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One of the most common discount 500 mg tranexamic fast delivery medications that cause constipation, and most dangerous 500mg tranexamic fast delivery treatment erectile dysfunction, of adolescents’ risky behaviors is using illicit drugs discount tranexamic 500 mg with visa symptoms 8-10 dpo. Illicit drugs include marijuana/hashish cheap tranexamic 500 mg otc medicine in balance, cocaine (including crack), heroin, hallucinogens, inhalants, or psychotherapeutic 2 medications not taken under a health provider’s supervision. This Adolescent Health Highlight presents statistical information about the extent, types, and patterns of adolescents’ use of illicit drugs; discusses their effects on adolescents’ health and well‐being; shares findings from research about factors that can help adolescents avoid substance use and abuse; and presents strategies for preventing illicit drug use among adolescents and treating those with drug problems. Types and patterns of illicit drug use Marijuana (and hashish, a product derived from marijuana, and included here in all discussions of marijuana use) is by far the most commonly used illicit drug among adolescents. However, adolescents use a wide range of illicit drugs—some newly developed, some “rediscovered. Thus, it can be challenging to stay on top of all the varieties of illicit drugs adolescents are currently Unfortunately, word using. Moreover, some adolescents use multiple illicit drugs, either concurrently or over the 1 about “new” course of their adolescent years. Still, in 2011, half of adolescents (50 among adolescents th th percent) reported having used an illicit drug at least once by the 12 grade. Among 12 ‐graders, than does news 46 percent reported using marijuana; 22 percent reported using a prescription‐type about the harm psychotherapeutic drug (including amphetamines, sedatives, tranquilizers, and narcotics other associated with than heroin) without medical supervision; and about 8 percent reported using inhalants or these substances. About one in four 12 ‐graders (25 1 percent) reported having used one or more illicit drugs in the past 30 days. Monitoring the Future: National results on adolescent drug use: Overview of key findings, 2011. Over the same th period, the proportion of 10 ‐graders reporting using these drugs decreased from 9 percent to 5 1 percent (see Figure 2). It is 2011 most often smoked 4 in rolled cigarettes (“joints”) or in pipes, 2 but can also be ingested with food. Monitoring the Future: National results on adolescent drug use: Overview of key findings, 2011. It is Some adolescents most often smoked in rolled cigarettes (“joints”) or in pipes, but it can also be ingested with misuse prescription food. The proportion of adolescents who use marijuana has ebbed and flowed over the years. About psychotherapeutic th th th one in seven adolescents in 8 , 10 and 12 grades combined in 2011 reported having used drugs that include 1 marijuana in the past 30 days. Some adolescents misuse prescription medications, particularly as Ritalin and psychotherapeutic drugs, which include amphetamines (such as Ritalin and Adderall); sedatives; Adderall); sedatives; th tranquilizers; and narcotics (such as Vicodin and OxyContin). About one in five 12 ‐graders in tranquilizers; and 2011 reported having used one of these drugs without medical supervision at some time in his narcotics (such as or her life. A much smaller percentage (about three percent for amphetamines, the most Vicodin and commonly used prescription drug) reported having used one or more of these prescription OxyContin). Monitoring the Future: National results on adolescent drug use: Overview of key findings, 2011. Many household substances (such as glues, aerosols, butane, and solvents) can be inhaled to give a user a “high. Past‐year reported use of hallucinogens by th th th 8 , 10 , and 12 grade students has been fairly steady in recent years, at between two and six 1 percent. Among the illicit drugs that are used less commonly by 8 , 10 , and 12 grade students are cocaine, heroin, methamphetamine, and steroids (less than one percent for 1 each, for use in the past 30 days). Differences in illicit drug use by adolescent group In general, male In general, male adolescents are somewhat more likely than are their female counterparts to adolescents are use illicit drugs. Patterns of use change over the grades, but by 12th grade, white adolescents somewhat more are more likely than are their black or Hispanic peers to have used any illicit drug within the past likely than are their 1 year. Few other demographic patterns are consistent across types of illicit drugs and across female counterparts grade levels. Illicit substance use seems to be something many adolescents engage in 1 to use illicit drugs. According to a recent study, nonmedical prescription drug misuse is more prevalent among adolescents who live in rural areas. Adolescents living in rural areas were less likely to misuse prescription medications if they were enrolled in school and living in a two‐ 6 parent household. Effects of illicit drugs on adolescents Adolescents may be especially vulnerable to the damaging effects of drug use, because their Adolescents who use 7 brains are still developing. Use of illicit drugs is associated with many harmful behaviors and illicit drugs have can cause both short‐ and long‐term health problems. It is difficult to generalize about what higher death rates level of use is harmful, because effects vary by individual, and many illicit drugs have no than do their peers, standardized “dosage. These school problems from car crashes), include low attendance, poor academic performance, and a greater likelihood of dropping out 11,12 suicide, homicide, or being expelled. Furthermore, illicit drug use can affect relationships with family and friends by causing adolescents to be unreliable, forgetful, dishonest, or violent; it can also put and illness. Numerous physical problems are associated with illicit drug use, depending on the type of drug used. These problems can include, in the short term, lung failure, heart attack, and heart failure, 13 and in the long term, obesity, lung and cardiovascular disease, stroke, and cancer. Adolescents who use illicit drugs have higher death rates than do their peers, because of increased risk of injuries 13 (such as those resulting from car crashes), suicide, homicide, and illness. Many mental health disorders are also linked to illicit drug use, including depression, anxiety, paranoia, 13,14 hallucinations, developmental delays, delusions, and mood disturbances. Defining features that help protect adolescents from substance abuse Researchers have identified several “protective factors”—conditions and characteristics that make it more likely that adolescents will remain substance‐free (defined as no use of cigarettes, alcohol, or illicit drugs). These factors include strong positive connections with parents and other family members, the presence of parents in the home at key times of the day, and To encourage safe reduced access to illegal substances in the home. A strong connection to school and a deep choices, parents 3 religious commitment also can help adolescents avoid substance use. For example, students should explain who plan on completing four years of college are much more likely than are other students to 4 expectations report being substance‐free. Approaches to preventing and treating illicit drug use Several strategies have been shown to prevent illicit drug use; most of them overlap with what is known about evidence‐based substance abuse prevention in general. As children enter adolescence, school‐based drug prevention programs that focus on life‐skills training can prepare them to resist social pressures 16 and participate successfully in family, school, and community activities. In 2011, more than one in four (26 percent) high school students reported being offered, sold, or given an illegal 17 drug on school property. School‐ or community‐based parent training programs can help Typical signs and support the growth of adolescents’ positive skills and behaviors, so that they will not be drawn symptoms of illicit to drugs. An important first step is mood swings, to maintain an open and caring relationship with their adolescent. Adolescents who feel that weight loss, a drop they can trust and communicate with their parents are more likely to follow family rules. To in grades, possession encourage safe choices, parents should explain their expectations clearly, describe the of drug consequences of breaking the rules, and follow through consistently when necessary. More paraphernalia, or specifically, when it comes to preventing drug use, parents should: a) explain why drug use is increased problem harmful; b) communicate their expectations and rules relating to the use of drugs; c) check in behaviors. Lastly, it is important to teach parents, administrators, and teachers about signs of illicit drug use, so that adolescents using drugs can be identified and offered treatment. Typical signs and symptoms of illicit drug use include mood swings, weight loss, a drop in grades, possession of 19 drug paraphernalia, or the onset of, or increase in, problem behaviors. For example, signs of marijuana use include bloodshot eyes and appearing dizzy or uncoordinated; and signs of inhalant use may include aggressive behavior or outbursts, nausea, poor coordination, slurred or unintelligible speech, and muscle 20,21 weakness. When adolescents display signs of substance use, treatment should be sought to keep problems from worsening. Treatments that provide family therapy and support, and that involve multiple service systems, have been found to be effective, as have interventions such as cognitive‐ behavioral therapy, motivational interviewing, and/or contingency management (a form of behavioral therapy that gives participants vouchers or special privileges when they attend a The Child Trends 22 program regularly or follow treatment plans). In selecting an appropriate treatment, it is DataBank includes important to consider other problems that may accompany drug abuse, such as mental illness or brief summaries of delinquent behavior.

In this case buy 500 mg tranexamic with mastercard 606 treatment syphilis, communication of the benefits of bisphosphonates will not answer her ques- tion directly best 500mg tranexamic medicine neurontin. For some questions about therapy cheap tranexamic 500mg amex symptoms liver disease, there may be no need to discuss evidence buy 500mg tranexamic overnight delivery symptoms kidney failure dogs, because the patient and the provider may be in clear agreement about the treat- ment. Our patient’s question of aspirin as a preventive treatment against stroke and heart attacks is one that seems to require a discussion of the best available evidence. Though typical office visits are short, taking time to understand the patient’s perspective may help avoid cultural assumptions. For example, when seeing a patient who is culturally different from you, one might assume that the patient’s values are different as well. On the other hand, it is easy to make false assumptions of shared values based on misperceived similarities of backgrounds between the provider and the patient. Understanding the patient’s perspective comes from active questioning of the patient to determine their values and per- spectives and avoids assumptions about similarities and differences. Patients have varying levels of understanding of health-care issues, some with vast and others with limited previous health-care experience and levels of under- standing. The patient’s level of health literacy clearly affects her perspective on the question and how she will interpret any discussion of results and recom- mendations. During the initial phases of the discussion about her question, it is important to understand her health literacy and general literacy level. Asking the patient what she knows about the problem can provide an impression of health literacy. This may be adequate, but asking a question such as: “How comfortable are you with the way you read? For example, if a patient wishes to avoid taking a medication because he or she is more con- cerned about the side effects of treatment than the benefits of treatment, focus the discussion on the evidence in this area. Also, many studies report major morbidity and mortality of treatment, yet, patients may be more concerned about the quality-of-life effects of treatment over many years. In other studies, the use of composite outcomes can make it difficult to directly answer a patient’s question since some of these are more important to the patient than others. The patient in our example wishes to know whether aspirin reduces the risk of heart attack. Although one may find a study that shows a statistically significant reduction of myocardial infarction, if the result is only reported as a composite outcome along with other outcomes such as reduced incidence of angina and heart failure, the result will not directly address your patient’s ques- tion. Since this type of presentation of data is used by authors when an individ- ual outcome is not itself statistically significant, the combination of outcomes is used to achieve statistical significance and get the study published. But, the composite is often made up of various outcomes not all of which have the same value to the patient. The goal of a discussion with the patient is to explain the results of each of the composite components so that she can make up her mind about which of the outcomes are important to her. Recommendations for understanding the patient’s experience and expectations The patient’s perspective on the problem as well as the available evidence deter- mines the true need to proceed with further steps to communicate evidence. It is possible that the patient’s questions relate only to background information, which is clearly defined in the science of medicine and not dependent on your interpretation of the most recent research evidence for an answer. Then, if evi- dence is needed to answer a patient’s question, first check to see whether it truly addresses the patients query about her desired outcomes rather than outcomes that are not important to the patient. Step 2: Build partnerships Taking time for this step is a way to build rapport with the patient. After dis- cussing the patient’s perspective, an impression will have developed of whether one generally agrees or disagrees with the patient. At this point in the discussion, Communicating evidence to patients 203 it should be clear what, if any, existing evidence may be of interest to the patient. The physician will also have a good understanding of whether to spend a major- ity of their time discussing basic or more advanced information. Using phrases such as “Let me summarize what you told me so far” or “It sounds like you are not sure what to do next” can help to build partnership that will allow a transition to the third step in the process of communicating evidence. In the example, the patient who is interested in aspirin for prevention of strokes and heart attacks is frustrated by her lack of reduction of weight or cholesterol after implementing some lifestyle changes. Expressing empathy for her struggles will likely help the patient see you as partner in her care. Step 3: Provide evidence As health-care providers, numbers are an important consideration in our decision-making process. While some may want the results this way, many patients do not want results to be that specific or in numerical form. As a general rule, patients tend to want few specific numbers, although patients’ preferences range from not wanting to know more than a brief statement or the “bottom line” of what the evidence shows to wanting to know as much as is available about the actual study results. Check the patient’s preference for information by ask- ing: “Do you want to hear specific numbers or only general information? Another way to start is by giving minimal information and allowing the patient to ask for more, or follow this basic information by asking the patient whether more specific infor- mation is desired. Previous experiences with the patient can also assist in deter- mining how much information to discuss. Presenting the information There are a number of ways to communicate information to patients and under- standing the patient’s desires can help determine the best way to do this. The first approach is to use conceptual terms, such as “most patients” or “almost every patient” or “very few patients. A second approach is to use general numerical terms, such as “half the patients” or “1 in 100 patients. While these are the most common verbal approaches, both conceptual and numerical rep- resentations can be graphed, either with rough sketches or stick figures. In a few clinical situations, more refined means of communicating evidence have been 204 Essential Evidence-Based Medicine developed, such as decision aid programs available for prostate cancer screen- ing. The patient answers questions at a computer about his preferences regard- ing prostate cancer screening and treatment. These preferences then determine a recommendation for that patient about prostate cancer screening using a decision tree similar to the ones that will be discussed in Chapter 30. Unfortu- nately, these types of programs are not yet widely developed for most decision making. The quality of the evidence also needs to be communicated in addition to a discussion of the risks and benefits of treatment. For example, if the highest level of evidence found was an evidence-based review from a trusted source, the qual- ity of the evidence being communicated is higher and discussions can be done with more confidence. If there is only poor quality of evidence, such as would be available only from a case series, the provider will be less confident in the quality of the evidence and should convey more uncertainty. Pitfalls to providing the evidence The most common pitfall when providing evidence is giving the patient more information than she wants or needs although often the most noteworthy pit- falls are related to the misleading nature of words and numbers. The answer given to the patient is: “Usually headaches like yours are caused by stress. Only in extremely rare circumstances is a headache like yours caused by a brain tumor. In this example, expressing the common nature of stress headaches as “usually” can be very vague. When res- idents and interns in medicine and surgery were asked to quantify this term, they chose a range of percents between 50–95%. In this example stating that headaches due to a brain tumor occurred only in “extremely rare” circum- stances is also imprecise. When asked to quantify “extremely rare” residents and interns chose a range of percents between 1–10%. Knowing that the disease is rare or extremely rare may be consoling, but if there is a 1 to 10% chance that it is present, this may not be very satisfactory for the patient.

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In 1910 buy generic tranexamic 500mg line symptoms hiatal hernia, Abraham Flexner asked physicians and medical schools to stop teach- ing empiricism and rely on solid scientific information discount tranexamic 500 mg otc treatment 0f gout. In those days buy tranexamic 500 mg on line schedule 8 medications victoria, empiric facts were usually based on single-case testimonials or poorly documented 220 Essential Evidence-Based Medicine Table 20 order tranexamic 500mg without prescription symptoms 3 days past ovulation. Components of the H&P (with a clinical example) Chief complaint Why the patient sought medical care (e. He proposed teaching and applying the pathophysiological approach to diagnosis and treatment. We want to see the empirical data for a particular therapy or diag- nosis and ought to act only on evidence that is of high quality. The clinical examination In most cases in health care, a patient does not walk into the physician’s office and present with a pre-made diagnosis. They arrive with a series of signs and symptoms that one must interpret correctly in order to make a diagnosis and initiate the most appropriate therapy. Traditionally, this consists of several components collectively called the history and physical or H&P (Table 20. It is often a disorder of normal functioning that alarms the patient and tells the clinician in which systems to look for pathology. The history of the present illness is a chronological description of the chief complaint. The clinician seeks to determine the onset of the symptoms, their quality, frequency, duration, associated symptoms, and exacerbating and alleviating factors. A brief review of the patient’s symptoms seeks to find dysfunction in any other parts of the body that could be associated with the potential disease. It is important to include all the pertinent positives and negatives in reporting the history of the present ill- ness. The past medical history, past surgical history, family history, social and occu- pational history, and the medication and allergy history are all designed to get a picture of the patient’s medical and social background. This puts the illness into the context of the person’s life and is an integral part of any medical history. Some experts feel that this is the most important part of the practice of holistic medicine, helping ensure that the physician looks at the whole patient and the patient’s environment. The review of systems gives the clinician an overview of the patient’s addi- tional medical conditions. This aspect of the medical history helps the clinician develop other hypotheses as to the cause of the patient’s problem. It also gives the clinician more insight into the patient’s overall well-being, attitudes toward illness, and comfort level with various symptoms. The physical exam usually helps to confirm or deny the clinician’s suspicions based upon the history. An old adage states that in 80% of patients, the final diagnosis comes solely from the history. In another 15% it comes from the physical examination, and only in the remaining 5% from additional diagnostic testing. This may appear to overstate the value of the history and physical, but not by much. Clinical observation is a powerful tool for deciding what diseases are possible in a given patient, and most of the time the results of the H&P determine which additional data to seek. Once the H&P has been exhausted, the clini- cian must know how to obtain the additional required data in a reliable and accurate way by using diagnostic tests which can appropriately achieve the best outcome for the patient. For the health-care system, this must also be done at a reasonable cost not only in dollars, but also in patient lives, time, and anxiety if an incorrect diagnosis is made. Hypothesis generation in the clinical encounter While performing the H&P, the clinician develops a set of hypotheses about what diseases could be causing the patient’s problem. This list is called the differen- tial diagnosis and some diseases on this list are more likely than others to be present in that patient. When finished with the H&P, the clinician estimates the probability of each of these diseases and rank-orders this list. The probability of a patient having a particular disease on that list is referred to as the pretest prob- ability of disease. It may be equivalent to the prevalence of that disease in the population of patients with similar results on the medical history and physical examination. The numbers for pretest probability come from one’s knowledge of medicine and from studies of disease prevalence in medical literature. Let’s use the exam- ple of a 50-year-old North American alcoholic with no history of liver disease, who presents to an emergency department with black tarry stools that are sug- gestive of digested blood in the stool. This symptom is most likely caused by esophageal varices, by gastritis, or by a stomach ulcer. The prevalence of each of these diseases in this population is 5% for varices, 55% for ulcer, and 40% for gastritis. In this particular case, the probabilities add up to 100% since there are virtually no other diagnostic possibilities. This is also knows as sigma p equals one, and applies when the diseases on the list of differential diagnoses are all mutually exclusive. Rarely, a person fitting this description will turn out to have gastric cancer, which occurs in less than 1% of patients presenting like this and can be left off the list for the time being. If none of the other diseases are diag- nosed, then one needs to look for this rare disease. In this case, a single diagnostic An overview of decision making in medicine 223 test, the upper gastrointestinal endoscopy, is the test of choice for detecting all four diagnostic possibilities. There are other situations when the presenting history and physical are much more vague. In these cases, it is likely that the total pretest probability can add up to more than 100%. This occurs because of the desire on the part of the physi- cian not to miss an important disease. Therefore, each disease should be con- sidered by itself when determining the probability of its occurrence. This proba- bility takes into account how much the history and physical examination of the patient resemble the diseases on the differential diagnosis. The assigned proba- bility value based on this resemblance is very high, high, moderate, low, or very low. In our desire not to miss an important disease, probabilities that may be much greater than the true prevalence of the disease are often assigned to some diagnoses on the list. Physicians must take the individual patient’s qualities into consideration when assigning pretest probabilities. For example, a patient with chest pain can have coronary artery disease, gastroesophageal reflux disease, panic disorder, or a combination of the three. In general, panic disorder is much more likely in a 20- year-old, while coronary artery disease is more likely in a 50-year-old. When con- sidering this aspect of pretest probabilities, it becomes evident that a more real- istic way of assigning probabilities is to have them reflect the likelihood of that disease in a single patient rather than the prevalence in a population. This allows the clinician to consider the unique aspects of a patient’s history and physical examination when making the differential diagnosis. Constructing the differential diagnosis The differential diagnosis begins with diseases that are very likely and for which the patient has many of the classical symptoms and signs.

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Some of the harms that can arise from the use of methamphetamines and other stimulants include mental illness purchase 500mg tranexamic overnight delivery medicine joji, cognitive impairment purchase tranexamic 500mg online symptoms 2dp5dt, cardiovascular problems and 81 overdose tranexamic 500 mg without prescription symptoms throat cancer. This figure has remained stable since 2007 generic tranexamic 500mg overnight delivery schedule 8 medicines, but is lower 83 than the prevalence recorded between 1998 and 2004. However, among those who use amphetamine, the use of the powder form of the drug decreased significantly from 51% in 2010 to 29% in 2013, while the use of crystal-methamphetamine more than doubled since 2010 (from 22% to 50% in 2013) amongst methamphetamine users. There was also a significant increase in the proportion of users consuming methamphetamine daily or weekly (from 9% in 2010 to 16% in 2013). In addition, 16% of Australians identified methamphetamine as the illicit drug of most concern to the community (an increase from 10% in 2012). Violent behaviour is also more than six times as likely to occur among methamphetamine dependent people when they are using the drug, compared to 84 when they are not using the drug. As the most widely used of the illicit drugs in Australia, cannabis carries a significant burden of 87 disease. In particular, cannabis dependence among young adults is correlated with, and probably 88 contributes to, mental disorders such as psychosis. The harms that can arise as a result of the use of pharmaceutical drugs 90 depend on the drug used, but can include fatal and non-fatal overdose. Harms also include infection and blood vessel occlusion from problematic routes of administration, memory lapses, coordination impairments and aggression. There has been a significant increase in the misuse of pharmaceutical drugs in Australia. However, Australia has seen an increase in the prescription and use of licit opioids. In particular, the supply of 85 Ministerial Council on Drug Strategy (2006) National Cannabis Strategy 2006-2009, Commonwealth of Australia, Publications Approval No. Extent of illicit drug use, dependence, and their contribution to global burden of disease. Extent of illicit drug use, dependence, and their contribution to global burden of disease. National Drug Strategy 2016-2025 33 oxycodone and fentanyl increased 22 fold and 46-fold respectively between 1997 and 2012 and the number of prescriptions for opioid prescriptions subsidised by the Pharmaceutical Benefits Scheme 94 increased from 2. Consistent with these trends, hospital separations associated with prescription opioid poisoning have increased substantially while 95 those for heroin have decreased. While the effect of the drugs may be similar to other illicit drugs, their chemical structure is different and the effects are not always well known. One of the principal concerns with the use of new psychoactive substances is that the products, and their chemical compounds or makeup, are constantly evolving. There have also been a number of unexplained suicides associated with preceding use of synthetic cannabinoids (spice). Data around the use of new psychoactive substances in Australia obtained through the National Drug Strategy Household Survey indicate that in 2013, 1. These measures are taken from the Evaluation and Monitoring of the National Drug Strategy 2004- 97 2009 Final Report. The proposed measures use existing published data sources to help ensure continuity. The performance measures are high-level as data are not always comprehensive enough to provide robust national measures of activity and progress. It is not possible to directly match the objectives of the strategy, or each drug type, to a performance measure. Average age of uptake of drugs, by drug type Source: National Drug Strategy Household Survey, Australian Institute of Health and Welfare 2. Recent use of any drug, people living in households Source: National Drug Strategy Household Survey, Australian Institute of Health and Welfare 3. Arrestees’ illicit drug use in the month before committing an offence for which charged Source: Drug Use Monitoring Australia, Australian Institute of Criminology 4. Victims of drug-related incidents Source: National Drug Strategy Household Survey, Australian Institute of Health and Welfare 5. Drug-related burden of disease, including mortality Source: The Australian Burden of Disease Study, Australian Institute of Health and Welfare and School of Population Health, University of Queensland 97 Evaluation and Monitoring of the National Drug Strategy 2004-2009 Final Report. This includes consumers and communities, service providers, peaks, peer organisations and other alcohol, tobacco and other drug organisations. These sub-strategies provide direction and context for specific issues, while maintaining the consistent and coordinated approach to addressing drug use, as set out in this strategy. During the life of the National Drug Strategy 2016- 2025, the sub-strategies listed below will be updated or developed to address specific priorities. These are focussed on priority populations, drug type and the development of the workforce which is critical to implementation of the Strategy. Those drugs that are contraindicated at a certain phase of the pregnancy are listed next to the product name. For more information on specific drug monographs, see product entries or consult the manufacturer. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concern- ing the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpreta- tion and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Cost-effectiveness, feasibility and resource implications of antihypertensive and statin therapy. The underlying pathology is atherosclerosis, which develops over many years and is usually advanced by the time symptoms occur, generally in middle age. Acute coronary and cerebrovascular events frequently occur suddenly, and are often fatal before medical care can be given. Modification of risk factors has been shown to reduce mortality and morbidity in people with diagnosed or undiagnosed cardiovascular disease. This publication provides guidance on reducing disability and premature deaths from coronary heart disease, cerebrovascular disease and peripheral vascular disease in people at high risk, who have not yet experienced a cardiovascular event. People with established cardiovascular disease are at very high risk of recurrent events and are not the subject of these guidelines. Decisions about whether to initiate specific preventive action, and with what degree of intensity, should be guided by estimation of the risk of any such vascular event. The risk prediction charts that accompany these guidelinesb allow treatment to be targeted accord- ing to simple predictions of absolute cardiovascular risk. Recommendations are made for management of major cardiovascular risk factors through changes in lifestyle and prophylactic drug therapies. The guidelines provide a framework for the development of national guidance on prevention of cardiovascular disease that takes into account the particular political, economic, social and medical circumstances. Prevention of recurrent heart attacks and strokes in low and middle income populations.

Learning from malpractice claims about negligent quality tranexamic 500 mg medications on airplanes, adverse events in diagnostic decision making is perhaps doing more harm primary care in the United States 500 mg tranexamic amex medicine over the counter. It suggests a critical need to noses in the ambulatory setting: a study of closed malpractice claims buy tranexamic 500 mg with visa medicine interaction checker. Judgment under uncertainty: heuristics and emperor’s clothes provide illusory court comfort generic 500mg tranexamic amex symptoms of pregnancy. The pull system mystery explained: drum, buffer and Presented at: Annual Meeting of the Healthcare Management Di- rope with a computer. From the historical perspective, there is substan- many of these strategies show potential, the pathway to ac- tial good news: medical diagnosis is more accurate and complish their goals is not clear. Advances in the medical sciences enable has been done while in others the results are mixed. Innovation in have easy ways to track diagnostic errors; no organizations are the imaging and laboratory sciences provides reliable new ready or interested to compile the data even if we did. More- tests to identify these entities and distinguish one from over, we are uncertain how to spark improvements and align 1 another. It is perfectly ap- on overconfidence as a pivotal issue in an effort to engage propriate to marvel at these accomplishments and be thank- providers to participate in error-reducing strategies, this is just ful for the miracles of medical science. My goal in this commentary is nized discussion of what the goal should be in terms of to survey a range of approaches with the hope of stimulating diagnostic accuracy or timeliness and no established process discussion about their feasibility and likelihood of success. In This requires identifying all of the stakeholders interested in the history of medicine, progress toward improving medical diagnostic errors. Besides the physician, who obviously is at diagnosis seems to have been mostly a passive haphazard the center of the issue, many other entities potentially in- affair. Every day and are healthcare organizations, which bear a clear responsi- in every country, patients are diagnosed with conditions bility for ensuring accurate and timely diagnosis. Further- ful, however, that physicians and their healthcare organiza- more, patients are subjected to tests they don’t need; alter- tions alone can succeed in addressing this problem. Despite our best intentions to make diag- the help of another key stakeholder—the patient, who is nosis accurate and timely, we don’t always succeed. Patients are Our medical profession needs to consider how we can in fact much more than that. Goals that funding agencies, patient safety organizations, over- should be set, performance should be monitored, and sight groups, and the media can play to assist in the overall progress expected. The authors in this supplement to The American these parties, based on our current—albeit incomplete and untested— understanding of diagnostic error (Table 1). Statement of Author Disclosure: Please see the Author Disclosures section at the end of this article. Healthcare leaders need to expand their concept of prove both the specificity and sensitivity of cancer detection 4 patient safety to include responsibility for diagnostic errors, more than an independent reading by a second radiologist. These resources have substantial poten- aspects of diagnostic error can to some extent be mitigated 5 tial to improve clinical decision making, and their impact by interventions at the system level. Leaders of healthcare will increase as they become more accessible, more sophis- organizations should consider these steps to help reduce ticated, and better integrated into the everyday process of diagnostic error. System-related Suggestions Have Appropriate Clinical Expertise Available When Ensure That Diagnostic Tests Are Done on a Timely It’s Needed. Don’t allow front-line clinicians to read and Basis and That Results Are Communicated to Providers interpret x-rays. Encourage inter- “Morbidity and Mortality (M & M) Rounds on the Web” personal communication among staff via telephone, e-mail, sponsored by the Agency for Healthcare Research and and instant messaging. Establish pathways for physicians who to communicate information verbally and electronically saw the patient earlier to learn that the diagnosis has across all sites of care. Ensure medical prevent, detect, and mollify many system-based as well as records are consistently available and reviewed. Strive to cognitive factors that detract from timely and accurate di- make diagnostic services available on weekend/night/holi- agnosis. Minimize distractions and production pressures help reduce the likelihood of error. For patients to act so that staff have enough time to think about what they are effectively in this capacity, however, requires that physi- doing. Minimize errors related to sleep deprivation by at- cians orient them appropriately and reformulate, to some tention to work hour limits, and allowing staff naps if extent, certain aspects of the traditional relationship be- needed. Two new roles for patients to help reduce the chances for diagnostic error are proposed below. Take advantage of sugges- tions from the human-factors literature on how to improve Be Watchdogs for Cognitive Errors the detection of abnormal results. For example, graphic Traditionally, physicians share their initial impressions with displays that show trends make it more likely that clinicians a new patient, but only to a limited extent. Sometimes the will detect abnormalities compared with single reports or tab- suspected diagnosis isn’t explicitly mentioned, and the pa- ulated lists; use of these tools could allow more timely appre- tient is simply told what tests to have done or what treat- ciation of such matters as falling hematocrits or progressively ment will be used. Computer-aided per- checking for cognitive errors if they were given more in- ception might help reduce diagnostic errors (e. Controlled tri- its probability, and instructions on what to expect if this is als have shown that use of a computer algorithm can im- correct. They should be told what to watch for in the Graber A Safer Future: Measures for Timely Accurate Medical Diagnosis S45 Table 1 Recommendations to reduce diagnostic errors in medicine: stakeholders and their roles Direct and Major Role Physicians ● Improve clinical reasoning skills and metacognition ● Practice reflectively and insist on feedback to improve calibration ● Use your team and consultants, but avoid groupthink ● Encourage second opinions ● Avoid system flaws that contribute to error ● Involve the patient and insist on follow-up ● Specialize ● Take advantage of decison-support resources Healthcare organizations ● Promote a culture of safety ● Address common system flaws that enable mistakes —Lost tests —Unavailable experts —Communication barriers —Weak coordination of care ● Provide cognitive aids and decision support resources ● Encourage consultation and second opinions ● Develop ways to allow effective and timely feedback Patients ● Be good historians, accurate record keepers, and good storytellers ● Ask what to expect and how to report deviations ● Ensure receipt of results of all important tests Indirect and Supplemental Role Oversight organizations ● Establish expectations for organizations to promote accurate and timely diagnosis ● Encourage organizations to promote and enhance —Feedback —Availability of expertise —Fail-safe communication of test results Medical media ● Ensure an adequate balance of articles and editorials directed at diagnostic error ● Promote a culture of safety and open discussion of errors and programs that aim to reduce error Funding agencies ● Ensure research portfolio is balanced to include studies on understanding and reducing diagnostic error Patient safety organizations ● Focus attention on diagnostic error ● Bring together stakeholders interested to reduce errors ● Ensure balanced attention to the issue in conferences and media releases Lay media ● Desensationalize medical errors ● Promote an atmosphere that allows dialogue and understanding ● Help educate patients on how to avoid diagnostic error upcoming days, weeks, and months, and when and how to nated, and all medical records would be available and ac- convey any discrepancies to the provider. Until then, the patient can play a valuable role in If there is no clear diagnosis, this too should be con- combating errors related to latent flaws in our healthcare veyed. Patients can and should function as confidence and certainty, but an honest disclosure of uncer- back-ups in this regard. They should always be given their tainty and the probabilistic nature of diagnosis is probably a test results, progress notes, discharge summaries, and lists better approach in the long run. In the absence of reliable and would be more comfortable asking questions such as “What comprehensive care coordination, there is no better person else could this be? Healthcare organizations by ne- health services research protocols to better understand these cessity pay attention to Joint Commission expectations; errors and how to address them. In the proper order of these expectations should be expanded to include the many things, our knowledge of diagnostic error will increase other organizational factors that have an impact on diagnos- enough to suggest solutions, and patient safety leaders and tic error, such as encouraging feedback pathways and en- leading healthcare organizations will begin to outline goals suring the consistent availability of appropriate expertise. A measure of progress will be the extent to ther the cause of accurate and timely diagnosis by drawing which both physicians and patients come to understand the attention to this issue and ensuring that diagnostic error key roles they each can play to reduce diagnostic error rates. For the good of all those who are affected by diagnostic The media also must acknowledge a responsibility to pro- errors, these processes must start now. If there is anything to be learned from how aviation has improved the safety of air travel, it is the lesson of contin- Acknowledgements uous learning, not only from disasters but also from simple observation of near misses. The media could substantially This work was supported in part from a grant from the aid this effort in medicine by emphasizing the role of learn- National Patient Safety Foundation. Berner, EdD, for review of the manuscript and to Grace Thus far, funding agencies have underemphasized diag- Garey and Mary Lou Glazer for their assistance. This type of error is not regarded as one of Veterans Affairs Medical Center, Northport, New York, and 7 the low-hanging fruit. If the funding were avail- affiliation with a corporate organization or a manufacturer able, applications would follow. Patient safety organizations could play a substantial role in advancing diagnostic accuracy and timeliness simply by References bringing attention to this issue. This could take the form of dedicated conferences, or perhaps simply advancing diag- 1. Overconfidence as a cause of diagnostic error in nostic error as a featured theme at patient safety conferences medicine. Diagnostic error in internal med- lem, these forums play an invaluable role in bringing to- icine.

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In a prospective cohort study of 40 349 Japanese men and women followed up for 18 years (188) purchase 500 mg tranexamic amex treatment 02 binh, daily consumption of green and yellow vegetables and fruits was associated with a lower risk of stroke buy generic tranexamic 500 mg treatment 3rd degree burns, intracerebral haemorrhage buy tranexamic 500mg visa symptoms 8dpiui, and cerebral infarction mortality in both men and women cheap tranexamic 500mg with amex treatment whooping cough. A recent meta-analysis of 10 prospective cohort studies (189) has also shown that the consumption of fibre from cereals and fruits is inversely associated with risk of coronary heart disease. On the basis of the available evidence, a daily intake of at least 400 g of fruit and vegetables is recommended (86). However, much of this evidence is from observational studies, in which control for potential confounding factors, in particular socioeconomic position, is often inadequate. A cardioprotective diet should consist of a variety of foods, and should aim to achieve four major goals: a healthy overall diet, a healthy body weight, a desirable lipid profile, and a desirable blood pressure. There is strong observational evidence that reducing intakes of total fat (to less than 30% of calories), saturated fat (to less than 10% of calories), and salt (to less than 5 g or 90 mmol per day), and increasing fruits and vegetables (to 400–500 g daily) are likely to be beneficial. Applying these principles to develop diets that match individual preferences and local customs, and demon- strating their effectiveness in reducing cardiovascular risk, are important priorities for research. Advice was focused largely on decreasing intake of salt and fat and increasing intake of fruits, vegetables and fibre. Interventions included one-to-one advice, group sessions and written materials, and ranged in intensity from a single contact to multiple contacts over several years. Of the 23 trials reviewed, nine enrolled participants on the basis of screening for cardiovascular disease risk factors. The majority of studies involved interventions in health care settings; other settings included workplaces, community centres and homes. Greater effectiveness was observed among individuals told they were at greater risk of heart disease, and in interventions with greater intensity and duration. The authors estimated that the summary effects of the dietary interventions reviewed could reduce incidence of coronary heart disease by 12% and of stroke by 11%. This estimate is based on the assumption that dietary changes are sustained, and that the relative risk reductions attributable to changes in cholesterol and diastolic blood pressure can be combined additively. Evidence It has been estimated that inadequate physical activity is responsible for about one-third of deaths due to coronary heart disease and type 2 diabetes (191). There is evidence from observational studies that leisure-time physical activity is associated with reduced cardiovascular risk and cardio- vascular mortality in both men and women (192–194) and in middle-aged and older individuals (195, 196). Several meta-analyses have examined the association between physical activity and cardiovascular disease (197–202). Berlin & Colditz (200) found a summary relative risk of death from coronary heart disease of 1. A meta-analysis of studies in women showed that physical activity was associated with a reduced risk of overall cardiovascular disease, coronary heart disease and stroke, in a dose–response fashion (197). Physical activity improves endothelial function, which enhances vasodilatation and vasomotor function in the blood vessels (199). In addition, physical activity contributes to weight loss, glycaemic control (203, 204), improved blood pressure (205), lipid profile (206–208) and insulin sensitivity (209). The possible beneficial effects of physical activity on cardiovascular risk may be mediated, at least in part, through these effects on intermediate risk factors. Physical inactivity and low physical fitness are independent predictors of mortality in people with type 2 diabetes (210). Overall, the evidence points to the benefit of continued regular moderate physical activity, which does not need to be strenuous or prolonged, and can include daily leisure activities, such as walking or gardening (197). Studies indicate a dose–response relationship between overall physical activity and cardiovascular disease, which is linear at least up to a certain level of activity. Two reviews support the effectiveness of interventions to promote physical activity in the health care setting. Specific interventions included individual and group counselling, self-directed or prescribed physical activity, supervised and unsupervised physical activity, home- or facility-based physical activity, face-to-face and telephone support, written materi- als, and self-monitoring. Interventions were conducted by one or several practitioners, including physicians, nurses, health educators and exercise leaders. Of the seventeen trials reviewed, eight took place in the primary health care setting. The second review considered only studies in the primary health care setting, and found that brief interventions to promote physical activity produced moderate short-term improvements in self-reported physical activity levels (214). In both reviews, it was noted that the length of follow-up of the studies (typically 1 year or less) was insuffi- cient to draw conclusions about long-term effectiveness or whether outcomes would be maintained. Trials using more objective indicators of activity patterns and changes in cardiovascular risk factors would be helpful in determining how primary care teams can intervene most effectively. Evidence Obesity is a growing health problem in both developed and developing countries (2). Obesity is strongly related to major cardiovascular risk factors, such as raised blood pressure, glucose intolerance, type 2 diabetes, and dyslipidaemia (215, 218, 220, 222). Weight loss programmes using dietary, physical activity, or behavioural interventions have been shown to produce significant reductions in weight among people with pre-diabetes, and a signifi- cant decrease in diabetes incidence (225). A meta-analysis of randomized controlled trials (226) 36 Prevention of cardiovascular disease found that a net weight reduction of 5. Prospective studies are needed to determine the impact of weight reduction in the long term on cardiovascular morbidity and mortality trends. In a review of data from 24 prospective observational studies, Blair & Brodney (229) found that regular physical activity attenuated many of the health risks associated with overweight and obesity. Physically active obese individuals have lower morbidity and mortality than individuals of normal weight who are sedentary; physical inactivity and low cardiorespiratory fitness are as important as overweight and obesity as predictors of mortality. The results of non-randomized trials and observational studies indicate that interventions involving a greater frequency of contacts between patient and provider, and those provided over the long term, lead to more successful and sustained weight loss (226). A review of the effectiveness of weight-loss diets in adults with raised blood pressure (systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg) found modest weight losses, of 3–9% of body weight (227). The diets were associated with modest decreases in systolic and diastolic blood pressure of about 3 mmHg, and may lead to reduced dosage requirements for patients taking blood-pressure-lowering medications. In most trials, the provider/instructor was a dietician; however, the nature and duration of interventions varied significantly, with intervention periods ranging from 2 weeks to 3 years. In the two trials that reported post-intervention follow-up, it was found that participants tended to regain some, though not all, of the weight lost. Evidence Many studies have shown a U- or J-shaped association between mortality and alcohol consump- tion, in which people who drink light or moderate amounts have a lower death rate than non- drinkers, while those who drink large amounts have a higher death rate (232–240). People who drink heavily have a high mortality from all causes and cardiovascular disease, including sudden death and haemorrhagic stroke. In addition, they may suffer from psychological, social and other medical problems related to high alcohol consumption (237–240). Smaller protective associations and more harmful effects were found in women, in men living in countries outside the Mediterra- nean area, and in studies where fatal events were used as the outcome (238). The amount of alcohol associated with the lowest mortality rates was between 10 and 30 g (1–3 units) per day for men and half these quantities for women (1 unit is equivalent to 150 ml of wine, 250 ml of beer or 30–50 ml of spirits) (239). The benefits of alcohol in light to moderate drinkers may be overestimated in meta-analyses of observational studies, as a result of confounding and reverse causality. The meta-analysis was dominated by a few very large studies, which did not carefully assess the reasons for not drink- ing, and did not measure multiple potential confounders. It is primarily the non-drinking group that causes the U-shaped relationship, and this may contain both life-long abstainers and people who stopped drinking because of ill-health; this could result in a spurious association suggesting that there is a safe level of alcohol intake. A recent meta-analysis of 54 published studies con- cluded that lack of precision in the classification of abstainers may invalidate the results of studies showing the benefits of moderate drinking (243).

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