By A. Baldar. Pacific Union College. 2019.
After6months harms of initiating statin use for the primary prevention of cardio- to 6 years of follow-up buy entocort without prescription, statin use was associated with a decreased vascular events in adults 76 years and older order 100 mcg entocort free shipping. However purchase 100mcg entocort free shipping, in the available estimates when trials were stratified according to dose buy entocort canada. Nostudieswere tent across different clinical and demographic subgroups (even identifiedthatdirectlycomparedtreatmentwithstatinstitratedto among adults without marked dyslipidemia). Becausetheab- Harms of Statin Use soluteunderlyingriskislower,feweradultswhosmokeorhavedys- In randomized trials of statin use for the primary prevention of lipidemia,diabetes,orhypertensionanda7. As such, any decision to ini- withdrawal because of adverse events compared with placebo, tiateuseofalow-tomoderate-dosestatininthispopulationshould and there were no statistically significant differences in the risk of involve shared decision making that weighs the potential benefits experiencing any serious adverse event. It should also take into consideration the personal prefer- levels with statin use. Some comments requested clarification regarding the op- foundnoassociationwithstatinuse,41butananalysisfromtheWo- timal dose of statins. Thesepersonsshouldbescreenedandtreatedinaccordancetoclini- Recommendations of Others cal judgment for the treatment of dyslipidemia. Thetreatmentstrat- ment is no longer relevant and has been replaced by a preventive egy is treatment-to-target rather than by therapy dose (eg, 50% medication framework. Total cardiovascularrisk:areportoftheAmerican AspirinUsetoPreventCardiovascularDiseaseand cholesterol and risk of mortality in the oldest old. The tables and figures in this Pocket Guide follow the numbering of the 2017 Global Strategy Report for reference consistency. These include genetic abnormalities, abnormal lung development and accelerated aging. These comorbidities should be actively sought and treated appropriately when present as they can influence mortality and hospitalizations independently. Spirometry is the most reproducible and objective measurement of airflow limitation. Despite its good sensitivity, peak expiratory flow measurement alone cannot be reliably used as the only diagnostic test because of its weak specificity. Spirometry should be performed after the administration of an adequate dose of at least one short-acting inhaled bronchodilator in order to minimize variability. Spirometry in conjunction with patient symptoms and exacerbation history remains vital for the diagnosis, prognostication and consideration of other important therapeutic approaches. In the refined assessment scheme, patients should undergo spirometry to determine the severity of airflow limitation (i. Finally, their history of exacerbations (including prior hospitalizations) should be recorded. This classification scheme may facilitate consideration of individual therapies (exacerbation prevention versus symptom relief as outlined in the above example) and also help guide escalation and de-escalation therapeutic strategies for a specific patient. Pharmacotherapy and nicotine replacement reliably increase long-term smoking abstinence rates. However, individual patient factors must be considered when evaluating the patient’s need for supplemental oxygen. If effective resources and time are dedicated to smoking cessation, long-term quit success rates of up to 25% can be achieved. Counseling delivered by physicians and other health professionals significantly increases quit rates over self-initiated strategies. Stimulation of beta2-adrenergic receptors can produce resting sinus tachycardia and has the potential to precipitate cardiac rhythm disturbances in susceptible patients. Exaggerated somatic tremor is troublesome in some older patients treated with higher doses of beta2-agonists, regardless of route of administration. Antimuscarinic drugs Antimuscarinic drugs block the bronchoconstrictor effects of acetylcholine on M3 muscarinic receptors expressed in airway smooth muscle. Inhaled anticholinergic drugs are poorly absorbed which limits the troublesome systemic effects observed with atropine. Toxicity is dose-related, which is a particular problem with xanthine derivatives because their therapeutic ratio is small and most of the benefit occurs only when near-toxic doses are given. Results from withdrawal studies provide equivocal results regarding consequences of withdrawal on lung function, symptoms and exacerbations. Reduction of total personal exposure to occupational dusts, fumes, and gases, and to indoor and outdoor air pollutants, should also be addressed. Key points for the use of other pharmacologic treatments are summarized in Table 4. Symptoms, exacerbations and objective measures of airflow limitation should be monitored to determine when to modify management and to identify any complications and/or comorbidities that may develop. These changes contribute to increased dyspnea that is the key symptom of an exacerbation. Other symptoms include increased sputum purulence and volume, together with increased cough and wheeze. More than 80% of exacerbations are managed on an outpatient basis with pharmacologic therapies including bronchodilators, corticosteroids, and antibiotics. Acute respiratory failure — non-life-threatening: Respiratory rate: > 30 breaths per minute; using accessory respiratory muscles; no change in mental status; hypoxemia improved with supplemental oxygen via Venturi mask 25-30% FiO2; hypercarbia i. Acute respiratory failure — life-threatening: Respiratory rate: > 30 breaths per minute; using accessory respiratory muscles; acute changes in mental status; hypoxemia not improved with supplemental oxygen via Venturi mask or requiring FiO2 > 40%; hypercarbia i. The management of severe, but not life threatening, exacerbations is outlined in Table 5. Respiratory Support Oxygen therapy This is a key component of hospital treatment of an exacerbation. Supplemental oxygen should be titrated to improve the patient’s hypoxemia with a target saturation of 88- 92%. The indications for initiating invasive mechanical ventilation during an exacerbation are shown in Table 5. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Poor airway function in early infancy and lung function by age 22 years: a non-selective longitudinal cohort study. The lung health study: airway responsiveness to inhaled methacholine in smokers with mild to moderate airflow limitation. An official American Thoracic Society public policy statement: Novel risk factors and the global burden of chronic obstructive pulmonary disease. Occupational exposures are associated with worse morbidity in patients with chronic obstructive pulmonary disease. Lifetime risk of developing chronic obstructive pulmonary disease: a longitudinal population study. Risk factors for chronic obstructive pulmonary disease in a European cohort of young adults. Detecting chronic obstructive pulmonary disease using peak flow rate: cross sectional survey. The tobacco use and dependence clinical practice guideline panel s, and consortium representatives,. A clinical practice guideline for treating tobacco use and dependence: 2008 update. Economic evaluation of influenza vaccination in Thai chronic obstructive pulmonary disease patients. The efficacy and cost effectiveness of vaccination against influenza among elderly persons living in the community. Long-term treatment with inhaled budesonide in persons with mild chronic obstructive pulmonary disease who continue smoking. Long-term effect of inhaled budesonide in mild and moderate chronic obstructive pulmonary disease: a randomised controlled trial. Indacaterol on dyspnea in chronic obstructive pulmonary disease: a systematic review and meta-analysis of randomized placebo-controlled trials. Indacaterol, a once-daily beta2-agonist, versus twice-daily beta(2)-agonists or placebo for chronic obstructive pulmonary disease.
The overarching harm-minimisation approach that has proved so successful in previous iterations of the Strategy remains the direction for 2016-2025 purchase entocort 100 mcg free shipping. The National Drug Strategy 2016-2025 continues to build on the successful collaboration of health and law enforcement agencies in leading the implementation of the three pillars of harm minimisation: • demand reduction to prevent the uptake and/or delay the onset of use of alcohol order discount entocort, tobacco and other drugs cheap 100mcg entocort with amex; reduce the misuse of alcohol and the use of tobacco and other drugs in the community purchase generic entocort from india; and support people to recover from dependence and reintegrate with the community • supply reduction to prevent, stop, disrupt or otherwise reduce the production and supply of illegal drugs; and control, manage and/or regulate the availability of legal drugs • harm reduction to reduce the adverse health, social and economic consequences of the use of alcohol, tobacco and other drugs. Partnerships are not only important in implementation; they have also been essential in the development of the National Drug Strategy 2016-2025. The writing of the Strategy was informed by an extensive national consultation process, which included key informant interviews, online survey feedback and stakeholder forums. This process identified priorities for the next ten years, which will be vital in reducing drug-related harm. These are detailed in the Strategy, but can be summarised as: • increasing processes for community to identify and respond to key alcohol, tobacco and other drug issues • improving national coordination • developing and sharing data and research that supports evidence-informed approaches • developing innovative responses to prevent uptake, delay the first use and reduce harmful levels of alcohol, tobacco and other drug use • restricting or regulating the availability of alcohol, tobacco and other drugs • enhancing harm reduction approaches. National Drug Strategy 2016-2025 3 Measures for improving stakeholder and community engagement have been identified in the Strategy as a result of the consultation feedback process. Opportunities for consumers and communities, service providers, peer organisations and other interested parties to be engaged in alcohol, tobacco and other drug strategies over the next ten years will increase. The health and law enforcement sectors demonstrate an excellent working relationship for managing alcohol, tobacco and other drug issues and initiatives, which can be used as a model for improving engagement with other parts of the sector. During the period of the National Drug Strategy 2010-2015, evidence informed demand, supply and harm reduction strategies yielded positive results. In 2011-12, police reported 76,083 drug seizures; the highest number of drug seizures in the last 1 decade. The same year, 809 clandestine laboratories were detected nationwide; the highest number 2 ever detected in Australia. There was also a decline in the proportion of people exceeding lifetime risk guidelines for consuming alcohol from 20% in 2010 to 18. There were declines in the use of some illicit drugs between 2010 and 2013, including heroin and ecstasy and a decrease in the proportion of people injecting drugs during this period. While those people with the lowest socio-economic status were more likely to smoke and consume alcohol at risky quantities, the proportion of daily smoking declined for this group from 22% in 2010 5 to 19. The embedding of harm minimisation principles into the day-to-day operations of police, health services and other interested parties is also a worthy achievement. The Strategy takes Australia into the fourth decade with a consistent national drug policy framework, which has earned high international regard for its progressive, balanced and comprehensive approach and has made considerable achievements. The term ‘drug’ in this document refers to a substance that produces a psychoactive effect when consumed by humans, including tobacco, alcohol, pharmaceutical drugs and illicit drugs. It also takes 6 account of performance and image-enhancing drugs, and substances such as inhalants. This includes health harms such as injury, lung and other cancers; cardiovascular disease; liver cirrhosis; mental health problems; road trauma; social harms including violence and other crime. It also includes economic harms from healthcare and law enforcement costs, decreased productivity, associated criminal activity, reinforcement of marginalisation and disadvantage, domestic and family violence and child protections issues. Harmful drug use is also associated with social and health determinants such as discrimination, unemployment, homelessness, poverty and family breakdown. Since 1985, activities for the original National Campaign Against Drug Abuse and preceding National Drug Strategy iterations have demonstrated many of these harms can be minimised through coordinated, multi-agency approaches and community responses that address the harmful use of drugs and the underlying determinants of use. Cooperation between the law enforcement and health sectors is fundamental to drug harm responses and ongoing engagement with other key stakeholders is increasingly necessary for positive outcomes. Collaboration of this nature has facilitated referral pathways to alcohol and other drug treatment and supported less harmful substance use. The Strategy describes the national approach to prevent, minimise and address the drug harms to individuals, families and communities. It provides a national framework and guidance for action by Commonwealth, state and territory governments in partnership with service providers, local government and the community. As well as outlining the national commitment to the harm minimisation approach, the Strategy describes priority actions, groups and drug types and summarises effective demand, supply and harm reduction strategies. Trends in alcohol, tobacco and other drug use change regularly and the evidence base for effective responses to drug-related harm is constantly evolving. As a consequence, priority populations and drug types, including forms and delivery, change over time. Interventions should change with them and be informed by the latest available evidence. The Strategy is informed by current evidence on drug use and effective strategies. However, priorities and responses are expected to change during the term of the Strategy. The Strategy provides a framework for flexible, proactive and nationally coordinated responses and is designed to adapt to changes based on the principles of harm minimisation. Implementation of the approach presented in this Strategy, including funding, legislation and programs, is the responsibility of relevant agencies in Commonwealth, State and Territory 6 Ministerial Council on Drug Strategy (2004) The National Drug Strategy-Australia’s Integrated Framework 2004-2009. The mix of actions adopted in individual jurisdictions and the details of their implementation may vary to reflect local circumstances and priorities. Local innovation within the harm minimisation approach, responding to needs and emerging issues, leads to better outcomes. This approach considers the health, social and economic consequences of drug use on both the individual and the community as a whole and is based on the following considerations: • Use of drugs, whether licit or illicit, is a part of society, • Drug use occurs across a continuum, from occasional use to dependent use, • A range of harms are associated with different types and patterns of drug use, • Response to these harms can use a range of methodologies. This approach reduces total harm due to alcohol, tobacco and other drug use through coordinated, multi-agency responses that address the three pillars of harm minimisation. Strategies to minimise the harm from alcohol, tobacco and other drug use should be coordinated and balanced across the three pillars. It also includes supporting people to recover from dependence and enhance their integration with the community. Supply Reduction Supply reduction includes strategies and actions that prevent, stop, disrupt or otherwise reduce the production and supply of illicit drugs; and control, manage or regulate the supply of alcohol, tobacco and other licit drugs. Harm Reduction Harm reduction strategies aim to reduce the negative outcomes from alcohol, tobacco and other drug use when it is occurring by encouraging safer behaviours, creating supportive environments and reducing preventable risk factors. These principles underpin effective responses to alcohol, tobacco and other drug use. Partnerships The core partnership between health and law enforcement is central to the harm minimisation approach. However, a wide range of effective partnerships are critical components of the harm minimisation approach. This includes partnerships between both government and non-government agencies in areas such as education, treatment and services, justice, child protection, social welfare, fiscal policy, trade, consumer policy, road safety and employment. It also includes partnerships with researchers and communities, affected communities such as drug user organisations, Aboriginal and Torres Strait Islander communities, and other priority populations. Coordination and collaboration Coordination and collaboration at the international level, nationally and within jurisdictions leads to improved outcomes, innovative responses and better use of resources. The Strategy coordinates the national response to alcohol, tobacco and other drugs by establishing the harm minimisation approach. The Strategy also facilitates collaboration by describing the wide variety of responsibilities within the harm minimisation approach and their interdependence, as well as through the Strategy’s governance structure. Evidence informed responses Funding, resource allocation and implementation of strategies should be informed by evidence where possible. However, evidence is constantly improving and priorities and effective responses will develop during the term of the Strategy. Innovation and leadership in the development of new approaches is encouraged within the framework of harm minimisation. Supporting research and building and sharing evidence is a key mechanism that allows a national approach to leverage better outcomes from local implementation. Where evidence is not available or limited, effective policy should still be implemented, especially when this will expand the knowledge base. National direction, jurisdictional implementation The Strategy describes a nationally agreed harm minimisation approach to reducing the harm from alcohol, tobacco and other drug use. However, funding and implementation occurs at all levels of government and the Commonwealth Government, state and territory governments and local governments are all responsible for regulation and the funding of programs that reduce the harms of drug use.
Most of these issues have been discussed in the chap- ter on randomized clinical trials in Chapter 15 discount entocort online visa. The out- come assessment should also be done in a blinded manner to avoid diagnostic suspicion and expectation bias in the assessment of patient outcomes buy generic entocort 100 mcg. There can be signiﬁcant bias introduced into the study if the outcomes are not measured in a consistent manner cheap entocort 100 mcg visa. Death or life are clear and easily measured outcome variables although the cause of death as measured on a death certiﬁcate is not always a reliable cheap entocort express, clear, or objective outcome measure of the actual cause of death. Admission to the hospital appears to be clear and objective, but the reasons or threshold for admission to the hospital may be very subjective and subject to signiﬁcant inter- rater variability. Outcomes such as “full recovery at home” or “feeling better” have a higher degree of subjectivity associated with them. The researcher should determine whether the prognostic factor is merely a marker or actually a factor that is responsible for the causation. This determines whether or not there are alternative explanations for the outcomes due to some confounding variable. Count on the article being reviewed by a statistician who can determine if the authors used the correct statistical analysis, but be aware that the correct adjustment for extraneous factors may not have been done correctly if at all. If the authors suggest that a group of signs, symptoms, or diagnostic tests accu- rately predict an outcome, look for a validation sample in a second study which attempts to verify that indeed these results occurred because of a causal rela- tionship and not just by chance. Look for at least 10 and preferably 20 patients who actually had the outcome of interest for each prognostic factor that is eval- uated to give clinically and statistically signiﬁcant results. One is interested in the association of an inde- pendent variable such as drug use, therapy, risk factor, diagnostic test result, tumor stage, age of patient, or blood pressure with the dependent or outcome variable. Diagnostic-suspicion bias occurs when the physician caring for the patient knows the nature and purpose of the outcomes being measured and as a result, changes the interpretation of a diagnostic test, the actual care or observation of the patient. Expectation bias occurs when the person measuring the outcome knows the clinical features of the case or the results of a diagnostic test and alters their interpretation of the outcome event. This is less likely when the interven- tion and outcome measures are clearly objective. Ideally blind diagnosis, treat- ment, and assessment of all the patients going through the study will prevent these biases. Another problem in the outcomes selected occurs when multiple outcomes are lumped together. Many more studies of therapy are comparing two groups for several outcomes at once and these so-called composite outcomes have been discussed in Chapter 11 in greater detail. Commonly used measures of heart therapies might include death, an important outcome, non-fatal myocar- dial infarction, important but less than death and need for revascularization pro- cedure much less important than death. The use of these measures can lead to over-optimistic conclusions regarding the therapy being tested. When combined, multiple or composite outcomes may then show statistical signiﬁcance. The primary outcome measures were overall number of Survival analysis and studies of prognosis 363 deaths, and of deaths due to stroke, myocardial infarction, or vascular causes. The end result was that there were no decreases in death from stroke or myocardial infarction, but a 20% reduction in deaths in the patients with peripheral arterial disease. If these patient outcomes were considered as separate groups, the differences would not have been statistically signiﬁcant. Another danger is that some patients may be counted several times because they have several of the outcomes. There are basically three types of data that are used to indicate risk of an out- come. Interval data such as blood pressure is usually considered to be normally distributed and measured on a continuous scale. Nominal data like tumor type or treatment options is categorical and often dichotomous like alive and dead or positive and negative test results. Ordinal data such as tumor stage is also cate- gorical but with some relation between the categories. There are three types of analyses applied to this type of problem: frequency tables, logistic analysis, and survival analysis. Decision theory uses probability distributions to estimate the probability of an outcome. Frequency tables Frequency tables use a chi-square analysis to compare the association of the out- come with risk factors that are nominal or ordinal. For the chi-square analysis, data are usually presented in a table where columns are outcomes, rows are risk factors, and the frequencies appear as table entries. The observed data are com- pared with the data that would be expected if there were no association. The analysis results in a P value which indicates the probability that the observed outcome could have been obtained by chance when it was really no different from the expected value. Logistic analysis This is a more general approach to measuring outcomes than using frequency tables. Logistic regression estimates the probability of an outcome based on one or more risk factors. Results of logistic regression analysis are often reported as the odds ratio, relative risk, or hazard ratio. For one independent variable of interval-type data and relative risk, this method calculates how much of an increase in the risk of the outcome occurs for each incremental increase in the exposure to the risk fac- tor. An example of this would answer the question “how much additional risk of 364 Essential Evidence-Based Medicine stroke will occur for each increase of 10 mm Hg in systolic blood pressure? For multiple variables, is there some combination of risk factors that will bet- ter predict an outcome than one risk factor alone? The identiﬁcation of signiﬁcant risk factors can be done using multiple regressions or stepwise regression analyses as we discussed in Chapter 29 on clinical prediction rules. Survival analysis In the real world the ultimate outcome is often not known and could be dead as opposed to “so far, so good” or not dead yet. It would be difﬁcult to justify waiting until all patients in a study die so that survival in two treatment or risk groups can be compared. Besides, another common problem with comparing survival between groups occurs in trying to determine what to do with patients who are doing ﬁne but die of an incident unrelated to their medical problem such as death in a motor-vehicle accident of a patent who had a bypass graft 15 years earlier. This will alter the information used in the analysis of time to occlusion with two different types of bypasses. Finally, how should the study handle the patient who simply moves away and is lost to follow-up? The data con- sist of a time interval and a dichotomous variable indicating status, either failure (dead, graft occluded, etc. In the latter case, the patient may still be alive, have died but not from the disease of interest, or been alive when last seen but could not be located again. Early diagnosis may automatically confer longer survival if the time of diagnosis is the start time. This is also called lead-time bias, as discussed in Chapter 28, and is a common problem with screening tests. Censoring bias occurs when one of the treatment groups is more likely to be censored than the other. A survival analysis initially assumes that any patient censoring is independent of the outcome. Survival curves The distribution of survival times is most often displayed as a survivor function, also called a survival curve. It is important to note that “surviving” may indicate things other Survival analysis and studies of prognosis 365 9 x 9 x 8 O 8 O 7 x 7 x 6 6 5 x 5 x 4 4 3 O 3 O 2 x 2 x 1 x 1 x 1970 1975 1977 1980 t=0 t = 5 years Fig. Patient 1 lived longer than everyone except patient 4, although it appears that patient 1 didn’t live so long, since their previous survival (pre-1975) does not count in the analysis. We don’t know how long patient 4 will live since he or she is still alive at the end of the observation period and their data are censored at t = 5 years. Two other patients (3 and 8) are lost to follow-up, and their data are censored early (o). These curves can be deceptive since the number of individuals represented by the curve decreases as time increases. It is key that a statistical analysis is applied at several times to the results of the curves.
In most countries entocort 100 mcg discount, health inequalities have been widening over recent decades (15 order entocort 100mcg free shipping, 16) buy entocort now. Once disease is established buy entocort with mastercard, poor people are more likely to suffer adverse consequences than 62 Chapter Two. This is especially true of women, as they are often more vulnerable to the effects of social inequality and poverty, and less able to access resources. In Denmark, England and Wales, Finland, Italy, Norway, and Sweden inequalities in mortality increased between the Material deprivationMaterial deprivation 1980s and the 1990s. These widening inequalities have been attributed and psychosocial stressand psychosocial stress to two important changes. The ﬁrst is that cardiovascular disease death rates declined among Constrained choicesConstrained choices wealthy members of these societies, explaining about half of the widening and higher levels ofand higher levels of risk behaviourrisk behaviour gap. This might have been a result of faster changes in health behaviour in these groups and/or better access to health-care interventions. Second, widening inequalities in other causes of death (lung cancer, Increased risk of diseaseIncreased risk of disease breast cancer, respiratory disease, gastrointestinal disease and injuries) resulted from increasing rates of mortality among poorer groups. Rising Disease onsetDisease onset rates of lung cancer and deaths from chronic respiratory disease indi- cate the delayed effects of rising tobacco use among poorer members of society (16). The poor and people with less education are more likely to use tobacco products, consume energy-dense and high-fat food, be physically inactive, and be over- weight or obese (17 ). This social and economic difference in risk factor prevalence is particu- larly striking in high income countries, but is also rapidly becoming a prominent feature of low and middle income countries (18, 19). Poor people and those with less education are more likely to maintain risk behaviour for several reasons. These include inequality of opportuni- ties, such as general education; psychosocial stress; limited choice of consumption patterns; inadequate access to health care and health education; and vulnerability to the adverse effects of globalization. Aggressive marketing of harmful products, such as tobacco, sustain the demand for these products among those who have fewer opportunities to substitute unhealthy habits with healthier and often more expensive options. It is likely that several factors contribute to this relationship, but one explanation is that “energy-dense” foods, such as fried or processed foods, tend to cost less on a per-calorie basis when compared with fresh fruit and vegetables (20). Many people live in areas that cause them to be concerned for their safety, thereby reducing opportunities for outdoor physical activities. People living in disadvantaged communities marked by sprawling development are likely to walk less and weigh The United Republic of Tanzania more than others. People from deprived communities suffer more from demonstrates a mixed picture with cardiovascular diseases than residents of more afﬂuent communities, regard to risk factors. Inadequate access to good-quality health services, including diagnostic This ﬁnding supports the idea that and clinical prevention services, is a signiﬁcant cause of the social as countries develop economically, and economic inequalities in the burden of chronic diseases. The poor different risk factors affect differ- face several health-care barriers including ﬁnancial constraints, lack ent social and economic classes at of proximity and/or availability of transport to health-care centres, and different rates (19). Some people are unable to afford out-of-pocket charges for health care and might forfeit their wages by missing work. Transport costs can also prevent people from seeking care, especially those who must travel long distances to health centres. Even when health services are subsidized by the government or pro- vided free in low and middle income countries, it is the wealthier who gain more from such services. Findings from South Africa, for example, showed that among people with high blood pressure, the wealthiest 30% of the population was more than twice as likely to have received treatment as the poorest 40% (26). The poor and marginalized are often confronted with insufﬁcient respon- siveness from the health-care system. Communication barriers may signiﬁcantly decrease effective access to health services and inhibit the degree to which a patient can beneﬁt from such services. Migrants, for In 1994, the main obstacle to obtain- example, often face language and other cultural barriers. Almost Social inequality, poverty and inequitable access to resources, including 75% of people who could not obtain health care, result in a high burden of chronic diseases among women medicines reported unavailability as worldwide, particularly very poor women. However, In general, women tend to live longer with chronic disease than men, since then the situation has changed though they are often in poor health. The costs associated with health dramatically: availability of medi- care, including user fees, are a barrier to women’s use of services. By 2000, 65–70% of people who unless there is agreement from senior members (whether male or female) could not obtain medicines reported of the household. Women’s workload in the home and their caregiving unaffordability as the main reason, roles when other family members are ill are also signiﬁcant factors in while unavailability accounted for delaying decisions to seek treatment. Population-based surveys of blindness in Africa, Asia and many high income countries suggest that women account for 65% of all blind people world- wide. Cataract blindness could be reduced by about 13% if women received cataract surgery at the same rate as men. The decision to delay treat- ment is often inﬂuenced by the cost of the surgery, inability to travel to a surgical facility, differences in the perceived value of surgery (cataract is often viewed as an inevitable consequence of ageing and women are less likely to experience support within the family to seek care), and lack of access to health information (28). This section describes how chronic diseases cause poverty and draw individuals and their families into a downward spiral of worsening disease and impoverishment. In Bangladesh, for example, of those households that moved into the status “always poor”, all reported death or severe disabling diseases as one of the In Jamaica 59% of people with main causes. Existing knowledge underestimates the implications of chronic avoided some medical treatment as diseases for poverty and the potential that chronic disease prevention a result (30). Ongoing health care-related expenses for chronic diseases are a major problem for many poor people. Acute chronic disease-related events – such as a heart attack or stroke – can People in India with diabetes spend be disastrously expensive, and are so for millions of people. The poorest die without treatment, or to seek treatment and push their family into people – those who can least afford poverty. Those who suffer from long-standing chronic diseases are in the cost – spend the greatest pro- the worst situation, because the costs of medical care are incurred over portion of their income on medical a long period of time (34). On average, they spend 25% of their annual income on private care, compared with 4% in high income groups (31). Spending money on tobacco deprives people of education opportunities that could help lift them out of poverty and also leads to greater health-care costs. Indirect costs on food instead, saving the lives of 350 include: children under the age of ﬁve years each day. The poorest households in Bangla- » reduction in income owing to lost productivity from illness or death; desh spend almost 10 times as much on » the cost of adult household members caring for those who are ill; tobacco as on education (37). However, in low and middle users but belong to households that use income countries disability insurance systems are either underdeveloped tobacco (38). In the United Kingdom, the average cost of monthly health insurance pre- The illness of a main income earner in low and middle income countries miums for a 35-year-old female smoker signiﬁcantly reduces overall household income. People who have chronic is 65% higher than the cost for a non- diseases are not fully able to compensate for income lost during periods smoker. Male smokers pay 70% higher of illness when they are in relatively good health (36). Households often sell their possessions to cover lost income and health-care costs. In the short term, this might help poor households to cope with urgent medical costs, but in the long term it has a nega- tive effect: the selling of productive assets – property that produces income – increases the vulnerability of households and drives them into poverty. Such changes in the investment pattern of households are more likely to occur when chronic diseases require long-term, costly treatment (36). But one thing she clearly remembers is that each time she returned home without receiving adequate treatment and care. Name Maria Saloniki Today, this livestock keeper and mother of 10 children is Age 60 Country United Republic ﬁghting for her life at the Ocean Road Cancer Institute in Dar of Tanzania es Salaam. It took Maria more than three years to discover the Diagnosis Breast cancer words to describe her pain – breast cancer – and to receive the treatment she desperately needs. In fact, between these ﬁrst symptoms and chemotherapy treatment, Maria was prescribed herb ointments on several occasions, has been on antibiotics twice and heard from more than one health professional that they couldn’t do anything for her. The 60-year-old even travelled to Nairobi, Kenya to seek treatment, but it wasn’t until later, in Dar es Salaam, that a biopsy revealed her disease.
Bilateral or single lung transplants are habilitation programmes improve exercise capacity performed through a lateral thoracotomy possibly and quality of life buy cheap entocort online. The lung is prone to rejection and patient sufﬁciently to overcome the obstruction order entocort 100mcg amex, in the thus transbronchial biopsies are now used for rou- process of which the patients sleep is disturbed order entocort with visa, although tine monitoring effective entocort 100 mcg. Less than half notice that they have a restless or unrefreshing sleep, and about a third Prognosis complain of morning headache (due to carbon dioxide 50% of patients with severe breathlessness die within 5 retention). Sleepingpartnerswillhavenoticedloudsnor- years although even in severe cases stopping smoking ing in 95% and often notice the snore–apnoea–choke– improves the prognosis. Classical anatomy is a long soft palate, large neck Sleep apnoea/Pickwickian syndrome and excess tissue around the tonsils. Deﬁnition Sleep apnoea represents the cessation of airﬂow at the Complications level of the nostrils and mouth lasting at least 10 seconds, Oxygen saturations may fall very low. The pulmonary thepatientissaidtosufferfromsleepapnoeaifmorethan vasculature responds to hypoxia by vasoconstriction 15 such episodes occur in any 1 hour of sleep. Hypoxia also increases arrhythmias and there is an increased risk Prevalence of stroke and myocardial infarction. Investigations A simple sleep study with overnight pulse oximetry to- Sex gether with a history from sleeping companion may be Male preponderance. Many require a full sleep study (polysomno- gram), which consists of a pulse oximeter, a tidal volume Aetiology measurement, oronasal ﬂow and electroencephalogra- Risk factors include obesity, smoking, chronic obstruc- phy to record sleep and arousal patterns. Polycythaemia tive pulmonary disease and alcohol or other sedatives (raised haemoglobin and packed cell volume) may occur which exacerbate the problem by causing hypotonia and in advanced cases. Apnoea can be divided into the following: Management 1 Central apnoea when there is depression of the respi- Non-pharmacological treatment includes weight loss, ratory drive, e. Snoring arises because of turbulent airﬂow around the 2 Surgicaltreatmentmaybedifﬁcultaspatientsareoften soft palate with partial obstruction. Thereisareﬂex the redundant tissues in the soft palate and lateral increase in respiratory drive, which eventually rouses the pharynx is sometimes performed but its beneﬁt in Chapter 3: Restrictive lung disorders 117 true obstructive sleep apnoea is unproven and it changes and the cysts seen in honeycomb lung. It has been reclassiﬁed as usual interstitial pneu- Radiation monia, a form of idiopathic interstitial pneumonia. Extrinsic allergic alveolitis Ankylosing spondylitis and other connective tissue diseases (scleroderma, rheumatoid arthritis, sys- Prevalence temic lupus erythematosus) Uncommon. Sarcoidosis, berylliosis (exposure to this industrial al- loy mimics sarcoidosis) Age Tuberculosis Usually late middle age. Cryptogenic ﬁbrosing alveolitis (idiopathic pul- monary ﬁbrosis) Sex Asbestosis Slightly M > F The other main groups of causes are the pneumoco- nioses, which are occupational lung diseases in response Aetiology to ﬁbrogenic dusts such as coal and silicon, and drug- Unknown, but an indistinguishable disease is seen in induced, such as amiodarone. Pathophysiology Antinuclear factor is positive in one third of patients The lung has limited ability to regenerate following a se- and rheumatoid factor is positive in 50%. Fibrosis may be localised, bilateral of patients are current or former smokers, and smoking or widespread depending on the underlying cause. Patients are at an increased risk of secondary infection and even if the original insult is removed may develop progressive Pathophysiology ﬁbrosis and subsequent respiratory failure. The alveo- There appear to be areas of ﬁbroblast activation, which lar wall ﬁbrosis greatly reduces the pulmonary capillary lay down matrix, and healing of these leads to ﬁbrosis. It network, leading to the development of pulmonary hy- is not clear what causes the acute lung injury or the ab- pertension, right ventricular hypertrophy, with eventual normal healing process, but increased levels of cytokines right heart failure (cor pulmonale). They may present with secondary 118 Chapter 3: Respiratory system bacterial infection. Single-lung transplant and ﬁne end-inspiratory crackles in the mid to lower has been shown to be viable, but most patients have lungs. Microscopy Prognosis Characteristically chronic ﬁbrotic, scarred zones with Median survival of 5 years. Forty per cent die of progres- collapsed alveoli and honeycombing alternate with ar- sive respiratory failure, most of the others from acute in- eas of relatively unaffected lung. Newer injury, there are foci of activated ﬁbroblasts with little anti-ﬁbrotic and immunological therapies are being in- inﬂammation. Complications The disease is progressive and usually unresponsive to Extrinsic allergic alveolitis treatment, and patients develop respiratory failure, pul- Deﬁnition monaryhypertensionandcorpulmonale. Anacuteform An immune reaction within the lung to inhaled organic exists (Hamman–Rich syndrome or acute interstitial dusts. Disease Source Antigens r Lung biopsy is indicated if possible, usually trans- Farmer’s lung Mouldy Micropolyspora bronchial via bronchoscopy. Because of the patchy hay/vegetable faeni, nature of the disease, however, surgical lung biopsy material thermophilic of several sites may be needed. A trial of pred- and feathers nisolone 30 mg is indicated if the diagnosis is not well Malt worker’s Germinating Aspergillus established in case there is a responsive interstitial pneu- lung barley clavatus monitis. Azathioprine and ciclosporin have also been Humidiﬁer fever Contaminated Various bacteria humidiﬁers and/or tried. On 2 High-dose prednisolone is used to cause regression of examination there may be tachypnoea and cyanosis, the early stages of the disease, later stages where there with widespread ﬁne end-inspiratory crackles and is ﬁbrosis are not amenable to treatment. Farmer’s lung is an occupational disease in the United Kingdom with sufferers being entitled to compensation. Deﬁnition An acute form of respiratory failure caused by diffuse Complications pulmonary inﬁltrates and alveolar damage occurring Diffuse ﬁbrosis and formation of honeycomb lung in hours to days after a pulmonary or systemic insult. Investigations Incidence r Chest X-ray shows a diffuse haze initially, which de- Occurs in 20–40% of patients with severe sepsis. This is reversible initially, but becomes r Increasedvascularpermeabilityandepithelialdam- permanent with chronic disease. During this phase, there is alveolar collapse, lung Management compliance falls (i. Increased shunting and 2 Supportive treatment with following: r Ventilatory support – low volume, pressure-limited deadspace occurs (ventilation–perfusion mismatch) and hypoxaemia results. Prognosis Dependant on the underlying cause, mortality can be very high in patients with septic shock who develop Clinical features multi-organ failure. Increasing age and pre-existing dis- The ﬁrst sign is tachypnoea, followed by hypoxia, wors- ease worsen the outcome. Cystic ﬁbrosis Complications Often complicated by secondary infection (nosocomial Deﬁnition pneumonia). Autosomal recessive disorder with multisystem involve- ment including chronic suppurative lung disease, pan- Investigations creatic insufﬁciency and liver cirrhosis. With the ﬁbrotic 1in2500 births are homozygous, 1 in 25 carriers (het- phase, linear opacities become visible. Auscultation of the chest shows widespread carried on the long arm of chromosome 7. Cl is above 60 mmol/L on two sweat tests in at least Over 1000 other mutations have now been identiﬁed. Testing involves There is poor correlation between the genetics and the pilocarpin iontophoresis. Bronchiectasis(thickened,dilatedbronchial noeuvres and exercise, close liaison with a physiother- walls) ﬁlled with purulent, thick secretions and ar- apist is essential. There may also be immune- 2 Pharmacological: mediated damage by an inﬂux of neutrophils releasing r Antibiotics used on the basis of regular sputum cul- proteases. Respiratory exacerbations should be pancreas, small and large intestine, intrahepatic bile treated with high-dose antibiotic courses lasting 2 ducts and gallbladder. Oral ciproﬂoxacin is useful for Pseudomonas 3 There is increased Na and Cl concentration in the aeruginosa infections. The lower lobes of ﬂuenzae Strep pneumoniae, measles, pertussis and the lungs tend to be most affected because of gravita- varicella. In mild cases sputum production only occurs post- 3 Surgical treatment: If the patient has a life expectancy infection. More severely affected patients have chronic of less than 18 months, lung (or heart–lung) trans- halitosis, a cough with copious thick sputum, recurrent plantation is used with good result. Patients may be dys- tation has been used in patients with end-stage liver pnoeic, clubbed and cyanosed. Coarse crackles and sometimes wheeze (due to airﬂow Prognosis limitation) are heard over affected areas. Median age of survival is 31 years but is expected to rise with improving therapies. Bronchiectasis Deﬁnition Microscopy Bronchiectasis is a condition characterised by purulent Chronic inﬂammation in the wall of the abnormal sputum production with cystic dilation of the bronchi. In developed countries, cystic ﬁbrosis is the most com- mon cause, tuberculosis and post-childhood infections Complications are also common. Pathophysiology Impairment of the mucociliary transport mechanism Management leads to recurrent infections, which leads to further ac- The aim is to prevent chronic sepsis and reduce acute cumulation of mucus.
Indeed buy discount entocort 100mcg on-line, some people have a number of mentors generic entocort 100 mcg mastercard, each of whom helps with a particular area of development (e cheap entocort. Leadership development is a tremendous opportunity to fo- cus on your own resiliency buy entocort american express. The insights gained in leadership development, particularly with respect to identifying your core values and beliefs, your interpersonal style and your personality traits, are powerful and practical. When things are stressful and diffcult, and your vulnerabilities become apparent, your lead- ership skills and traits can help you to cope well. In addition, your leadership skills can help promote a system of medicine that promotes the health and well-being of all involved, includ- ing all health professionals as well as the patients and families they serve. However, establishing and maintaining lifestyle habits, this might even motivate their patients to adopt a healthy equilibrium between professional and personal life similarly healthy behaviours. Thus, an argument can be made is not easy, and it is not uncommon for practising physicians that medical education should encourage health professionals and residents to struggle with time management, competing to practise and exhibit healthy lifestyles. Recommendations demands between work and home, and tensions in intimate have been made on the basis of research fndings that spend- relationships. Physicians’ work-life balance is shaped by many ing more personal time with friends and family can decrease factors, including workload, practice specialty and setting, the stress. However, perhaps the strongest determinant must ensure that they have their own family physician, be alert of a healthy work-life balance is the ability to control one’s to colleagues in need of support, and when appropriate initi- schedule and the total number of hours worked. For the professional culture of Canadian surveys have shown that most physicians believe medicine to achieve a healthy balance between work and home their workload is too heavy and that their family and personal life, these concepts must not only be taught, but must also be lives have suffered because of their choice of medicine as a strongly encouraged by individuals in positions of authority at career. A lack of balance between work and home life can lead all levels of medical education. On the job, the consequences may include cynicism, decreased job satisfaction, The following chapters will discuss how to maintain positive poor work performance and absenteeism. These stresses can interpersonal relationships during training and throughout spill over into personal life, straining relationships and leading one’s career. Specifc attention will be paid to physicians’ rela- to family discord and isolation from friends. The Canadian Medical Association’s Policy on Physician Health Key references and Well-being emphasizes that physicians should be aware of Armstrong A, Alvero R, Dunlow S, Nace M, Baker V, Stewart the essential components of well-being, such as rest, exercise, E. They identifed four risk factors for a disrupted quences of work-home interference among medical residents. In addition, • describe some interventions that can improve the personal many doctors are embarrassed to fnd that they need relation- relationships of physicians. They are often “wounded healers” who have already faced stressors that make them vulnerable to mental illness, Case or who have undiagnosed mental health problems (e. Most of the residents in the such problems are likely to be compounded in spousal rela- program have intimate partners, and several have children. Although the One of the residents told the program director that this onset of relationship diffculties can be insidious, physicians resident had not had a chance to spend meaningful time should be alert to the warning signs, such as more frequent with their partner, with the exception of a yearly vacation. Useful strategies that develop and safeguard intimacy in a relationship include: protecting time to communicate with one’s partner; reading Introduction about the dynamics of relationships; attending a marital retreat; Certain traits that seem to go with the territory of medicine attending couples therapy; and taking time to manage one’s can have a detrimental effect on physicians’ personal lives. Refection for educators Warde and colleagues, reported increased marital and parental Get to know the spouses and signifcant others in the lives satisfaction have been closely associated with a decrease in of the residents in your program early on in residency confict between professional and familial roles. Educate residents’ spouses about the physician the confict between the demands training and home-life, and health resources available to their families (e. These individuals are often the frst to in both parental and marital satisfaction. Adequate vacation time, fexible Case resolution work hours and equitable part-time work are conditions of The program director organizes a day-long retreat for the employment that are conducive not only to improved family residents and their signifcant others. The program director life and mental well-being but also to greater job satisfaction brings in a well-known speaker to discuss issues surround- and productivity. Physicians are most satisfed as parents when ing physician health, including work-lifebalance, ways to they have a supportive spouse and when the work–home con- maintain healthy intimate relationships, and recognizing ficts of both partners are minimal. The resident body fnds the expe- medical practice can also affect physicians’ relationships with rience very useful and decide to make this an annual event their children. For instance, Armstrong’s group, found that to help prevent family stress related to residency training physicians who worked for a salary were more fulflled in their and to help recognize the roles that each of their families parental role than physicians who worked on fee-for-service play in their own residency program. Finally, the employment status of one’s spouse seems to play a role in parental satisfaction. It is also im- medical families, and portant to value the work and other pursuits of one’s partner, • explore challenges specifc to those relationships. Case As seductive as the practise of medicine can be, Michael Myers A resident requests a meeting with their supervisor over reminds us to “say yes to the relationship and practise say- coffee. The resident becomes distraught while disclosing ing no to other offers” (Myers 2001). Spend a minimum of that she miscarried her frst pregnancy three weeks ago twenty minutes alone with your spouse each day and plan a and that her partner, a more senior resident, is preoccu- date together every week. The resident acknowledges that her partner has tried Monica Hill and Nancy Love quote the novelist Henry James to be supportive, but feels that “he just doesn’t get it. Unbalanced criticism, defensiveness, Successful marriages and similar partnerships are built on ridicule, a posture of superiority, and “shutting off ” are poi- knowledge, friendship, fondness and admiration (Gottman sonous to this process (Hill and Love 2008). For physicians as for anyone else, this means having population, domestic violence and abuse occurs in medical time together to develop the essential advantage of such rela- families too. It includes affection, expressiveness, sexuality, cohesion, compatibility, autonomy Dual-physician relationships and confict resolution (Myers 2001). Confict between work and familial roles is inevitable at times, whether one or both partners are physicians. Classically, role Work and family life strain has been more frequently noted among female physi- The issue of deferring intimacy in favour of medical work has cians, but in reality male physicians experience it as well. Half been described in the literature on medical marriages (Myers of married women physicians are married to other physicians 2001 and Gabbard 1989). Dual-physician relationships bring sional advancement over the nurturing of intimate relation- certain challenges, such as complicated schedules and career ships, working long hours at the expense of their home lives. Careers postpone their investment in the “emotional bank account” of can be shaped, reshaped and salvaged more easily than rela- their families or in some cases, avoid admitting that they in fact tionships and families. Paradoxically, however, “the marital interests can be satisfying, which can lead to greater mutual relationship is the main source of coping with the stress of understanding, support and shared parenting (Schrager et al medical practice” (Gabbard 1989). It would seem, however, whether by preference, mutual decision or default, that women physicians continue to take Physicians who enjoy successful intimate partnerships learn more responsibility on the home front than their male counter- early that certain attributes that serve them well at work are parts. For example, while physicians of female physicians being the primary or sole income earner are accustomed to their role as experts and expect to be in in their households. In contrast to Protecting and nurturing our intimate relationships may require most physicians’ experience of medical education, marriage is a re-examination of our professional responsibilities and work non-competitive. As you develop your resident group or consider Relationships, however, do require work in realtime, a sense of your eventual practice setting, keep these questions in mind: humour, and a degree of luck. John Gottman, a respected re- • Does your group discuss shock-absorber systems for searcher in marriage and relationships, stresses the importance parental leaves and urgent family issues? She had speculated that a child would keep geographical triangle: home, school and workplace. Keeping her relationship together, given her partner’s attraction to logistics as simple as possible will beneft your marriage and “more medicine” and achievement. He expresses fear of giving in Raising children together to his feelings lest they derail his career focus. With the For many women physicians, the question of when to plan counsellor’s help, they review their priorities with regard childbearing is especially challenging when training demands to career plans and the timing of child-bearing. Supportive sessions lead to a better understanding of their mutual colleagues and training programs are nearly as important as a objectives, and of the supports available to them to help supportive partner. Furthermore, resi- dency training directors never accompany graduated residents impact on your family, whose sleep is being disturbed by the to the infertility clinic. The concept that it takes a village to raise a child applies to medical families, too. Women physicians are particularly aware Vacations are one of the non-urgent but important elements that the more they work, and the greater number of children of time management. Vacations in which play and fun—and they choose to have, the greater the chance that they will need not perfection—are modelled, where being rather than doing to rely on child care arrangements beyond the family. Many are valued and pleasure for its own sake is enjoyed, are healthy women physicians and dual-career couples fnd live-in help with for the whole family (Maier 2005) regard to child care invaluable. External assistance with regard to other household duties can also be a time-management tool Summary that benefts everyone. Managing the expectations of our partners and others can be problematic in medical relationships.
Desirable attributes of a clinical guideline (1) Accurate the methods used must be based on good-quality evidence (2) Accountable the readers (users) must be able to evaluate the guideline for themselves (3) Evaluable the readers must be able to evaluate the health and ﬁscal consequences of applying the guideline (4) Facilitate resolution of the sources of disagreement should be able to be conﬂict identiﬁed buy generic entocort 100mcg on line, addressed entocort 100 mcg cheap, and corrected (5) Facilitate application the guidelines must be able to be applied to the individual patient situation without any increase in mortality or morbidity generic 100 mcg entocort amex. The process of utilization review is strongly supported by managed care organizations and third-party payors order discount entocort on-line. The guidelines upon which these rules are based ought to be evidence-based (Table 29. Ideally a panel of interested physicians is assembled and collects the evidence for and against the use of a particular set of diagnostic or therapeutic maneuvers. Some guidelines are simply consensus- or expert-based and the results may not be consistent with the best available evidence. When evaluating a guideline it ought to be possible to determine the process by which the guideline was developed. These domains are: scope and purpose of the guideline, stakeholder involvement, rigor of development, clarity and presentation, applicability and editorial independence. This process only indirectly assesses the quality of the studies that make up the evidence used to create the guideline. There are several general issues that should be evaluated when appraising the validity of a practice guideline. They should be those outcomes that will matter to patients and all relevant outcomes should be included in the guideline. This must include explicit descriptions of the manner in which the evidence was col- lected, evaluated, and combined. The magnitudes of beneﬁts and risks should be estimated and beneﬁts com- pared to harms. This must include the interests of all parties involved in provid- ing care for the patient. These are the patient, health-care providers, third-party payors, and society at large. The preferences assigned to the outcomes should reﬂect those of the people or patients who will receive those outcomes. The costs both economic and non-economic should be estimated and the net health beneﬁts compared to the costs of providing that beneﬁt. Alternative pro- cedures should be compared to the standard therapies in order to determine the best therapy. Finally, the analysis of the guideline must incorporate reason- able variations in care provided by reasonable clinicians. A sensitivity analysis accounting for this reasonable variation must be part of the guideline. Once a guideline is developed, physicians who will use this guideline in prac- tice must evaluate its use. For example, in 1992 a clinical guideline was developed for the management of children aged 3 to 36 months with fever but no resources to detect and treat occult bacteremia. This guideline was published simultane- ously in the professional journals Annals of Emergency Medicine and Pediatrics. After a few years, the guideline was only selectively used by pediatricians, but almost universally used by emergency physicians. The pediatricians are able to closely follow their febrile kids while emergency physicians are unable to do this. Therefore, emergency physicians felt better doing more testing and treating of febrile children in the belief that they would prevent serious sequelae. This guideline has been removed since most of the children in this age group are now immunized against the worst bacteria causing occult bacteremia, hemophilus and pneumococcus. Even if a practice guideline is validated and generally accepted by most physi- cians, there may still be a delay in the general acceptance of this guideline. Physicians’ behavior has been studied and cer- tain interventions have been found to change behavior. These include direct intervention such as reminders on a computer or ordering forms for drugs or diagnostic tests, follow-up by allied health-care personnel, and education from opinion leaders in their ﬁeld. One of the most effective interventions involved using prompts on a computer when ordering tests or drugs. These resulted in improved drug-ordering practices and long-term changes in physician behav- ior. Less effective were audits of patient care charts and distributed educational materials. In some cases, these very short presentations actually produced negative results leading to lower use of high quality evidence in physician practices. The construct called Pathman’s Pipeline demonstrating the barriers to uptake of validated evidence was discussed in Chapter 17. Practice guidelines should be developed using a preset process called the evidence- and outcomes-based approach. Separate the main steps of the policy- making process, the outcome and desirability. First estimate the speciﬁc out- comes and probability of each one of the proposed interventions. Explicitly estimate the effect of the intervention on all outcomes that are important to patients. Estimate how the outcomes will likely vary with different patient characteristics and based on estimates of outcomes from the highest-quality experimental evidence avail- able. Use formal methods such as systematic reviews or formal critical appraisal of the component studies to analyze the evidence and estimate the outcomes. To accurately understand patient preferences, use actual assessments of patients’ preferences to determine the desirability of the outcomes. Critical appraisal of clinical practice guidelines2 (1) Are the recommendations valid? These must be con- sidered from the perspective of the patient as well as the physician. All rea- sonable physician options should be considered including comments on those options not evidence-based but in common practice. This must be reproducible by anyone reading the paper outlining how the guideline was developed. The different outcomes should be described explicitly and the reasons why each outcome was chosen should be given. The guideline developers must balance the need to have experts create a guideline with the potential conﬂicts of interest of those experts. It should be tested in various settings to determine if physicians are willing to use it and to ensure that it accomplishes its stated goals. The guidelines should be simple enough and make enough sense for most clinicians to use them. The evidence for the guideline should be explicitly listed and graded using a commonly used grading scheme. The results of the studies should be compelling with large effect sizes to back up the use of the evidence. It should be clear from the presentation of the evidence how uncertainty in the evidence has been handled. The guide- lines ought to meet your needs for improving the care of the patient you are seeing. Patient prefer- ences must be considered after a thorough discussion of all the options. It must be reasonable for any physician to provide the needed follow-up and support for patients who require the recommended health care. Clinical prediction rules Physicians are constantly looking for sets of rules to assist them in the diagnos- tic process. The deﬁnition of clinical prediction rules is that they are a decision- making support tool that can help physicians to make a diagnosis. They are derived from original research and incorporate three or more variables into the decision process. Their development is an excellent model for how prediction rules should be created. The main reason for developing this rule was to attempt to decrease the number of ankle x-rays ordered for relatively minor trauma. The rule has been successfully applied in various settings and resulted in decreased use of ankle x-rays.