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Supportive Therapies: Intermittent Hemodialysis buy generic seroquel 100mg medicine vile, Continuous Renal Replacement Therapies buy seroquel 200 mg without prescription treatment wax, and Peritoneal Dialysis 19. Patients with multiple organ failure (M OF) and ARF can be treated with various continuous therapies Indication Clinical Condition Preferred Therapy or IHD. Continuous therapies provide better hemodynamic stability; however, if not moni- Uncomplicated ARF Antibiotic nephrotoxicity IHD, PD tored carefully they can lead to significant Fluid removal Cardiogenic shock, CP bypass SCUF, CAVH volume depletion. In general, hemodynami- Uremia Complicated ARF in ICU CVVHDF, CAVHDF, IHD cally unstable, catabolic, and fluid-over- Increased intracranial pressure Subarachnoid hemorrhage, CVVHD, CAVHD loaded patients are best treated with continu- hepatorenal syndrome ous therapies, whereas IHD is better suited Shock Sepsis, ARDS CVVH, CVVHDF, CAVHDF for patients who require early mobilization Nutrition Burns CVVHDF, CAVHDF, CVVH and are more stable. It is likely that the mix Poisons Theophylline, barbiturates Hemoperfusion, IHD, CVVHDF of modalities used will change as evidence Electrolyte abnormalities Marked hyperkalemia IHD, CVVHDF linking the choice of modality to outcome ARF in pregnancy Uremia in 2nd, 3rd trimester PD becomes available. For now, it is probably appropriate to consider all these techniques as viable options that can be used collectively. Ideally, each patient should have an individu- alized approach for management of ARF. Outcomes FIGURE 19-23 CRRT CRRT Efficacy of continuous renal replacem ent 100 IHD 6 IHD therapy (CRRT) versus interm ittent 5 80 hem odialysis (IH D): effect on blood urea 4 3 nitrogen, A, and creatinine levels, B, in 60 acute renal failure. It is apparent that CRRT tech- 40 niques offer im proved solute control and fluid m anagem ent with hem odynam ic stability, however a relationship to outcom e has not been dem onstrated. In a recent retrospective 30 analysis van Bom m el found no difference in BUN levels am ong survivors and non- 20 survivors with ARF W hile it is clear that lower solute concentrations can be achieved with 0 1 2 3 4 5 6 CRRT whether this is an im portant criteria im pacting on various outcom es from ARF still Days needs to be determ ined. A recent study form the Cleveland Clinic suggests that the dose of dialysis m ay be an im portant determ inant of outcom e allowing for underlying severity of illness. In this study the authors found that in patients with ARF, 65. There appeared to be an influence of dose of dialysis on outcom e in patients with interm ediate levels of severity of illness as judged by the Cleveland Clinic Foundation acuity score for ARF (see Fig. Patients receiving a higher Kt/V had a lower m ortality than predicted. These data illustrate the im portance of the underlying severity of illness, which is likely to be a m ajor determ inant of outcom e and should be considered in the analysis of any studies. The choice of dialysis membrane and its influence on survival from ARF has been of major interest to investigators over the last few years. W hile the evidence tends to support a survival advantage for biocompatible membranes, most of the studies were not well controlled. The most recent multicenter study showed an improvement in mortality and recov- ery of renal function with biocompatible membranes; however, this effect was not significant in oliguric patients. M ORTALITY IN ACUTE RENAL FAILURE: COM PARISON OF CRRT VERSUS IHD IHD CRRT Investigator Type of Study No Mortality, % No Mortality, % Change, % PValue Mauritz Retrospective 31 90 27 70 20 ns Alarabi Retrospective 40 55 40 45 10 ns Mehta Retrospective 24 85 18 72 13 ns Kierdorf Retrospective 73 93 73 77 16 < 0. Although several investigators have not been able to in the management of acute renal failure (ARF) over the last four demonstrate an advantage of these therapies in influencing mortality, decades, the perception is that the associated mortality has not we believe this may represent the difficulty in changing a global out- changed significantly. Recent publications suggest that there come which is impacted by several other factors. It is probably may have been some improvement during the last decade. Both more relevant to focus on other outcomes such as renal functional IHD and peritoneal dialysis (PD) were the major therapies until a recovery rather than mortality. W e believe that continued research is decade ago, and they improved the outcome from the 100% mortali- required in this area; however, there appears to be enough evidence ty of ARF to its current level. The effect of continuous renal replace- to support the use of CRRT techniques as an alternative that may be ment therapy on overall patient outcome is still unclear. The preferable to IHD in treating ARF in an intensive care setting. Supportive Therapies: Intermittent Hemodialysis, Continuous Renal Replacement Therapies, and Peritoneal Dialysis 19. As experience with these techniques grows, innovations in technology will likely keep pace. O ver the last 3 years, m ost of the m ajor m anufacturers of dialysis equipm ent have devel- oped new pum ps dedicated for continuous renal replacem ent therapy (CRRT). M em brane technology is also evolving, and antithrom bogenic m em branes are on the horizon.

The circuitry mediat- campal and catecholaminergic terminals converge on spiny neu- ing the translation of motivational stimuli into adaptive motor rons and are in apposition to each other order 200mg seroquel otc silent treatment. Opioid modulation and sensitization in the nucleus accumbens septi and on dopamine neurons in of dopamine release elicited by sexually relevant stimuli: a high- the ventral tegmental area discount 300mg seroquel free shipping symptoms to diagnosis. The role of excitatory amino acids in behavioral repeated administration of cocaine or amphetamine is transient sensitization to psychomotor stimulants. Progr Neurobiol 1998; and selectively involves AMPA receptors. Self-administered nico- glutamatergic signaling in the induction and expression of be- tine activates the mesolimbic dopamine system through the ven- havioral sensitization. Adaptive responses of circuits during cue-elicited cocaine craving. Proc Natl Acad Sci -aminobutyric acid neurons in the ventral tegmental area to USA 1996;93:12040–12045. Effect of prior ethanol amine: behavioral and neurochemical studies. Behav Pharmacol experience on dopamine overflow in accumbens of AA and ANA 1995;6:133–142. The potential anti- motion and dopamine release preferentially in the nucleus ac- addictive agent, 18 methoxycoronaridine, blocks the sensitized cumbens shell of rats administered repeated cocaine. J Pharmacol locomotor and dopamine responses produced by repeated mor- Exp Ther 1996;275:1019–1029. Effects of repeated nicotine nism by which amphetamine releases dopamine. J Neurosci pre-treatment on mesoprefrontal dopaminergic and behavioral 1997;17:3254–3261. Decreased striatal dopami- in striatal synaptosomes after repeated amphetamine. J Pharma- nergic responsiveness in detoxified cocaine-dependent subjects. Reproducibility of repeated amine- and K -mediated dopamine release in rat striatum after measures of endogenous dopamine competition with repeated amphetamine: differential requirements for Ca2 - [11C]reclopride in the human brain in response to methylphen- and calmodulin-dependent phosphorylation and synaptic vesi- idate. Molecular and cellular basis of ad- and nicotine predisposes rats to self-administer a low dose of diction. Effects of cocaine, nicotine, dizocilpine BTB protein that can prevent behavioral sensitization in rat. J and alcohol on mice locomotor activity: cocaine-alcohol cross- Neurosci 2000,20:6210–6217. Molecular alterations in the neostria- porter binding sites. Expression of the tran- lar actions of chronic morphine and cocaine in dopaminergic scription factor dFosB in the brain controls sensitivity to co- brain reward regions. Homer: a protein York Academy of Sciences, Volume 654). New York: New York that selectively binds metabotropic glutamate receptors. AMPA receptors by the extracellular immediate early gene prod- 72. Prior expe- phencyclidine exposure: involvement in frontostriatal cognitive rience of morphine application alters the c-fos response to deficits. Dopamine depletion in the medial pre- Res 2000;77(1):55–64. Stress-induced cross-sensitiza- ical responses to cocaine. Blockade of D-1 dopa- short- and long-term withdrawal. Psychopharmacology 1998; mine receptors in the medial prefrontal cortex produces delayed 136:24–33. Facilitation of sexual behaviors in the in the nucleus accumbens.

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When asked to rate the influence exerted by hospitals and other providers purchase 200mg seroquel with mastercard treatment quinsy, it tended to be respondents from CCGs rated as inadequate who were more likely to accord the highest influence to these bodies (Figure 7) purchase seroquel 300mg overnight delivery medications like adderall. This may reflect the reality of powerful local hospital trusts or it might reflect a lack of will or capability in tackling these providers. The next section shifts focus from the influence of CGGs to an analysis of relative influence within them. Most especially, there was the contentious issue of whether managers or clinicians were exercising power and, relatedly, what influence, if any, other role holders such as the lay members, the secondary care doctors and the nurses had. Influence within Clinical Commissioning Groups Given that the policy intent, as shown in Chapter 1, was to create commissioning organisations led by clinicians – and most especially by GPs – we wanted to know whether or not these institutions had lived up to that aspiration. We began with a question which asked about the relative influence of different groups on the redesign of services. The four groups were managers, GPs, other clinicians excluding GPs and lay members. In broad terms, managers and GPs were seen to be the most influential by far. In 2014, of the two, GPs were marginally ahead; however, by 2016 the rankings had reversed and managers were marginally ahead in terms of ranked influence. This is especially notable given that the majority of respondents were GPs. Other members of the governing bodies (including the lay members, secondary care doctors and nurses) were rated as far less influential. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 23 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. FINDINGS FROM THE NATIONAL SURVEYS 45 40 35 30 Year 25 2014 20 2016 15 10 5 0 Managers GPs Other clinicians Lay members excluding GPs FIGURE 8 Influence of managers, GPs, other clinicians and lay members in the redesign of services. Some answers from 2016 were then broken down to show how different kinds of respondents answered this question. It was evident that finance officers tended to see managers as the most influential figures. GP members of governing boards and others (directors of public health and other managers) tended likewise to see managers as influential. Next, we delved deeper into the perceived influence of GPs, as broken down by role of respondent. As the results in Figure 10 show, GP members of the boards were, ironically, the least convinced that they had much influence. Accountable officers, for example, may have wished to reflect the idea that they were the servants of a membership organisation. We also wanted to know in what capacity GPs were acting when they influenced service redesign. Was it as official governing members, as clinical leads who did not have a seat on the governing body, as locality leads, or as leaders of GP federations? Perhaps not a surprise, given the role of many respondents, GPs sitting on the governing bodies were seen as the most influential of the GP categories. Of note also was that the perceived influence of locality-level commissioning GPs declined between 2014 and 2016. A related question concerned who sets the compelling vision. Were GPs and other clinicians making a leadership contribution through envisaging alternative service provision or was this vital leadership role filled by others? In 2014, the results for clinicians were the same (between 25% and 26% of respondents said that GPs set the compelling vision). The main difference between the two time periods was in the proportion of 25% Clinicians Managers Neither 54% Both equally 19% 2% FIGURE 12 Who sets the compelling vision for service redesign? This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 25 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising.

It was coined at a time when investigative st technologies were crude (compared to those of the early 21 century) cheap seroquel 50 mg with mastercard medications 44 175. At the time cheap seroquel 100mg line 911 treatment for hair, it was assumed that if no organic basis could be demonstrated (with the technology of the day), none existed. Those conditions for which no physical explanation could be Pridmore S. With technological advances, the boundaries of “organic” should be moved. Schizophrenia, for example, was considered to be a functional disorder, but imaging and genetic studies have clearly demonstrated a physical basis. The same applies to many other psychiatric disorders. The term organic, therefore, says more about the technology of the day than the existence of pathology. It can be argued that psychiatry is generally concerned with pathology at a molecular level (e. Putting confusing terminology aside: HCF testing is a valuable means of detecting conditions which may present as psychiatric disorders but which require the services of other branches of medicine. For example, patients may present with a picture suggestive of schizophrenia or depression which is secondary to space occupying lesions, toxic, endocrine or metabolic abnormalities, and in such circumstances, HCF testing frequently reveals abnormalities. In general, if memory, orientation, concentration and language are intact, the performance of learned skilled movements and recognition of stimuli will also be intact. Thus, the former may be regarded as a screening test, such that if they are intact, the latter need not be tested. This is a standardised, widely employed screening test of HCF. It examines orientation in some detail and then briefly touches on registration and recall, attention/concentration, language and constructional abilities. Brevity is its strength (allowing wide breadth examination) and its weakness (not providing a comprehensive assessment). This is a screening test which may be used to indicate whether more extensive (time consuming) examination is necessary. Memory Memory is the ability to revive past thoughts and sensory experiences. It includes three basic mental processes: registration (the ability to perceive, recognise, and establish information in the central nervous system), retention (the ability to retain registered information) and recall (the ability to retrieve stored information at will). Short-term memory (which for this discussion includes what has been called immediate memory by others) has been defined as the recall of material within a period of up to 30 seconds after presentation. Intuitively, there is something different between short tem and long term memory. At the library, there is something different Pridmore S. Long term memory can be split into recent memory (events occurring during the past few hours to the past few months) and remote memory (events occurring in past years). In addition to physical lesions, intoxication, emotional arousal, psychomotor retardation, thought disorder and motivation must be considered. Tests of memory During the psychiatric interview good information about memory is available. Memory testing provides quantification (but this may not be necessary). After some general conversation, the examiner may say something like, “Thank you Mr X, I understand what you have been saying. When a patient who has been treated respectfully but makes excuses or refuses cognitive testing, there is probably cognitive impairment. Where memory function is the primary problem the patient may not be able to remember why he/she is present.

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Antiaggressive effects can be the Predatory aggression buy generic seroquel 100 mg on line symptoms 24 hours before death, such as mouse killing (muricide) in rats result of many (side) effects of drugs cheap 50mg seroquel with visa symptoms wisdom teeth, and the proposed or locust killing (insecticide) in mice, occurs spontaneously animal models are capable of detecting and describing these in a proportion of individuals, depending on the strain used effects. Consequently, they have a high predictable validity 1706 Neuropsychopharmacology: The Fifth Generation of Progress toward their effects in humans, although it is very difficult 6. A new class of psychoactive to predict for which human disorder or symptom (77). In: Garat- One of the biggest obstacles in the study of the psycho- tini S, Siggs SB, eds. Amsterdam: Excerpta pharmacology of aggression and the predictability for the Medica, 1969:70–76. Psychopharmacolo- only primary aggression disorder in DSM-IV is intermittent gia 1973;31:305–320. The pharmacology of isolation-induced aggressive be- haviour in mice. In: of different underlying disorders; this situation makes it ex- Thompson T, Dews PB, eds. Advances in behavioral pharmacol- tremely difficult to compare human with animal aggression ogy, vol. Social behaviour in rats and mice: an strong that there are specific neural substrates in the brain ethologically based model for differentiating psychoactive drugs. In: and it is more than likely that similar mechanisms are avail- GlickSD, Goldfarb J, eds. Selective anti-aggresive properties of DU27725: etho- the system, such as the postsynaptic 5-HT receptor (80), logical analyses of intermale and territorial aggression in the male 1B rat. Genetic modification of this system (5-HT1B- benzodiazepine receptor complex, and aggression. Recent Dev Al- receptor knockout mouse) has added considerable evidence cohol 1997;13:139–171. Behavioural effects of the latter is only a small part of a much bigger and very psychoactive drugs on agonistic behaviour of male territorial rats (resident-intruder paradigm). In: MiczekKA, KrukMR, Olivier complex circuitry in the brain involved in agonistic be- B, eds. Preclinical aggression research is under considerable pres- 16. Alcohol and heightened sure because of ethical and societal constraints on doing aggression in individual mice. Alcohol Clin Exp Res 1998;22: 'biologically' oriented research in understanding the 698–705. Psychopharma- However, further research, using animal models of aggres- cology (Berl) 1993;110:451–459. Increased aggression after ethanol self- aggression and violence. Analysis of the behavioral profiles administration in male resident rats. Alcohol-heightened aggre- great promise over the next decade for discovering novel sion in mice: attenuation by 5–HT1A receptor agonists. Psycho- neurochemical pathways in the brain involved in the control pharmacology (Berl) 1998;139:160–168. Aggression heightened by area, generating inducible, and brain region–specific mu- alcohol or social instigation in mice: reduction by the 5-HT(1B) receptor agonist CP-94,253. Psychopharmacology (Berl) 1999; tants will engender exciting tools to study the role of genes, 146:391–399. The psychopharmacology of aggression: to- gression, and important new clues for the study and treat- ward a new day. Differential effects of oxazepam and lorazepam on aggressive responding. Effects of clorazepate, REFERENCES diazepam, and oxazepam on a laboratory measurement of aggres- sion in men. Intraspecies aggression in rats: effects of D-amphet- violence: towards a nosology of human aggressive behavior. Psychopharmacology (Berl) 1974;39: chopharmacol Bull 1993;29:57–63. Serenics: a new class of drugs Commun Behav Biol 1968;2:65–87.

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Valsartan reduces the incidence of atrial fibrillation in patients with heart failure: results from the Valsartan Heart Failure Trial (Val-HeFT) best 300mg seroquel medications causing hyponatremia. Temporal relations of atrial fibrillation and congestive heart failure and their joint influence on mortality: the Framingham Heart Study purchase seroquel 50mg amex symptoms 10dpo. ACC/AHA/ESC 2006 Guidelines for the HRS/EHRA/ECAS Expert Consensus Management of Patients With Atrial Statement on Catheter and Surgical Ablation Fibrillation: full text: a report of the of Atrial Fibrillation: recommendations for American College of Cardiology/American personnel, policy, procedures and follow-up. Heart Association Task Force on Practice A report of the Heart Rhythm Society (HRS) Guidelines and the European Society of Task Force on Catheter and Surgical Cardiology Committee for Practice Ablation of Atrial Fibrillation developed in Guidelines (Writing Committee to Revise partnership with the European Heart the 2001 Guidelines for the Management of Rhythm Association (EHRA) and the Patients With Atrial Fibrillation): developed European Cardiac Arrhythmia Society in collaboration with the European Heart (ECAS); in collaboration with the American Rhythm Association and the Heart Rhythm College of Cardiology (ACC), American Society. Heart Association (AHA), and the Society PMID: 16987906. Endorsed and approved by the governing bodies of the 15. Statement on Catheter and Surgical Ablation 2011 ACCF/AHA/HRS Focused Update on of Atrial Fibrillation: recommendations for the Management of Patients With Atrial patient selection, procedural techniques, Fibrillation (Updating the 2006 Guideline): patient management and follow-up, a report of the American College of definitions, endpoints, and research trial Cardiology Foundation/American Heart design: a report of the Heart Rhythm Society Association Task Force on Practice (HRS) Task Force on Catheter and Surgical Guidelines. Van Gelder IC, Groenveld HF, Crijns HJ, et Rhythm Association (EHRA), a registered al. Lenient versus strict rate control in branch of the European Society of patients with atrial fibrillation. N Engl J Cardiology (ESC) and the European Cardiac Med. Endorsed by the governing bodies of the American College of Cardiology Foundation, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, the Asia Pacific Heart Rhythm Society, and the Heart Rhythm Society. Surgical Maze procedure as a treatment for Management of New Onset Atrial atrial fibrillation: a meta-analysis of Fibrillation. Hopkins University Evidence-based Practice Center under Contract No. Rockville, Cardiac resynchronization therapy reduces MD: Agency for Healthcare Research and left atrial volume and the risk of atrial Quality; January 2001. Implantation Trial with Cardiac Resynchronization Therapy). Effect of cardiac resynchronization on the incidence of atrial fibrillation in patients 27. Management of atrial fibrillation: review of 2006;114(1):18-25. Methods Guide for Effectiveness and echocardiography. AHRQ series paper 5: grading the strength Chapters available at of a body of evidence when comparing www. Evidence-based Practice Center Systematic Effective Health Care Program. PMID: 21463926 ES-35 Introduction Background Definition and Impact of Atrial Fibrillation Atrial fibrillation (AF) is a supraventricular tachyarrhythmia (any tachycardic rhythm originating above the ventricular tissue) and is characterized by uncoordinated atrial activation 1 with consequent deterioration of mechanical function. Although the type of AF can change over time, it is often helpful to characterize it at a given moment, as this may guide treatment. Types of AF include first-detected, paroxysmal (arrhythmia terminates spontaneously within 7 days), persistent (arrhythmia is sustained beyond 7 days), long-standing persistent (usually lasting for more than 1 year), and permanent AF (in which cardioversion has failed or has not been 1 attempted). The prevalence of AF 3 increases with age and approaches 8 percent in patients older than 80 years of age. As such, AF is the most common sustained arrhythmia seen in clinical practice. AF affects men and women 1 equally; however, approximately 60 percent of patients older than 75 years of age are female. The impact of AF is compounded by its known association with significant mortality, morbidity, and health care costs. Not only is the risk of death in patients with AF twice that of patients without AF, but AF can result in myocardial ischemia or even infarction, heart failure exacerbation, and tachycardia-induced cardiomyopathy if the ventricular rate is not well- 4-7 controlled. In some patients, AF can severely depreciate quality of life by causing shortness of 8-11 breath, intractable fatigue, and near-syncope.

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Roter DL cheap 200 mg seroquel mastercard medicine in the middle ages, Stewart M cheap 300 mg seroquel mastercard treatment programs, Putnam SM, Lipkin M, Stiles W, Inui TS. Moore GF, Audrey S, Barker M, Bond L, Bonell C, Hardeman W, et al. Process evaluation of complex interventions: Medical Research Council guidance. Chronic disease management: what will it take to improve care for chronic illness? Barriers to service use for postpartum depression symptoms among low-income ethnic minority mothers in the United States. Does the chronic care model serve also as a template for improving prevention? Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Moher D, et al. Morse JM, Stern PN, Corbin J, Bowers B, Clarke AE, Charmaz K. Developing Grounded Theory: The Second Generation (Developing Qualitative Inquiry). May C, Murray E, Finch T, Mair F, Treweek SA, Ballini L, et al. Questions asked and answered in pilot and feasibility randomized controlled trials. Bugge C, Williams B, Hagen S, Logan J, Glazener C, Pringle S, et al. A process for Decision-making after Pilot and feasibility Trials (ADePT): development following a feasibility study of a complex intervention for pelvic organ prolapse. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 83 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. Fellow-Smith E, Moss-Morris R, Tylee A, Fossey M, Cohen A, Nixon T. Investing in Emotional and Psychological Wellbeing for Patients with Long-term Conditions. The Family Nurse Partnership Programme: Information Leaflet. The Cardinal Needs Schedule – a modified version of the MRC Needs for Care Assessment Schedule. CAN: Camberwell Assessment of Need: A Comprehensive Needs Assessment Tool for People with Severe Mental Illness. The development and evaluation of a holistic needs assessment and care planning learning package targeted at cancer nurses in the UK. Building the House of Care for people with long-term conditions: the foundation of the House of Care framework. How Healthcare Professionals in Scotland Develop their Communication Skills, Attitudes and Behaviours. An Independent Report for NHS Education for Scotland. Making it Easy, A Health Literacy Plan for Scotland. How to Score the SF-12 Physical and Mental Health Summary Scales. Boston, MA: The Health Institute, New England Medical Center; 1998. SF12: Stata Module to Validate SF12 Input and Calculate SF12 Version 2 t Scores. It encourages linking with other sectors to more appropriately address these problems for patients and to access alternative types of resources. The PCAM also encourages new ways of working that enhance opportunities for health promotion, even in those with few current health or social problems, to maintain healthy behaviour.