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In addition order viagra capsules 100mg with mastercard, there should be corresponding radiation protection training requirements for other clinical personnel that participate in the conduct of procedures utilizing ionizing radiation cheap viagra capsules 100 mg visa, or in the care of patients undergoing diagnosis or treatment with ionizing radiation purchase discount viagra capsules. Scientific and professional societies should contribute to the development of the syllabuses, and to the promotion and support of the education and training. Scientific congresses should include refresher courses on radiation protection, attendance at which could be a requirement for continuing professional development for professionals using ionizing radiation. Professionals involved more directly in the use of ionizing radiation should receive education and training in radiation protection at the start of their career, and the education process should continue throughout their professional life as the collective knowledge of the subject develops. It should include specific training on related radiation protection aspects as new equipment or techniques are introduced into a centre. A major test Adequate education and training of medical staff and practitioners is considered paramount and the major route to ensuring appropriate radiological protection in medicine. In pursuit of medical, dental, radiography and other health care degrees, education and training should be part of the curriculum and for specialists, such as radiologists, nuclear medicine specialists and medical physicists, as part of the curriculum of postgraduate degrees. The term ‘education’ usually refers to imparting knowledge and understanding on the topics of radiation health effects, radiation quantities and units, principles of radiological protection, radiological protection legislation, and the factors in practice that affect patient and staff doses. The term ‘training’ refers to providing instruction with regard to radiological protection for the justified application of the specific ionizing radiation modalities (e. Education and training are officially recognized with accreditation and certification. Accreditation and certification Organizations should be established to provide ‘accreditation’ that officially recognizes education and training on the radiological protection aspects of the use of diagnostic or interventional radiation procedures in medicine. Such organizations have to be approved by an authorizing or regulatory body, and required to meet standards that have been set by that body. A system of ‘certification’ shall be established for officially stating that an individual medical or clinical professional has successfully completed the education or training provided by an accredited organization for the diagnostic or interventional procedures to be practised by the individual, demonstrating competence in the subject matter in a manner required by the accrediting body. As the number of diagnostic and interventional medical procedures using ionizing radiations is rising steadily, and procedures resulting in higher patient and staff doses are being performed more frequently, the need for education and training of medical staff (including medical students) and other health care professionals in the principles of radiation protection will be a more compelling challenge for the future. Fostering information exchange Fostering information exchange is another key general challenge for improving radiological protection in medicine. Intergovernmental organizations, national regulatory bodies, medical professional associations, and medics and patients themselves should be part of a rich network of information exchange. This brochure underlines, on the one hand, the obvious benefits to health from medical uses of radiation, in X ray diagnostics, interventional radiology, nuclear medicine and radiotherapy, and, on the other hand, the well established risks from high doses of radiation (radiotherapy, interventional radiology), particularly if improperly applied, and the possible deleterious effects from small radiation doses (such as those used in diagnostics). This brochure describes the dilemma of protection of patients in uncomplicated prose: appropriate use of large doses in radiotherapy prevents serious harm, but even low doses carry a risk that cannot be eliminated entirely. Diagnostic use of radiation, therefore, requires methodology that would secure high diagnostic gains while minimizing the possible harm. The text provides ample information on opportunities to minimize doses and, therefore, the risk from diagnostic uses of radiation, indicating that this objective may be reached by avoiding unnecessary (unjustified) examinations, and by optimizing the procedures applied both from the standpoint of diagnostic quality and in terms of reduction of excessive doses to patients. Optimization of patient protection in radiotherapy must depend on maintaining sufficiently high doses to irradiated tumours, securing a high cure rate, while protecting the healthy tissues to the largest extent possible. Problems related to special protection of the embryo and foetus in the 3 http://rpop. Strategy As described in the previous, vidi, chapter, the number of challenges still presented by radiological protection in medicine is enormous. In order to address these challenges and succeed in addressing them, a strategy is required. Altmaier, Federal Minister of Germany for the Environment, Nature Conservation and Nuclear Safety at the Bonn conference [2]. It did not only consider the protection of patients and their comforters but also the related and, many times, interrelated occupational protection of the medical staff attending the patients and the protection of members of the public who are usually casually exposed from medical sources. Notwithstanding this, the Bonn conference could well follow the pattern marked by the Malaga conference. Heinen-Esser, again comes to the rescue with a relevant suggestion by declaring: “I would be delighted if we were to adopt a new action programme by the end of this week and meet the shared objective of this conference: Setting the Scene for the Next Decade. It seems that the general strategy should be the achievement of a renewed international Action Plan, this time covering all aspects of radiological protection in medicine. New standards It is to be noted that there is an important framework for such a strategy and for a new action plan. The new requirements comprehend ten specific mandatory ‘commandments’, namely: (1) The government shall ensure that relevant parties are authorized to assume their roles and responsibilities and that diagnostic reference levels, dose constraints, and criteria and guidelines for the release of patients are established. The world now seems to be ready for a serious systematic and orderly intergovernmental process for internationalizing the protection of patients and medical staff. The new Action Plan should be undertaken in co-sponsorship and cooperation with: — Specialized agencies of the United Nations family; — Relevant regional organizations; — National regulators; — Medical professional organizations; — Senior specialists in the practices of radiodiagnosis and radiotherapy, and in radiological protection; — The pertinent industry of manufacturers of medical equipment. The strategic aim of such an Action Plan should be an intergovernmental international radiation safety regime for the practice of medicine. First volume translated into Castilian: Historia de la radiación, la radioactividad y la radioprotección — La Caja de Pandora; con prólogo de Abel J. González, Sociedad Argentina de Radioprotección, Buenos Aires (2012), http://radioproteccionsar. Lahfi The role and relevance of efficacy to the principle of justification in the field of radiation protection of the patient B. Moores A preliminary study on the impact of a redesigned paper based radiology requisition form with radiation dose scale on referring clinicians — As a model for developing countries A. Ascención Ybarra Lessons learnt from errors and accidents to improve patient safety in radiotherapy centers K. Asnaashari Lahroodi Gel dosimetry for radiotherapy patient dose measurements and verification of complex absorbed dose distributions M. Castellanos Film dosimetry for validation of the performance of commercially available 3D detector arrays for patient treatment plan verifications K. Chełmiński Radioprotective effect of bolus on testicular dose during radiation therapy for testicular seminoma J. Cordero Ramírez Issues on patient safety during radiation therapy — Concerns of regulatory authority P. Dubner Organ and effective doses from verification techniques in image-guided radiotherapy V. Dufek Application of the risk matrix approach in radiotherapy: An Ibero-American experience C. Duménigo Neutron contamination in radiotherapy treatments — Evaluation of dose and secondary cancer risk in patients M. Gershkevitsh Direct calibration of Australian hospital reference chambers in linac beams P. Harty Prevention and management of accidental exposures in radiotherapy in the Czech Republic I. Ismail Determination of entrance and exit doses in vivo in radiotherapy photon beams — A simple approach A. Malicki Dose from secondary radiation outside the treatment fields at different treatment distances with the use of multi-leaf collimators, physical and enhanced dynamic wedges R. Melchor Operational health physics during the commissioning phase of the West German Proton Therapy Centre Essen B.

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However 100mg viagra capsules for sale, larger amounts and chronic use do have significant medical consequences cheap 100 mg viagra capsules with visa, and for patients with pre-existing mental illness regular use can - 78 - Survival and Austere Medicine: An Introduction worsen symptoms 100 mg viagra capsules otc. Cannabis may be of value in the same way that any pharmacologically active substance can be, but this is not an endorsement of its recreational use. Honey While not technically a plant no discussion of botanical and herbal medicine would be complete without the mention of using honey as a healing agent. This is a common item in food storage programmes, but it needs to be in your medicinal storage preparations also. Change daily, cleansing the wound area with a strong solution of Echinacea root, repack with honey, then redress sterilely. A real strong solution of Echinacea will have a numbing effect which will make the wound cleansing less painful. A tablespoon eaten every 1-2 hours for a week or so should clear up an acute condition, then a tablespoon 3 x daily for a week or so should clear up the condition entirely. Other medicinal plants While there are many plants, which have medicinal, properties table 9. Other common medicines and there plant origins Plant Name Medication Clinical Uses Name Erthroxylum Coca Cocaine Local anaesthetic Atropa Belladonna Atropine Anti-Cholinergic – treats nerve (Deadly nightshade) agent exposure Mucuna Species L-Dopa Anti-Parkinson’s drug Ephedra sinica Ephedrine Sympathomimetic / Decongestant Pilocarpus jaborandi Pilocarpine Glaucoma therapy Cinchona ledeenana Quinine Anti-malarial Theobroma cacao Theophylline Asthma treatment Chondodendron Tubocurarine Muscle relaxant tomentosum Daphne genkina Yuanhuacine Induces abortion Figures 8. Poppy extracts provide the most practical option for managing severe pain in an austere situation. Beware: possession with the intention to use as a drug is illegal in many countries. For the majority there is very little evidence aside from anecdote to their efficacy. A common underlying principle of most alternative therapies is good nutrition and a healthy lifestyle – the value of this is clearly not in dispute. A number of alternative therapies are based on scientific theories from hundreds of years ago which have been superseded by modern science. To accept these underlying principles requires you to suspend your belief in some of the fundamental concepts of modern science and especially physics. It is vital you should take the time to look at the evidence for an alternative therapy or diagnostic modality before counting on them as a main part of your medical preparations. The weakest sort of evidence is anecdote and testimonials, and you should be very careful accepting any therapy that only has this level of evidence to support it. Conventional medicine does not have trials proving every therapy works and neither should alternative therapies by expected to either. Some things we intuitively know are correct – you do not need a randomised controlled trial to prove that a parachute is better than nothing if you are about to jump out of a plane. The caveat to this statement is “that the rationale as to why a therapy works should make sense and not involve the suspension of the laws of physics in order to be able to accept it”. Colloidal silver is silver atoms in solution, grouped together in clusters – essentially metallic silver in suspension – in an uncharged, non-ionic form. There is a large body of evidence showing silver compounds (which release ionic silver) are effective topical antibiotics particularly in burns, chronic skin infections, and ulcers. There is no evidence that silver compounds are effective with systemic infections. This is not considered to be a serious condition, but the changes are irreversible. In summary, there is no evidence that colloidal silver works as a broad-spectrum topical or systemic antimicrobial, and given what we know about how silver produces its antimicrobial effect we have no reason to think that at a molecular level it would work. This does not mean that it doesn’t, but the absence of good evidence makes it less likely. The Placebo Effect: The “placebo effect” refers to the fact that for any therapy a percentage of people will respond (it ranges from 0-30% depending on the therapy), and show a benefit that is not related to any pharmacological effect of the drug, and this benefit persists when a sham therapy is substituted for the real one. It is important to be aware of this in an austere situation – not so much for you but for your patients. If you present yourself to the patient with confidence, and prescribe a therapy with confidence and conviction a significant number of patients will show - 82 - Survival and Austere Medicine: An Introduction improvement even if you are only giving them a sham therapy – such as an alcohol based tonic – the value of this in a survival situation shouldn’t be underestimated. The body is vastly more complicated than what we currently understand and despite its negative press if the placebo effect of a specific therapy helps people get better and is otherwise harmless (that’s a very important proviso) then it is potentially useful. One of the most useful points of references when considering the medical problems associated with shelter living is looking at the problems encountered on submarines or in the Antarctic. The similarities are obvious – enclosed space, cramped conditions, loss of privacy, potentially no natural light, same people day in and day out, and real or potential hazards. The people selected to work in these environments are carefully psychologically and physically screened so it is not possible to make truly direct comparisons with a shelter group, but we feel it is still very worthwhile examining the problems seen in those environments. This is likely to be a major problem even for only a couple of weeks and a major problem long term; combating boredom is going to be a major issue. Research has shown that a human alone can only cope with 3 days of inactivity with limited stimulation before significant psychological distress occurs. This is seen in the form of loss of motivation, decline in intellectual activities (losing your edge), mood swings, and somatic complaints (headache, dizziness, nausea). Several studies have shown that the average person needs 10-12 hours of activity per day to avoid boredom. Establishing a pattern, which occurs everyday, is really important for psychological well-being. Everyone should be given an area of responsibility and important activities that are theirs to perform. Books, craft supplies, and games are vital to avoid boredom – catering for the range of ages which will be in the shelter. For children (and adults) structured teaching serves two purposes; reducing boredom and providing the opportunity for education about survival topics and issues. Following any catastrophic disaster there will be an immense sense of loss; loss of family and friends, loss of possessions, loss of usual routine, and loss of lifestyle. This will be on top of a background of high levels of anxiety over immediate safety, and security, and the future. For the majority this will hopefully be relatively transient and be observed as a period of low mood and emotional lability. But they still retain the ability to function and over time improve simply with strong group support and encouragement. There is a formal diagnostic criterion for this but simply put it means someone with severe low mood to the point they are no longer able to function in their work or personal relationships. It is characterised by a pervasive sense of hopelessness, inability to concentrate, poor or excessive sleep, poor or excessive eating, and a loss of ability to enjoy things in life. Its usual management is social support combined with supportive psychotherapy and/or the use of antidepressant medications. If someone is completely incapacitated or suicidal with major depression this may force some hard decisions on your group.

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He or she is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that includes the delivery of safe buy viagra capsules with a mastercard, effective purchase viagra capsules 100 mg with mastercard, patient-centered purchase generic viagra capsules on-line, timely, efficient, and equitable care. He or she is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that includes the delivery of safe, effective, patient-centered, timely, efficient, and equitable care. Has professional and respectful interactions with patients, caregivers, and members of the interprofessional team (e. He or she is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that includes the delivery of safe, effective, patient-centered, timely, efficient, and equitable care. He or she is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that includes the delivery of safe, effective, patient-centered, timely, efficient, and equitable care. An improvement plan is in place to facilitate achievement of competence appropriate to the level of training. The Milestones are a product of the Internal Medicine Subspecialty Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Internal Medicine. Subject to statutory exception and to the provisions of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press. First published 2010 Printed in the United Kingdom at the University Press, Cambridge A catalog record for this publication is available from the British Library Library of Congress Cataloging in Publication data Mayer, Dan. To the extent permitted by applicable law, Cambridge University Press is not liable for direct damages or loss of any kind resulting from the use of this product or from errors or faults contained in it, and in every case Cambridge University Press’s liability shall be limited to the amount actually paid by the customer for the product. Every effort has been made in preparing this publication to provide accurate and up-to-date information which is in accord with accepted standards and practice at the time of publication. Although case histories are drawn from actual cases, every effort has been made to disguise the identities of the individuals involved. Nevertheless, the authors, editors, and publishers can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation. The authors, editors, and publishers therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this publication. Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use. However, the publisher has no responsibility for the websites and can make no guarantee that a site will remain live or that the content is or will remain appropriate. Kaplan v vi Contents 17 Applicability and strength of evidence 187 18 Communicating evidence to patients 199 Laura J. Henry Pohl, then Associate Dean for Aca- demic Affairs, asked me to develop a course to teach students how to become lifelong learners and how the health-care system works. The first syllabus was based on a course in critical appraisal of the medical literature intended for inter- nal medicine residents at Michigan State University. The basis for the orga- nization of the book lies in the concept of the educational prescription proposed by W. The goal of the text is to allow the reader, whether medical student, resident, allied health-care provider, or practicing physician, to become a critical con- sumer of the medical literature. This textbook will teach you to read between the lines in a research study and apply that information to your patients. For reasons I do not clearly understand, many physicians are “allergic” to mathematics. It seems that even the simplest mathematical calculations drive them to distraction. Although the math content in this book is on a pretty basic level, most daily interaction with patients involves some understanding of mathematical processes. We may want to determine how much better the patient sitting in our office will do with a particular drug, or how to interpret a patient’s concern about a new finding on their yearly physical. Far more commonly, we may need to interpret the information from the Internet that our patient brought in. The math is limited to simple arithmetic, and a handheld calculator is the only computing ix x Preface instrument that is needed. The layout of the book is an attempt to follow the process outlined in the edu- cational prescription. You will be given information about the answer after pressing “submit” if you get the question wrong. When you press “submit,” you will be shown the correct or suggested answer for that question and can proceed to the next question. After finishing, a sample of correct and acceptable answers will be shown for you to compare with your answers. Decisions are made by language and the language includes both words and numbers, but before evidence-based decision-making came along, relatively little consideration was given to the types of statement or proposi- tion being made. Hospital Boards and Chief Executives, managers and clinicians, made statements but it was never clear what type of statement they were mak- ing. Was it, for example, a proposition based on evidence, or was it a proposition based on experience, or a proposition based on values? All these different types of propositions are valid but to a different degree of validity. This language was hard-packed like Arctic ice, and the criteria of evidence- based decision-making smash into this hard-packed ice like an icebreaker with, on one side propositions based on evidence and, on another, propositions based on experience and values. As with icebreakers, the channel may close up when the icebreaker has moved through but usually it stays open long enough for a decision to be made. We use a simple arrows diagram to illustrate the different components of a decision, each of which is valid but has a different type of validity. Evidence-based decision-making is what it says on the tin – it is evidence-based – but it needs to take into account the needs and values of a particular patient, service or population, and this book describes very well how to do that. Foremost, I want to thank my wife, Julia Eddy, without whose insight this book would never have been written and revised. Her encourage- ment and suggestions at every stage during the development of the course, writ- ing the syllabi, and finally putting them into book form, were the vital link in creating this work. At the University of Vermont, she learned how statistics could be used to develop and evaluate research in psychology and how it should be taught as an applied science. She encouraged me to use the “scientific method approach” to teach medicine to my students, evaluating new research using applied statistics to improve the practice of medicine. This group of committed students and faculty has met monthly since 1993 to make constructive changes in the course. Their suggestions have been incorporated into the book, and this invaluable input has helped me develop it from a rudi- mentary and disconnected series of lectures and workshops to what I hope is a fully integrated educational text. I am indebted to the staff of the Office of Medical Education of the Department of Internal Medicine at the Michigan State University for the syllabus material that I purchased from them in 1993. I think they had a great idea on how to intro- duce the uninitiated to critical appraisal.

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In this study buy 100mg viagra capsules fast delivery, although dietary total n-3 fatty acid intake correlated inversely with total mortality viagra capsules 100 mg with amex, no effect on total myocardial infarction cheap viagra capsules american express, nonsudden cardiac death, or total cardiovascular mortality was observed. After adjustment for classical risk factors, the reduction was only 32 percent and no longer significant. There are fewer data with regard to the effects of fish and n-3 poly- unsaturated fatty acids on stroke. In the Zutphen Study, consumption of more than 20 g/d of fish was associated with a decrease in the risk of stroke (Keli et al. In contrast, in the Chicago Western Electric Study and the Physicians’ Health Study, fish intake was not signifi- cantly associated with decreased stroke risk (Morris et al. Some studies, however, did not show an effect on platelet aggregation after the consumption of 4. There was a significant reduction in risk for cardiac death for the experimental group after 27 months, and a reduction after a 4-year follow-up. The extent to which these reductions in risk were due to n-3 fatty acids is uncertain. This group also expe- rienced a 20 percent reduction in all-cause mortality and a 45 percent reduction in sudden deaths compared with the control group. Vitamin E, in contrast to n-3 polyunsaturated fatty acids, had no beneficial effects on cardiovascular endpoints. A meta-analysis of 31 placebo- controlled trials estimated a mean reduction in systolic and diastolic blood pressure of 3. Further- more, a statistically significant dose–response effect occurred with the smallest reduction observed with intakes of less than 3 g/d and the largest reduction observed with intakes at 15 g/d. Because impaired heart rate variability is associated with increased arrhythmic events (Farrell et al. However, the beneficial effect was found only in men with low initial heart rate variability. Several studies have examined whether n-3 polyunsaturated fatty acids affect growth of adipose tissue. Parrish and colleagues (1990, 1991) found that rats given a high fat diet supplemented with fish oil had less fat in perirenal and epididymal fat pads and decreased adipocyte volumes compared with rats fed lard. Adipose tissue growth restriction appeared to be the result of limiting the amount of triacylglycerol in each adipose tissue cell rather than by limiting the number of cells. The researchers concluded that the rats supplemented with n-3 fatty acids demonstrated reduced oxidation of fat and increased carbo- hydrate utilization. Little data exist with respect to the specific effects of dietary n-3 polyunsaturated fatty acids on adiposity in humans; therefore, prevention of obesity cannot be considered an indicator at this time. While several studies have reported a nega- tive relationship between polyunsaturated fatty acid intake and risk of diabetes (Colditz et al. A review of the epidemiological data on this association concluded that polyunsaturated fatty acids, and possibly long- chain n-3 fatty acids, could be beneficial in reducing the risk of diabetes (Hu et al. Studies conducted in rodents have shown that administration of fish oil results in increased insulin sensitivity (Chicco et al. Substituting a proportion of the fat in a high fat diet with fish oil prevented the devel- opment of insulin resistance in rats (Storlien et al. Thus, animal evidence suggests that the fatty acid composition of the diet may be an important factor in the effect of dietary fat on insulin action. Whether a change of dietary fat composition will alter insulin sensitivity in humans remains an open question. Studies in humans have demon- strated a relationship between increased insulin sensitivity and the proportion of long-chain n-3 polyunsaturated fatty acids in skeletal muscle phospho- lipids (Borkman et al. Risk of Cancer Experimental evidence suggests several mechanisms in which n-3 poly- unsaturated fatty acids may protect against cancer. Animal studies with n-3 fatty acid or fish-oil supplementation have shown inhibition of mammary carcinogenesis and tumor growth (Grammatikos et al. Across-country epidemiological studies have shown an inverse relation- ship between dietary fish intake and breast cancer incidence and mortality (Kaizer et al. Moreover, despite these results, most case-control and prospective studies have not reported a protective effect of fish consumption on breast cancer (Willett, 1997). Ecological studies have also shown inverse relationships between fish and fish oil intake and colorectal cancer (Caygill and Hill, 1995; Caygill et al. Results from case-control and prospective studies have been somewhat equivocal (Boutron et al. However, Willett and colleagues (1990) found that higher fish con- sumption was associated with less colon cancer in women. Risk of Nutrient Inadequacy Vegetable oils, such as soybean oil, flaxseed oil, and canola oil, contain high amounts of α-linolenic acid. Low intakes of α-linolenic acid can result in inadequate biosynthesis of the longer-chain n-3 polyunsaturated fatty acids, resulting in an exces- sive ratio of n-6 polyunsaturated fatty acids (see Chapter 8). High intakes of n-3 polyunsaturated fatty acids (α-linolenic acid) can also result in inadequate biosynthesis of long chain n-6 poly- unsaturated fatty acids that are important for prostaglandin and eicosanoid synthesis (see Chapter 8). Based on the median energy intake by the various age groups (Appendix Table E-1), it is estimated that approximately 0. Data from interventional studies to support the benefit of even higher intakes of α-linolenic acid were not considered strong enough to justify establishing an upper boundary greater than 1. In the United States, saturated fatty acids provided 11 to 12 percent of energy in adult diets and 12. The intake of cholesterol by American adults ranges from less than 100 mg/d to just under 770 mg/d (Appendix Table E-15). It is important to recognize that lower intakes of saturated fatty acids and cholesterol are observed for vegetarians, especially vegans (Janelle and Barr, 1995; Shultz and Leklem, 1983). Because certain micronutrients, saturated fats, and cholesterol are consumed mainly through animal foods, it is possible that diets low in saturated fat and cholesterol are associated with low intakes of these micronutrients. When the micronutrient intakes of Seventh-day Adventist vegetarians and nonvegetarians were measured, there were no significant reductions in micronutrient intakes with the lower saturated fat (7. Similarly, the intakes of most micronutrients were not significantly lower for vegans, except for vitamin B12 (0. Analysis of nutritionally adequate menus indicates that there is a mini- mum amount of saturated fat that can be consumed so that sufficient levels of linoleic and α-linolenic acid are consumed (as an example see Appendix Tables G-1 and G-2). Other than soy products that are high in n-6 and n-3 fatty acids, many vegetable-based fat sources are also high in saturated fatty acids, and these differences should be considered in plan- ning menus. To minimize saturated fatty acid intake requires decreased intake of animal fats (e. Saturated fatty acids can be reduced by choosing lean cuts of meat, trimming away visible fat on meats, and eating smaller por- tions. The amount of butter that is added to foods can be minimized or replaced with vegetable oils or nonhydrogenated vegetable oil spreads. Vegetable oils, such as canola and safflower oil, can be used to replace more saturated oils such as coconut and palm oil. Such changes can reduce saturated fat intake without altering the intake of essential nutrients. A reduction in the frequency of intake or serving size of certain foods such as liver (375 mg/3 oz slice) and eggs (250 mg/egg) can help reduce the intake of cholesterol, as well as foods that contain eggs, such as cheese- cake (170 mg/slice) and custard pie (170 mg/slice).