. Within nations, governments have the primary responsibility for providing this leadership. In some cases leadership may be initiated by civil society organizations prior to government action. It is unlikely that there will be just one correct path to improved health: each country will need to determine the optimal mix of policies that its particular circumstances best fit. Each country will need to select measures within the reality of its economic and social resources. More proactive leadership is needed, worldwide, to portray a holistic vision of food and nutritional issues as they affect overall health. Where this leadership has existed, it has been possible to make governments take notice and introduce the necessary changes. The question remains of how to develop and strengthen leadership capacity to reach a critical mass. Governments throughout the world have developed strategies to eradicate malnutrition, a term traditionally used synonymously with 136 undernutrition. However, the growing problems of nutritional imbal- ance, overweight and obesity, together with their implications for the development of diabetes, cardiovascular problems and other diet-related noncommunicable diseases, are now at least as pressing. This applies especially to developing countries undergoing the nutrition transition; such countries bear a double burden of both overnutrition, as well as undernutrition and infectious diseases. Unless there is political commit- ment to spur governments on to achieve results, strategies cannot succeed. Setting population goals for nutrient intake and physical activity is necessary but insufficient. Giving people the best chance to enjoy many years of healthy and active life requires action at the community, family and individual levels. The core role of health communication is to bridge the gap between technical experts, policy-makers and the general public. The proof of effective communications is its capacity to create awareness, improve knowledge and induce long-term changes in individual and social behaviours --- in this case consumption of healthy diets and incorporating physical activity for health. An effective health communication plan seeks to act on the opportunities at all stages of policy formulation and implementation, in order to positively influence public health. Sustained and well targeted communication will enable consumers to be better informed and make healthier choices. Informed consumers are better able to influence policy-makers; this was learned from work to limit the damage to health from tobacco use. Consumers can serve as advocates or may go on to lobby and influence their societies to bring about changes in supply and access to goods and services that support physical activity and nutritional goals. The cost to the world of the current and projected epidemic of chronic disease related to diet and physical inactivity dwarfs all other health costs. If society can be mobilized to recognize those costs, policy-makers will eventually start confronting the issue and themselves become advocates of change. Experience shows that politicians can also be influenced by the positions taken by the United Nations agencies, and the messages that they promote. Medical networks have also been found to be effective advocates of change in the presence of a government that is responsive to the health needs of society. Consumer nongovernmental organizations and a wide variety of civil society organizations will also be critical in raising consumer consciousness and supporting the climate 137 for constructive collaboration with the food industry and the private sector. Ideally, the effort should include a range of different parties whose actions influence people’s options and choices about diet and physical activity. Alliances for action are likely to extend from communities to national and regional levels, involving formal focal points for nutrition within different public, private and voluntary bodies. The involvement of consumers associations is also important to facilitate health and nutrition education. Alliances with other members of the United Nations family are also important --- for example, with the United Nations Children’s Fund on maternal --- child nutrition and life-course approachesto health. Private sectorindustry with interests in food production, packaging, logistics, retailing and marketing, and other private entities concerned with lifestyles, sports, tourism, recreation, and health and life insurance, have a key role to play.

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