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By: Vinay Kumar, MBBS, MD, FRCPath

  • Donald N. Pritzker Professor and Chairman, Department of Pathology, Biologic Sciences Division and Pritzker School of Medicine, The University of Chicago, Chicago, Illinois


An effective interview should focus on drug use bacteria vs archaea cheap bactexina online american express, patterns and consequences of use infection quest wow purchase bactexina paypal, past attempts to bacteria on skin buy bactexina 250mg cheap deal with problems bacteria zinc discount bactexina 250 mg line, medical and psychiatric history (the "what, who, when, where, how")-not on the reasons (the "why") for addiction problems. Questions should be asked in a direct and straightforward manner, using simple language and avoiding street terms. Assumptive or quantifiable questions, such as those in figure 3­3, yield more accurate responses in the initial phases of the interview. A thorough and comprehensive medical, social, and drug use history should be taken on all patients being evaluated for substance Figure 3­2 Targeted, Open-Ended Questions About Drug and Alcohol Use "How has heroin use affected your life? Physical Examination the physical examination should focus on physical findings related to addiction. Several physical findings may lead the physician to suspect addiction in patients who deny drug use or have equivocal screening results. Figure 3­5 lists physical examination findings that suggest addiction or its complications. The physical complications of opioid addiction should be identified and addressed as part of the overall treatment plan. It is vitally important to assess for signs of opioid intoxication, overdose, or withdrawal during Figure 3­4 Components of a Complete Substance Abuse Assessment History Substance use history. Laboratory Evaluations Laboratory testing is an important part of the assessment and evaluation of patients who have an addiction. Laboratory tests cannot make a diagnosis of addiction, but a variety of laboratory evaluations are useful in the comprehensive assessment of patients who have an addiction. The recommended baseline laboratory evaluation of patients who are addicted to opioids is shown in figure 3­9. Appropriate counseling should be provided, and consent obtained, before testing for certain infectious diseases. Abnormalities or medical problems detected by laboratory evaluation should be addressed as they would be for patients who are not addicted. Several findings may alert physicians to potential complications to treatment with buprenorphine. Liver enzyme abnormalities also may suggest liver disease from toxicity, infection, or other factors. Materials about hepatitis C also are available on the Agency for Healthcare Research and Quality Web site at. Positive serology tests for syphilis may indicate active or past infection with Treponema pallidum. All patients with such positive test results should be treated onsite or referred to a local health department for further evaluation and treatment. It should be noted, however, that biologic false positive results on serology tests for syphilis are common in individuals who abuse drugs intravenously. Physicians should be familiar with all reporting requirements for infectious diseases in their State. Evaluations of Drug Use Tests for illicit drugs are not sufficient to diagnose addiction and cannot substitute for a clinical interview and medical evaluation of the patient (Casavant 2002). Physicians must decide which drug tests are necessary in each clinical setting, including office-based buprenorphine treatment. Physicians and laboratory personnel must understand the limitations of the assays used, the pharmacokinetic characteristics of the drugs assayed, the parent 34 Patient Assessment compound­metabolite relationships, and how to interpret laboratory results (Hammett-Stabler et al. Testing for drugs can be performed on a number of bodily fluids and tissues, including urine, blood, saliva, sweat, and hair. A comprehensive discussion of urine drug testing in the primary care setting can be found in Urine Drug Testing in Primary Care: Dispelling the Myths & Designing Strategies (Gourlay et al. When selecting drug tests, physicians should consider the cost to patients, as testing for all possible drugs of abuse can be costly. In buprenorphine treatment, appropriate tests for illicit drug use should be administered as part of patient assessment. Physicians should explain the role of drug testing at the beginning of treatment for addiction. The literature supports the therapeutic utility of random drug testing in clinical settings (Preston et al. Laboratory test results can be used in the physician­ patient interaction to further treatment objectives, to address patient denial, and to reinforce abstinence from other drugs. Initial and ongoing drug screening should be used to detect or confirm the recent use of drugs. When a patient requests treatment with buprenorphine, a toxicology screen can help to establish that the patient is indeed using either a proscribed substance such as heroin or a prescribed substance such as oxycodone. A negative test does not necessarily mean that the patient is not using an opioid. It may mean that the patient has not used an opioid within a period of time sufficient to produce measurable metabolic products or that the patient was not using the drug for which he or she was tested. Thus, as with any patient, the physician is alerted to a spectrum of possibilities and works with the patient using the information collected from the toxicology screen. Several manufacturers produce combination urine collection and test kits that facilitate in-office urine testing. In-office testing facilitates prompt evaluation of clinical parameters and allows the physician to present the results to the patient and to make immediate therapeutic use of the information. Toxicology testing for drugs of abuse that takes place at scheduled visits cannot be truly random; nevertheless, it is clinically worthwhile. Urine samples should be collected in a room where they cannot be diluted or otherwise adulterated and where patients are not permitted to bring briefcases, purses, bags, or containers of any sort. If these conditions are not feasible, temperature-sensitive strips, specific gravity, and creatinine can be used to minimize the possibility of false or adulterated urine specimens. Another option that is sometimes feasible is to collect a sample of oral fluid (saliva) to be sent to a laboratory for testing. Timely shipment of samples for testing and rapid turnaround time for the results are also important issues that should be resolved Patient Assessment 35 before undertaking office-based treatment of opioid addiction. If a patient subsequently wants to use the drug test result for other purposes, both the physician and the patient should understand the limits of the office testing and other requirements for the test. Department of Transportation, private-sector testing requirements may be less rigorous. Further information about the detection of drugs in urine and other biological samples is found in appendix E. The diagnosis of opioid dependence always takes precedence over that of opioid abuse. In such a case, a short course of buprenorphine may be considered for detoxification. Among individuals who are opioid addicted, other common medical conditions are related to the use of other drugs and to the life disruptions that often accompany addiction. These conditions include nutritional deficiencies and anemia caused by poor eating habits; chronic obstructive pulmonary disease secondary to cigarette smoking; impaired hepatic function or moderately elevated liver enzymes from various forms of chronic hepatitis (particularly hepatitis B and C) and alcohol consumption; and cirrhosis, neuropathies, or cardiomyopathy secondary to alcohol dependence. Common Comorbid Medical Conditions Individuals addicted to opioids may have the same chronic diseases seen in the general population and should be evaluated as appropriate for diseases that require treatment. In addition, a number of medical conditions are commonly associated with opioid and other drug addictions. During the course of a medical history and physical examination, the possible existence of these conditions should be evaluated. Refer to figure 3­11 for a detailed list of selected medical disorders related to drug and alcohol use. Infectious diseases are more common among individuals who are addicted to opioids, individuals who are addicted to other drugs, and individuals who inject drugs. Individuals who abuse drugs and alcohol are Summary After completing a comprehensive assessment of a candidate for treatment, the physician should be prepared to Establish the diagnosis or diagnoses Determine appropriate treatment options for the patient Make initial treatment recommendations Formulate an initial treatment plan Plan for engagement in psychosocial treatment Ensure that there are no absolute contraindications to the recommended treatments Assess other medical problems or conditions that need to be addressed during early treatment Assess other psychiatric or psychosocial problems that need to be addressed during early treatment the next section describes methods for determining the appropriateness of buprenorphine treatment for patients who have an opioid addiction. Patient Assessment 37 Figure 3­11 Selected Medical Disorders Related to Alcohol and Other Drug Use Cardiovascular Alcohol: Cardiomyopathy, atrial fibrillation (holiday heart), hypertension, dysrhythmia, masks angina symptoms, coronary artery spasm, myocardial ischemia, high-output states, coronary artery disease, sudden death. Cocaine: Hypertension, myocardial infarction, angina, chest pain, supraventricular tachycardia, ventricular dysrhythmias, cardiomyopathy, cardiovascular collapse from body-packing rupture, moyamoya vasculopathy, left ventricular hypertrophy, myocarditis, sudden death, aortic dissection. Tobacco: Atherosclerosis, stroke, myocardial infarction, peripheral vascular disease, cor pulmonale, erectile dysfunction, worse control of hypertension, angina, dysrhythmia.

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The major limitation in developing an algorithm for diabetes management in older persons is the lack of studies comparing different agents antibiotic you cant drink on buy bactexina 100mg low price, their effectiveness infection of the uterus order bactexina 500 mg online, and their safety in this age group infection japanese movie discount bactexina express. Most of the treatment options or combinations of treatment options are extrapolated from data in younger and middle-aged populations antibiotic 932264 buy discount bactexina 250 mg on line. Additionally, people with cognitive and functional impairment and depression are not included in clinical trials and these variables are hard to assess in observational studies, and usually not considered in outcome analyses. Sub-category A: Frail A target blood pressure of up to 150/90 mmHg may be appropriate. Sub-category B: Dementia A target blood pressure of 140/90 mmHg should be attempted in these individuals with cognitive impairment. Among individuals with advanced dementia, strict control of blood pressure may not have any added advantage. Most (60-80%) people with type 2 diabetes die of cardiovascular complications, and up to 75% of specific cardiovascular complications have been attributed to hypertension136. Hypertensive people with diabetes are also at increased risk for diabetes-specific complications including nephropathy and retinopathy. Treating hypertension reduces the risk of stroke and other adverse cardiovascular events. A 2011 meta-analysis of randomized controlled trials in hypertensive people aged 75 and over concluded that treatment reduced cardiovascular morbidity and mortality and the incidence of heart failure, even though total mortality was not affected137. Specific randomized clinical trials which have compared the effects on clinical outcomes of achieving different blood pressure values in older adults with diabetes are lacking. In the absence of randomized clinical trials data, the generally recommended target blood pressure target for older people with diabetes is less 38 than 140/90 mmHg133,138,139. Pharmacological treatment of very old people with hypertension decreases the risk of cardiovascular morbidity and mortality141-143. Lifestyle interventions are the recommended first step in managing high blood pressure in older people, although specific data on older people with diabetes are lacking. These have been mostly from trials on hypertensive older individuals and some with subset analysis of the diabetic population involved in these trials. Beta-blockers can be considered, especially in people with an elevated pulse rate147. Beta-blockers should be considered as part of combination therapy for people with tachycardia and/or coronary artery disease. However, they have been shown to be inferior to other agents in reducing some cardiovascular outcomes and in slowing progression of diabetic kidney disease146,149. Therapy using two (or three) agents may also be required to control blood pressure and are sometimes considered as initial treatment of severe hypertension. It should be noted that some combinations should be avoided (see Recommendations). A baseline and regular evaluation of end organ damage and other comorbidities should be performed. It is important to consider and rule out secondary causes of hypertension which could be potentially reversible. Healthcare professionals and caregivers should have an understanding of medicines effects and side-effects. Training, proficiency of staff and availability of appropriate equipment for measurement of blood pressure should be ascertained. The appropriateness of statin use in individuals with non-atherosclerotic dementia should be considered. Pharmacotherapy should be approached with caution in people with advanced dementia with poor caregiver support. Significant benefits have been demonstrated from lipid lowering to reduce cardiovascular morbidity and mortality153. Lowering serum cholesterol by 1 mmol/l reduces risk of coronary heart disease mortality by 50% in people aged 40-49 years while the risk reduction is 33% in those aged 50-69 years and 15% in those aged 70-89 years154. In addition, in old age, there is an inverse relationship between high cholesterol and the risk of stroke155 and there are conflicting data on the relationship between high cholesterol and non-cardiovascular mortality. However evidence for benefits of treatment in people aged over 80 years is limited and clinicians need to make decisions based on individualized management. Hyperlipidaemia is not only an important risk factor for coronary artery disease but also for aortic valve disease, stroke, and peripheral vascular disease including abdominal aortic aneurysm and also multiinfarct type of dementia in older people. Secondary causes of elevated lipids should be excluded especially excessive alcohol consumption and hypothyroidism. Statins are associated with a decrease in recurrent ischaemic stroke but an increase in haemorrhagic stroke in secondary prevention in people with cerebrovascular disease161. In older adults, exposure to higher doses of statins or higher potency statins does not increase their effectiveness, but does increase the risk of adverse effects such as myopathy and cognitive impairment. With ageing, there is a decrease in body size, particularly in muscle mass, and in hepatic and renal function, so the same dose will result in a greater degree of exposure in older people. The most common adverse effect that limits treatment with statins is muscle symptoms - myalgia, myositis, and rarely rhabdomyolysis. The risks of muscle symptoms are related to the dose of the statin and the risk of muscle damage increases with age over 70 years, and with age-associated factors such as multiple medication use, comorbidity, and sarcopenia. In people with dementia, statins do not significantly affect cognitive decline, global function, behaviour or activities of daily living162. Statins should be discontinued when the potential benefits are no longer clinically relevant. In people with severe physical or cognitive impairments, or those in their last year of life, therapeutic aims often change from preventative to palliative and reducing the risk of vascular events or mortality may not be relevant. Data on the use of other agents in older people are limited and the usual considerations apply. Nicotinic acid may worsen hyperglycaemia is not recommended in older people with diabetes166,167. Bile acid sequestrants are associated with poor compliance and more sideeffects in older individuals168 and should be used with caution. A search for atherosclerotic disease such as coronary artery disease, peripheral artery disease, symptomatic carotid artery disease or abdominal aortic aneurysms, and a family history of premature coronary artery disease should be part of a comprehensive screen at diagnosis and at regular intervals thereafter. Secondary causes of elevated lipids, particularly metabolic dyslipidaemia should be considered. Monitoring of lipid levels may not be necessary on a routine basis but careful monitoring for potential statin side-effects, especially on muscle, is essential. Sub-category B: dementia Increase involvement of caregivers during inpatient stay. Remain vigilant about recognizing and managing psychiatric disorders which may arise. Remain vigilant about delirium or swallowing disorders that can lead to pneumonia of hypoglycaemia. An older inpatient with hyperglycaemia, with or without a prior diagnosis of diabetes, is at increased risk of premature mortality and disease-specific morbidity. Hypoglycaemia among hospitalized older people with diabetes is also a frequent problem. Hypoglycaemia is responsible for up to 25% of fatal events that occur in people with diabetes admitted into United States hospitals annually. Although iatrogenic hypoglycaemia is associated with adverse outcomes, it may be a marker for illness rather than causal in itself. Several factors, such as administration of exogenous insulin, mismatch of insulin administration with nutrition, and the loss of normal counter-regulatory responses, place older people with diabetes at a higher risk for hypoglycaemia than people without diabetes. Thus, proper management of both hypo- and hyperglycaemia during inpatient care is essential. Furthermore, many older adults with diabetes rely on family members, friends, or healthcare-givers to help them manage medical conditions, as well as to implement dayto-day treatments. Diabetes affects approximately 25% of the population 65 years, and that percentage is increasing rapidly, particularly in minorities who represent an important fraction of the uninsured/underinsured169. Diabetes is an important cause of hospital admissions and comorbidity and impacts on mortality and quality of life170. There is clear evidence that older people with diabetes have a difficult time managing diabetes when frailty and/or dementia is present, especially during the hospital stay. Many clinical guidelines and publications have addressed and recommended inpatient management of hyper- and hypoglycaemia in older adults [4,100]. Similar to the general populations, there are three situations in which hyperglycaemia can occur in hospitals ­ people with known diabetes, previously undiagnosed diabetes, or transient hospital related hyperglycaemia. These complications can lead to increased healthcare costs, as well as adverse clinical outcomes.

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Repeated episodes of noise exposure increase the likelihood that the tinnitus will become permanent antimicrobial journals impact factor bactexina 100 mg for sale. Drugs and tinnitus Tinnitus can be induced by a number of medications and drug interactions antibiotics resistant bacteria purchase bactexina cheap online. Such tinnitus is usually temporary (typically lasting 1 to antibiotics for sinus infection and breastfeeding order bactexina mastercard 2 weeks postexposure) but can be permanent-especially with the use of aminoglycoside antibiotics or the cancer chemotherapeutic drug cisplatin antimicrobial susceptibility testing buy bactexina on line amex. Aspirin is well known to cause temporary tinnitus, although the dosage generally has to be rather high to induce tinnitus. Other medications that can cause temporary tinnitus include nonsteroidal anti-inflammatory drugs, loop diuretics, and quinine. Drugs used to treat mental health and sleep conditions also may trigger or exacerbate tinnitus. A cure for primary tinnitus does not yet exist, and despite claims to the contrary, no method has 6. No cure for primary tinnitus been proven to provide long-term suppression of tinnitus. We can help patients by relieving the functional effects of tinnitus, such as sleep disturbance, difficulty concentrating, problems with hearing, and difficulty relaxing. A brief overview of the evidence-based interventions discussed later in this guideline can be presented. Research suggests that tinnitus results from the compensatory adaptation of the central auditory 7. Clinical observations establish the near universal association of tinnitus with hearing loss. Hearing loss associated with tinnitus can range in severity from minimal to profound, and most people with hearing loss do not experience tinnitus. Changes in inhibitory and excitatory neurotransmitters occur throughout the auditory pathway in association with tinnitus. Definition of tinnitus Refer to Other Professionals Patients with persistent, bothersome tinnitus can be referred to health care professionals, particularly those who offer evidence-based approaches to tinnitus management. These would include audiologists, otolaryngologists/otologists, psychiatrists, and psychologists. Recommendation based on observational studies with a preponderance of benefit over harm. Organization Contact Information (Website) Otolaryngology­Head and Neck Surgery 151(2S) Description Publication American Academy of Hearing aids, in general, are underutilized, as 3 of 4 people with hearing loss and 6 of 10 with moderate to severe hearing loss do not use hearing aids. The recommendation of hearing aids for tinnitus is mostly based on empiric evidence. As many tinnitus patients suffer from hearing loss and benefit from the use of sound to mitigate effects of tinnitus, a natural first step is to offer them hearing aids. These studies are limited by methodologic issues that include selection bias, small sample size, short treatment duration, and use of confounding additional treatments such as sound therapy and/or counseling. Based on long-term retrospective studies, patients suffering from hearing loss and tinnitus receive at least modest benefit from amplification in coping with their tinnitus. It is unfortunate that the expense of hearing aids is usually not fully covered by medical insurance plans. Chien and Lin127 analyzed National Health and Nutritional Examination Surveys data from 1999 to 2006 and noted that hearing aids were used by only 14. A recent review of studies of hearing aid nonuse identified key issues with hearing aid value, amount of perceived benefit, and fit and comfort of the devices. Although Shekhawat et al129 acknowledged the general low quality of evidence in a review of the use of hearing aids for tinnitus, they did report that 17 of 18 reviewed trials showed benefit with hearing aid use. Supporting Text the purpose of this statement is to inform clinicians about the role of sound therapy as an option for treatment of persistent, bothersome tinnitus. Action Statement Profile Quality improvement opportunity: To promote awareness and utilization of sound therapy as a reasonable management option in patients with persistent, bothersome tinnitus Downloaded from oto. Numerous methods of sound therapy have been used since tinnitus masking was introduced in the 1970s. Both employ broadband noise sound generators, hearing aids, or combination devices (sound generator and hearing aid circuitry housed in the same unit) in the management process. The clinical application of sound therapies has generally focused on managing reactions to tinnitus and suppressing perception of tinnitus. Evidence is currently lacking that the tinnitus can be suppressed using acoustic stimulation. Some individuals experience residual inhibition following total or partial masking (ie, tinnitus suppression or temporary disappearance of the tinnitus sensation after exposure to an external sound). Evidence to support most tinnitus treatment strategies used in current practice is either lacking or of poor quality,137 including the use of sound therapy. These authors noted that this "absence of conclusive evidence should not be interpreted as evidence of lack of effectiveness," and they stated that "optimal management may involve multiple strategies. Although half of the studies reported benefit from sound therapy, none showed any significant differences between treatments. Only 6 trials met inclusion criteria, and these trials varied in design, type of sound therapy device used, and outcome measures employed to evaluate treatment effect. Neuromonics tinnitus treatment has been the subject of several peer- and nonpeer-reviewed clinical studies conducted by developers of this intervention protocol153-157; however, the reported merits of Downloaded from oto. Therefore, patients seeking sound therapy must be provided realistic expectations regarding potential outcomes as well as costs (both emotional as well as financial) associated with the various forms of sound therapy. Sound therapy may be a reasonable management option to offer patients when appropriate counseling is provided by the clinician. Cognitive behavioral therapy, originally developed for treatment of depression and anxiety, has been shown to be effective in the treatment of tinnitusrelated distress (Figure 2). Cognitive behavioral therapy teaches skills to identify negative thoughts that result in distress and restructure them so the thoughts are more accurate or helpful (Table 13). The treatment also includes behavioral interventions such as learning relaxation techniques, exposure to feared stimuli, instruction on sleep hygiene, and auditory enrichment. Alternate Thought I have tinnitus and parts of life are rotten and parts of life are good. Identifying thought distortion-discounting the positive Identifying thought distortion-predicting the future Sometimes the tinnitus is not as loud. Identifying thought distortion-all or none thinking Some people have learned to be happy and Identifying thought distortion-focusing on still have tinnitus. I can also listen to some relaxing music or go fishing, and distract myself or enjoy myself a bit. I have been coping with it, perhaps not Identifying thought distortion-predicting the so well; maybe I can learn some coping future techniques if I go to therapy. My tinnitus is present all the time but the Identifying thought distortion-all or none volume fluctuates and sometimes it is thinking not as noticeable, like when I am at the beach. I have had a rough night of sleep; however, I Identifying thought distortion- have been able to work many times in the catastrophizing past with little sleep. I am not as efficient with work when I have slept poorly, but it is unlikely I will get fired. Cognitive behavioral therapy has been used to treat tinnitus for 3 decades, and 1 study with 15-year follow-up showed stability of improvement after the end of such therapy. Cognitive behavioral therapy can also be performed remotely using online resources. Audiologists or other health professionals trained in cognitive behavioral intervention can also provide this treatment. Cognitive behavioral therapy is covered by Medicare and other insurance plans, but many mental health professionals do not accept insurance for these services, increasing direct costs to the patient. Supporting Text the purpose of this statement is to avoid the routine use of medications for tinnitus, as medications have not been shown to alleviate tinnitus and may have adverse effects. No medications have been shown to reliably eliminate or reduce tinnitus perception. Benefits of the recommendation against use of medications in routine treatment of tinnitus include avoiding unproven therapy, avoiding side effects (including production or worsening of tinnitus), avoiding false hope, avoiding the use of medications that may be harmful in certain patient populations (such as the elderly), avoiding the potential for substance use disorder, and avoiding unnecessary medication costs. This key action statement does not apply to those patients with comorbid disorders, such as anxiety, seizure disorder, or depression, where treatment with these agents could be indicated and useful.

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The Detaining Power shall supply such documents to antimicrobial nanotechnology cheap bactexina 250 mg without a prescription prisoners of war who possess none antibiotics for uti duration order bactexina in india. Badges of rank and nationality infection jaw bone purchase discount bactexina, decorations and articles having above all a personal or sentimental value may not be taken from prisoners of war virus x book discount 500mg bactexina amex. Sums of money carried by prisoners of war may not be taken away from them except by order of an officer, and after the amount and particulars of the owner have been recorded in a special register and an itemized receipt has been given, legibly inscribed with the name, rank and unit of the person issuing the said receipt. The Detaining Power may withdraw articles of value from prisoners of war only for reasons of security; when such articles are withdrawn, the procedure laid down for sums of money impounded shall apply. Such objects, likewise the sums taken away in any currency other than that of the Detaining Power and the conversion of which has not been asked for by the owners, shall be kept in the custody of the Detaining Power and shall be returned in their initial shape to prisoners of war at the end of their captivity. Only those prisoners of war who, owing to wounds or sickness, would run greater risks by being evacuated than by remaining where they are, may be temporarily kept back in a danger zone. Prisoners of war shall not be unnecessarily exposed to danger while awaiting evacuation from a fighting zone. The Detaining Power shall supply prisoners of war who are being evacuated with sufficient food and potable water, and with the necessary clothing and medical attention. If prisoners of war must, during evacuation, pass through transit camps, their stay in such camps shall be as brief as possible. It may impose on them the obligation of not leaving, beyond certain limits, the camp where they are interned, or if the said camp is fenced in, of not going outside its perimeter. Subject to the provisions of the present Convention relative to penal and disciplinary sanctions, prisoners of war may not be held in close confinement except where necessary to safeguard their health and then only during the continuation of the circumstances which make such confinement necessary. Prisoners of war may be partially or wholly released on parole or promise, in so far as is allowed by the laws of the Power on which they depend. Such measures shall be taken particularly in cases where this may contribute to the improvement of their state of health. Upon the outbreak of hostilities, each Party to the conflict shall notify the adverse Party of the laws and regulations allowing or forbidding its own nationals to accept liberty on parole or promise. Prisoners of war who are paroled or who have given their promise in conformity with the laws and regulations so notified, are bound on their personal honour scrupulously to fulfil, both towards the Power on which they depend and towards the Power which has captured them, the engagements of their paroles or promises. In such cases, the Power on which they depend is bound neither to require nor to accept from them any service incompatible with the parole or promise given. Except in particular cases which are justified by the interest of the prisoners themselves, they shall not be interned in penitentiaries. Prisoners of war interned in unhealthy areas, or where the climate is injurious for them, shall be removed as soon as possible to a more favourable climate. The Detaining Power shall assemble prisoners of war in camps or camp compounds according to their nationality, language and customs, provided that such prisoners shall not be separated from prisoners of war belonging to the armed forces with which they were serving at the time of their capture, except with their consent. Prisoners of war shall have shelters against air bombardment and other hazards of war, to the same extent as the local civilian population. With the exception of those engaged in the protection of their quarters against the aforesaid hazards, they may enter such shelters as soon as possible after the giving of the alarm. Any other protective measure taken in favour of the population shall also apply to them. Detaining Powers shall give the Powers concerned, through the intermediary of the Protecting Powers, all useful information regarding the geographical location of prisoner of war camps. The said conditions shall make allowance for the habits and customs of the prisoners and shall in no case be prejudicial to their health. The foregoing provisions shall apply in particular to the dormitories of prisoners of war as regards both total surface and minimum cubic space, and the general installations, bedding and blankets. The premises provided for the use of prisoners of war individually or collectively, shall be entirely protected from dampness and adequately heated and lighted, in particular between dusk and lights out. In any camps in which women prisoners of war, as well as men, are accommodated, separate dormitories shall be provided for them. The Detaining Power shall supply prisoners of war who work with such additional rations as are necessary for the labour on which they are employed. Prisoners of war shall, as far as possible, be associated with the preparation of their meals; they may be employed for that purpose in the kitchens. Furthermore, they shall be given the means of preparing, themselves, the additional food in their possession. Uniforms of enemy armed forces captured by the Detaining Power should, if suitable for the climate, be made available to clothe prisoners of war. In addition, prisoners of war who work shall receive appropriate clothing, wherever the nature of the work demands. The profits made by camp canteens shall be used for the benefit of the prisoners; a special fund shall be created for this purpose. When a camp is closed down, the credit balance of the special fund shall be handed to an international welfare organization, to be employed for the benefit of prisoners of war of the same nationality as those who have contributed to the fund. In case of a general repatriation, such profits shall be kept by the Detaining Power, subject to any agreement to the contrary between the Powers concerned. Prisoners of war shall have for their use, day and night, conveniences which conform to the rules of hygiene and are maintained in a constant state of cleanliness. In any camps in which women prisoners of war are accommodated, separate conveniences shall be provided for them. Also, apart from the baths and showers with which the camps shall be furnished, prisoners of war shall be provided with sufficient water and soap for their personal toilet and for washing their personal laundry; the necessary installations, facilities and time shall be granted them for that purpose. Isolation wards shall, if necessary, be set aside for cases of contagious or mental disease. Prisoners of war suffering from serious disease, or whose condition necessitates special treatment, a surgical operation or hospital care, must be admitted to any military or civilian medical unit where such treatment can be given, even if their repatriation is contemplated in the near future. Special facilities shall be afforded for the care to be given to the disabled, in particular to the blind, and for their rehabilitation, pending repatriation. Prisoners of war shall have the attention, preferably, of medical personnel of the Power on which they depend and, if possible, of their nationality. Prisoners of war may not be prevented from presenting themselves to the medical authorities for examination. The detaining authorities shall, upon request, issue to every prisoner who has undergone treatment, an official certificate indicating the nature of his illness or injury, and the duration and kind of treatment received. A duplicate of this certificate shall be forwarded to the Central Prisoners of War Agency the costs of treatment, including those of any apparatus necessary for the maintenance of prisoners of war in good health, particularly dentures and other artificial appliances, and spectacles, shall be borne by the Detaining Power. They shall include the checking and the recording of the weight of each prisoner of war. Their purpose shall be, in particular, to supervise the general state of health, nutrition and cleanliness of prisoners and to detect contagious diseases, especially tuberculosis, malaria and venereal disease. In that case they shall continue to be prisoners of war, but shall receive the same treatment as corresponding medical personnel retained by the Detaining Power. They shall, however, receive as a minimum the benefits and protection of the present Convention, and shall also be granted all facilities necessary to provide for the medical care of, and religious ministration to prisoners of war. They shall continue to exercise their medical and spiritual functions for the benefit of prisoners of war, preferably those belonging to the armed forces upon which they depend, within the scope of the military laws and regulations of the Detaining Power and under the control of its competent services, in accordance with their professional etiquette. They shall also benefit by the following facilities in the exercise of their medical or spiritual functions: a) They shall be authorized to visit periodically prisoners of war situated in working detachments or in hospitals outside the camp. For this purpose, the Detaining Power shall place at their disposal the necessary means of transport. For this purpose, Parties to the conflict shall agree at the outbreak of hostilities on the subject of the corresponding ranks of the medical personnel, including that of societies mentioned in Article 26 of the Geneva Convention for the Amelioration of the Condition of the Wounded and Sick in Armed Forces in the Field of August 12, 1949. This senior medical officer, as well as chaplains, shall have the right to deal with the competent authorities of the camp on all questions relating to their duties. Such authorities shall afford them all necessary facilities for correspondence relating to these questions. During hostilities, the Parties to the conflict shall agree concerning the possible relief of retained personnel and shall settle the procedure to be followed. They shall be allocated among the various camps and labour detachments containing prisoners of war belonging to the same forces, speaking the same language or practising the same religion. They shall enjoy the necessary facilities, including the means of transport provided for in Article 33, for visiting the prisoners of war outside their camp. They shall be free to correspond, subject to censorship, on matters concerning their religious duties with the ecclesiastical authorities in the country of detention and with international religious organizations. Letters and cards which they may send for this purpose shall be in addition to the quota provided for in Article 71. For this purpose, they shall receive the same treatment as the chaplains retained by the Detaining Power.

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