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By E. Goran. Bethany College, West Virginia.

A primary cause of physician variability lies in the complexity of clinical prob- lems cheap 80mg propranolol with mastercard. Clinical decision making is both multifaceted and practiced on highly individualized patients propranolol 40mg overnight delivery. Some factors to consider with clinical decision making include patient expectations discount 80mg propranolol free shipping, changing reimbursement policies, competition, malpractice threat, peer pressure, and incomplete information. Overall, physi- cians are well-meaning and confront not only biological but also sociological and political variability. There are some barriers to the process of using best evidence in medical deci- sion making. Some physicians believe that if there is no evidence from well-done ran- domized control trials, then the treatment in questions should not be used. Most physi- cians gladly accept much weaker evidence, yet don’t have the clinical expertise to put that evidence into perspective for a particular clinical encounter. Some of the reasons for the high degree of uncertainty in physician deci- sion making are noted in Table 20. Physicians want some certainty before they are willing to use an intervention, yet tend to do what was learned in medical school or learned from the average practitioner. The rationalization for this is that if everyone is doing the treatment, it must be appropriate. Some physician treatment decisions are based on the fact that a disease is common or severe. If a disease is common, or the outcome severe, they are more will- ing to use whatever treatment is available. There are even times when physi- cians feel the need simply to do something, and the proposed treatment is all they have. There is also a certain amount of fascination with new diagnostic or treatment modalities that results in wholesale increases in usage of those methods. Causes of variability in physician performance (1) Complexity of clinical problem multiple factors influence actions (2) Uncertainty of outcomes of variability of outcomes in studies decisions (3) Need to act feeling on our part that we have to “do something” (4) Large placebo effect spontaneous cures (sometimes doing nothing but educating is the best thing) (5) Patient expectations expectation from patients and society that what we do will work (6) Political expectations do what is cheapest and best (7) Malpractice threat don’t make any mistakes (8) Peer pressure do things the same way that other physicians are doing them (9) Technological imperative we have a new technology so let’s use it Physician judgment Patient preferences Best Shared Final Analysis evidence judgment decision Potential outcomes Fig. One way physicians can do better is by having better clinical research and improved quality of evidence for clinical decisions. Physicians must also increase their ability to use the available evidence through improving individual and col- lective reasoning and actions. If there is good evidence for a certain practice, it ought to be done the best way known at all times. Practice guidelines are one way of automating part of the decision-making process for physicians. In 1910, Abraham Flexner asked physicians and medical schools to stop teach- ing empiricism and rely on solid scientific information. In those days, empiric facts were usually based on single-case testimonials or poorly documented 220 Essential Evidence-Based Medicine Table 20. 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.

Master of Public Administration: Department of Political Science Southwest Texas State University buy propranolol 80 mg overnight delivery. Practical guidelines on the use of lime for the prevention and control of avian influenza proven 80mg propranolol, foot and mouth disease and other infectious diseases proven propranolol 80mg. National Agricultural Biosecurity Center Consortium Carcass Disposal Working Group. Biting flies such as mosquitoes, midges, horse flies, tsetse flies and sand flies, can transmit viruses, bacteria, protozoa and nematodes. Non-biting house flies, blow flies, and flesh flies mechanically transfer disease pathogens on their legs and other body parts, or by dropping infected faeces or even vomit. These organisms may fly, or be carried, large distances from wetland habitats by wind or vehicles. Other important disease-carrying vectors associated with wetlands include snails, crustacea and ticks. Vector control strategies aim to reduce transmission by reducing or eliminating the vectors and by reducing contact between them and potential hosts. Measures vary depending on the disease and vector species, but may be broadly categorised as environmental management, biological control and chemical control. Environmental management Environmental management measures may involve altering hydrology, topography or vegetation to reduce the capacity of the local habitat to maintain populations of disease vectors and to provide suitable habitat for vector predators. This can be conducted through environmental modification where there is a temporary, long-lasting or permanent physical transformation of vector habitats (e. Modification or manipulation of human habitation or behaviour can reduce contact between disease carrying vectors and animals and humans. Biological control Biological control measures use living organisms such as larvivorous fish or bacteria, to manipulate pathogens, parasites, predators, competitors, alternate hosts and other symbionts of target organisms. Introduction of sterile vectors can also help reduce the vector population and hence disease transmission. Advantages of such measures include specificity against target organisms and no chemical contamination of the environment. However, there are a number of potential disadvantages: the efficacy of reducing disease transmission through biological control measures is unknown for many vector species; there are various (often significant) ecological considerations; rearing organisms may be expensive; there may be difficulty in their application and production; and their use will be limited to aquatic sites where temperature, pH and organic pollution meet the requirements of the agent. However, chemicals may cause damage to wetland environments and their wildlife and prolonged use may lead to the development of resistance in some vector populations. Using pesticides for the control of vectors may not be considered ‘wise use’ of a wetland site particularly if they affect non-target species. The efficacy of chemicals in reducing vector populations depends on the appropriateness of formulations, local conditions and the vector species itself. Appropriateness of vector control measures should be based on the vector species, life stages involved, type and extent of habitats to be treated, the presence of non-target species of special concern, in addition to other environmental impacts, such as any likely adverse effects on wetland ecosystem function. Vector control programmes Integrated vector management strategies (to also be integrated into the wetland management plan ►Section 3. When designing a vector control programme, an assessment should be made of vector ecology (species, habitat, population, distribution and breeding cycle), the immune status of the host populations at risk, and the nature and prevalence of the parasite. Common objectives for a strategy include the prevention and control of outbreaks, stopping preventable deaths and minimising illness. Advice on the most appropriate vector control measures and the availability of control resources should be sought from the appropriate national and international authorities. Remove low-growing vegetation and brush to reduce the structural support required by ticks to contact hosts. Remove leaf litter and underbrush to eliminate habitats for ticks and their small mammal hosts. Controlled burning of habitats favoured by ticks can reduce tick abundance from six months to one year. Larger host mammals such as deer, may be contained within certain areas separating them from areas inhabited by people (e. The environmental impact of suggested control measures should be evaluated and appropriate approvals should be granted before they are undertaken. Environmental management – adapting behaviour of people and animals People – personal protection: Wear light coloured clothing to enable ticks to be observed easily. Wear clothing to cover arms, legs, and feet whenever outdoors, tucking trousers into socks or wearing gaiters helps prevent tick access to legs. Check yourself, others and companion animals thoroughly for ticks and manually remove any ticks found (►Tick removal). Grasp the tick as close to the skin surface as possible and pull upwards with a steady, even pressure. Pull firmly enough to lift up the skin, holding this tension for 3-4 minutes and the tick should back out. Do not twist the tick as this may cause the mouth to detach and remain in the skin. If you have any additional disease concerns, put the tick in a plastic bag and freeze it for taking to a medical professional. Animals: Manually remove ticks from animals if practical to do so (►Tick removal). If tick infestation occurs, livestock can be dipped in recommended acaricides or pesticides. There are vaccines available for some tick-borne diseases and even against some species of ticks themselves. Strict quarantine measures are important for domestic animal movements, particularly when importing into tick-borne disease-free areas. Integrated tick control An integrated approach which uses personal protection methods, tick monitoring, habitat modification and acaricide application may be most effective in controlling ticks. Tick control measures should be tailored to the biology and seasonality of particular species.

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Ventilations: ŸŸ Airway: Head-tilt/chin-lift past a neutral position ŸŸ Opens the airway* ŸŸ Ventilations (2): 1 second in duration ŸŸ Gives 2 ventilations using a pocket ŸŸ Ventilations (2): Visible chest rise mask* ŸŸ Ventilations (2): Delivered in 5–7 seconds 5 buy generic propranolol 40 mg on line. Shock advised: ŸŸ Clear: Ensures no one is touching the patient while ŸŸ Says “clear”* shock being delivered ŸŸ Presses shock button to deliver shock* ŸŸ Delivers shock: Depresses shock button within 10 seconds 10 cheap propranolol 40mg amex. Scene size up: ŸŸ Sequence is not critical if all goals are ŸŸ Scene safety* accomplished and verbalized buy cheap propranolol 40 mg online. Chest compressions: Ÿ Hand position: Centered on lower half of sternum Ÿ Exposes chest Ÿ Depth: About 2 inches Ÿ Initiates 30 chest compressions using Ÿ Number: 30 compressions correct hand placement at the proper rate Ÿ Rate: 100–120 per minute (15–18 seconds) and depth, allowing for full chest recoil* Ÿ Full chest recoil: 26 of 30 compressions 4. Ventilations: ŸŸ Airway: Head-tilt/chin-lift slightly past a neutral ŸŸ Opens the airway* position ŸŸ Gives 2 ventilations using a pocket ŸŸ Ventilations (2): 1 second in duration mask* ŸŸ Ventilations (2): Visible chest rise ŸŸ Ventilations (2): Delivered in 5–7 seconds 5. Shock advised: ŸŸ Clear: Ensures no one is touching the patient while ŸŸ Says “Clear”* shock being delivered ŸŸ Presses shock button to deliver shock* ŸŸ Delivers shock: Depresses shock button within 10 seconds 10. Scene size up: ŸŸ Sequence is not critical if all goals are accomplished ŸŸ Scene safety* and verbalized. Chest compressions: ŸŸ Finger position: Centered on lower half of sternum ŸŸ Exposes chest about 1 finger-width below the nipple line ŸŸ Initiates 30 chest compressions using ŸŸ Depth: About 1½ inches correct finger placement at the proper ŸŸ Number: 30 compressions rate and depth, allowing for full chest ŸŸ Rate: 100–120 per minute (15–18 seconds) recoil* ŸŸ Full chest recoil: 26 of 30 compressions 4. Ventilations: ŸŸ Airway: Head-tilt/chin-lift to a neutral position ŸŸ Opens the airway* ŸŸ Ventilations (2): 1 second in duration ŸŸ Gives 2 ventilations using an infant ŸŸ Ventilations (2): Visible chest rise pocket mask* ŸŸ Ventilations (2): Delivers in 5–7 seconds 5. Shock advised: ŸŸ Clear: Ensures no one is touching the patient while ŸŸ Says “Clear”* shock being delivered ŸŸ Presses shock button to deliver shock* ŸŸ Delivers shock: Depresses shock button within 10 seconds 10. Spontaneous patient movement: ŸŸ Pulse check: Rescuer performing ventilations opens ŸŸ Checks for breathing and pulse the airway and checks for breathing and brachial pulse simultaneously for at least 5, but no more than 10 seconds Basic Life Support for Healthcare Providers Handbook 45 46 American Red Cross Section 3: Additional Topics Basic Life Support for Healthcare Providers Handbook 47 Key Skills When providing care to patients, rescuers need to be competent in the psychomotor skills, such as opening the airway and giving compressions and ventilations. In addition, rescuers need to integrate the key skills of critical thinking, problem solving, communication and team dynamics to achieve the best possible outcomes. Critical Thinking Critical thinking refers to thinking clearly and rationally to identify the connection between information and actions. When you use critical thinking, you are constantly identifying new information and situations, adapting to them logically to determine your best actions and anticipating patient reactions. Critical thinking is an essential skill in healthcare, and especially in basic life support situations. A simple example of critical thinking in action during a basic life support resuscitation may occur when a team leader is informed that it is becoming more difficult to ventilate a patient with the bag-valve-mask resuscitator. Using critical thinking, the team leader re-evaluates the situation to determine potential causes including overventilation, hyperventilation or poor airway positioning. Problem Solving Problem solving refers to the ability to find solutions to challenging or complex situations or issues that arise, using readily available resources. In situations requiring basic life support and resuscitation, problems or issues can arise at any point. These situations must be addressed with minimal interruption to patient care to ensure the best possible outcomes. Use whatever resources are at hand, including equipment, other team members or even bystanders if needed. You need to communicate with patients, their families and bystanders as well as colleagues. To effectively communicate with patients, families and bystanders, you need to: ŸŸ Build rapport. In doing so, you need to demonstrate credibility and trustworthiness, confidence and empathy. Communication with the patient and family Patients requiring resuscitation are unresponsive, making communication with the family that much more important. Remember, during emergencies, families are stressed and may not always hear what you are saying. Minimize their fears, as necessary, but avoid giving any misleading information or false hope. Communication with the family about a patient’s death Unfortunately, not all patients survive and you may be involved in communicating with the family about a patient’s death. In this situation: ŸŸ Provide the information honestly and with compassion, in a straightforward manner, including information about events that may follow. Basic Life Support for Healthcare Providers Handbook 49 Ÿ Anticipate a myriad of reactions by family members such as crying, sobbing, shouting, anger, screaming or physically lashing out. Communication with the team As a healthcare or public safety professional, you are often working as part of a team to provide care to patients. It can be difficult for any one person to be aware of all activity that is going on throughout treatment. Therefore, it is critical to effectively communicate with your fellow rescuers to provide effective care. When you are part of a team, it is critical that you communicate with members of your team. Everyone on the team needs to have a voice and be part of the process in order to be able to speak up if a problem arises. Crew resource management is an important team-based response approach to emergency care. The group members demonstrate respect for one another and use clear, closed-loop communication. Teamwork is crucial during resuscitation because the ultimate goal is saving a life, and effective team care requires a coordinated effort of the team leader and the team members. Table 3-1 Elements of an Effective Team Elements of an Effective Team Leader Elements of an Effective Team Member ŸŸ Sets clear expectations ŸŸ Has the necessary knowledge and ŸŸ Prioritizes, directs and acts skills to perform your role decisively ŸŸ Stays in assigned role but assists ŸŸ Encourages team input and others as needed as long as you can interaction maintain your responsibilities ŸŸ Focuses on the big picture ŸŸ Communicates effectively with the ŸŸ Assigns and understands roles team leader if: ŸŸ Allows team input and interaction -ŸYou are lacking any knowledge or ŸŸ Monitors performance while skills. Professional rescuers must keep their education and training current, and stay abreast of science changes, new evidence-based guidelines and other developments in emergency care. Legal Considerations Adults who are awake, alert and oriented have a basic right to accept or refuse care. If the patient is a minor, consent must be obtained from a parent or legal guardian, if available.

And companies such as the recently launched Calico from Google will make attempts at reaching these goals order 40 mg propranolol with amex. Remote Touch While the human touch is the key in the practice of medicine order 80 mg propranolol fast delivery, after some time we will have to use remote touch due to the shortage of doctors and increasing number of patients buy 80mg propranolol with amex. The force feedback technique used by the video game industry has the potential to be used in medicine as well. It has been demonstrated that biopsy sampling can be simulated in a 3D environment using a force- feedback controlled device. Surgeons could be trained with the technique to get better at a procedure even before operating on real patients. Robotic Interventions The number of studies examining the use of robots in the operating room has been increasing rapidly in the past couple of years. Robots can be used in remote surgery, surgical rehearsal in pre-operative planning, intra-operative navigation, simulation and training, among others. It is clear robotic interventions can add a lot to the success of operations and different procedures. One of the best examples is still the Da Vinci system, but other robots in the fields of emergency response or radiosurgery are also available. Surgical instruments will be so precise in a few years’ time that it will be impossible to control them manually, therefore robotic or mechatronic tools will be needed in order to reach the required accuracy. Robotic Nurse Assistant With the growing number of elderly patients, introducing robot assistants to care homes and hospitals is inevitable. It could be a fair solution for moving patients and performing basic medical procedures such as drawing blood. In the next step, it might also perform analysis on the blood from detecting biomarkers to obtaining genetic data. Semantic Health Records The only way to constantly improve a system is to generate and analyze data to find solutions for improving it. The basic requirement of improving healthcare is everyone accessing their own medical/health data stored in semantic databases facilitating public health research as well. Semantic datasets could generate alerts about upcoming medical issues and potential complications. Smartwatch Smartphones have not been able to replace pagers due to practical reasons, but an easily accessible wearable device might have the potential to make this step. A smartwatch could be used for consultations, making calls, sending messages, scheduling visits, as a pager or even for displaying fresh lab test results. We are not far from destroying all obstacles in exchanging medical information, drug, medical equipment or life itself through the so called biological teleportation and the advances of 3D printing. Virtual trials In the era of open access and crowdsourced scientific information, we will have to find a solution for conducting clinical trials without experimenting on people gathering the same amount of information in the same quality as before but in a much faster, non-invasive, humane and reliable way. Every country needs an E-patient Dave, a Jack Andraka and a Regina Holliday to fulfill these goals. Virtual Dissection Medical students will study anatomy on virtual dissection tables and not on human cadavers. What we studied in small textbooks will be transformed into virtual 3D solutions and models using augmented reality. We can observe, change and create anatomical models as fast as we want, as well as analyze structures in every detail. Patients could go through an upcoming operation step by step or choose a hospital based on its „virtual experience” package. Moreover, as the first bi-directional brain- machine interface became available, monkeys in an experiment could use a brain implant not only to control a virtual hand, but also to get feedback that tricks their brains into "feeling" the texture of virtual objects. Virtual-Digital Brains Ian Pearson, in his book, You Tomorrow, wrote about the possibility that one day we would be able to create digital selves based on neurological information. As Google hired Ray Kurzweil to create the ultimate artificial intelligence controlled brain, this opportunity should not be so far away. We might have been searching for the clues of living forever in the wrong places so far. Wearable e-skins Measuring easily quantifiable data is the key to a better health, therefore the future belongs to digestible, embedded and wearable sensors; the latter working like a thin e-skin. These sensors will measure all important health parameters and vital signs from temperature, and blood biomarkers to neurological symptoms 24 hours a day transmitting data to the cloud and sending alerts to medical systems when a stroke is happening real time. Examples include hydration sensors for athletes and intelligent textiles that change color indicating diseases. Whether you are a patient or a medical professional, follow the 1 main trends and try to be up-to-date by using digital methods. Constantly look for solutions to improve your practice as a 2 medical professional or your health as a patient. Embrace digital in a comfortable way and use techniques that 3 make your life easier and your work more efficient. No matter how important role digital will play in our lives, human 8 touch is and will always be the key in the doctor-patient relationship. You Tomorrow This work is licensed under the Creative Commons Attribution-NonCommercial- NoDerivs 3. The formation of the Ghana Psychic and Traditional Healers Association in 1961 and the establishment of the Centre for Scientific Research into Plant Medicine in 1975 attest to this fact. Also in 1991 the government established a unit for the coordination of Traditional Medicine (which is now Traditional and Alternative Medicine Directorate) which was followed by the setting up of the Food and Drugs Board in 1992, which among others, is to certify the sale of Traditional Medicine products to the public. Although all these documents provide a legal policy framework for the development of Traditional Medicine, there is no single document that coordinates the general policy direction of government in the area of traditional medicine. It cuts across sectoral boundaries and provides a national position for which all sectors have to buy into. Almost all the relevant traditional medicine institutions and organizations were involved in the process of developing the document.

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Muscle stasis propranolol 40mg sale, vascular damage or hypercoagulability (Virkoff’s necrosis leads to the release of high quantities of creatine triad) cheap propranolol 40mg fast delivery. Other risk factors include increasing age effective propranolol 40 mg, malignant dis- ease, varicose veins and smoking. Varicose veins Definition Pathophysiology Distended and dilated lower limb superficial veins as- The starting point for thrombosis is usually a valve sinus sociated with incompetent valves within the perforating in the deep veins of the calf, primary thrombus adheres veins. Incidence Common Clinical features The condition is often silent and pulmonary embolism Age may be the first sign. Familial predisposition, obesity, pregnancy and prolonged standing are estab- Investigations lished aetiological factors. Ultrasound or Doppler ultrasound scans can be used to confirm the diagnosis; below-knee thromboses cannot Pathophysiology be easily seen and may only be diagnosed with venogra- r Primary varicose veins are common and show a fa- phy. Alternatively, in patients with a low clinical risk for milial tendency, which may either be due to intrinsic deepveinthrombosismaybescreenedusingtheD-dimer valve incompetence or loss of elasticity in the veins. If the D-dimer is normal no further investigation is r Secondary varicose veins develop after valve function required. The valves in the perforating Management veins are disrupted, so that blood refluxes from the Bedrestandcompressionstockings;patientswithabove- deep veins to the superficial veins. These changes are referred to as lipodermatoscle- patients with a large iliofemoral thrombosis. Chapter 2: Hypertension and vascular diseases 83 Clinical features Clinical features Patients complain of cosmetically unsightly veins and The pain may be dull or burning, usually superficial and aching, heavy legs. There may be a family history or his- on examination there may be one or more visible cord- tory of previous deep vein thrombosis. The superficial veins are prone Complications to thrombus formation due to stasis, causing tender, If there is a portal of entry, e. Investigations The site of the incompetent valve can be identified by the Investigations TrendelenbergtourniquettestorbyDopplerultrasound. No investigations are necessary, except to diagnose un- derlying deep venous insufficiency. Management Elderly patients are managed conservatively with weight reduction, regular exercise and avoidance of constricting Management garments. Sclerotherapy and laser therapy can be used The condition usually responds to symptomatic treat- for small varices, but only surgery is effective if there ment with rest, elevation of the limb and non-steroidal is deeper valve incompetence. After the acute attack, treatment of underlying r To interrupt incompetent connections between deep chronic venous insufficiency may be necessary, scle- and superficial veins. The sapheno-femoral junction rotherapy or laser therapy may be used as treatment for is visualised and the saphenous vein is ligated and varicose veins. Definition Ulceration of the gaiter area (lower leg and ankle) due to venous disease. Superficial thrombophlebitis Definition Incidence Inflammation of veins combined with clot formation. Aetiology/pathophysiology r Thrombophlebitis arising in a previously normal vein Age may result from trauma, irritation from intravenous Increases with age. Aggravating factors include old age, obesity, re- current trauma, immobility and joint problems. Aetiology The aetiology of most congenital heart disease is un- Pathophysiology known, and associations are as follows: r Genetic factors: Down, Turner, Marfan syndromes. Chronic venous ulceration is the last stage of lipo- r Environmental factors: Teratogenic effects of drugs dermatosclerosis(the skin changes of oedema, fibrosis around veins and eczema, which occurs in venous sta- and alcohol. Pathophysiology Clinical features Normally in postnatal life the right ventricle pumps de- Distinguishable from arterial ulcers by clinical features oxygenated blood to lungs and the left ventricle pumps and a history of chronic venous insufficiency (see Table oxygenatedbloodatsystemicbloodpressuretotheaorta, 2. Investigations Congenital heart lesions can be considered according Phlebography is performed to assess the underlying state to one or more of of the veins. Blood from the left side of the heart is re- Management turned to the lungs instead of going to the systemic Healing often takes weeks, possibly months. Skin grafts may speed healing, but only if venous pres- Clinically lesions can be divided into two categories: sure is reduced, e. Surgery to remove r Acyanotic heart disease, which include the left to right incompetent veins before ulceration occurs. Definition Prevalence Abnormal defect in the ventricular septum allowing pas- Up to 1% of live born infants are affected by some form sage of blood flow between the ventricles. Chapter 2: Congenital heart disease 85 Age continued large left to right shunt, the combination of Congenital increased pulmonary blood volume and high-pressure shear forces causes hypertrophy and deposition of col- Sex lagen in the walls of pulmonary arterioles. Eventually M = F these changes become irreversible and pulmonary hy- pertension develops, usually during childhood. The re- sultant high pressure in the right side of the heart causes Aetiology areductionand eventual reversal of the shunt with as- In most cases the aetiology is unknown but may include sociated development of cyanosis termed Eisenmenger maternal alcohol abuse. On ex- r Small defects result in little blood crossing to the right amination there is usually a pulmonary ejection mur- sideoftheheartandnohaemodynamiccompromise– mur and there may be tachypnoea and tachycardia if ‘maladie de Roger’. The murmur is, however, causes a loud pulmonary component to the second quieter as there is less turbulent flow. Initially increased pulmonary blood flow does not cause arise in pressures within the pulmonary circulation Investigations due to the vascular compliance. If, however, there is a r Chest X-ray: Abnormalities are only seen with large defects when cardiomegaly and prominent pul- monary vasculature may be seen. Measurement of the size of the defect and the blood flow allows prediction of the outcome.

The predicted risk of an individual can be a useful guide for making clinical decisions on the intensity of preventive interventions: when dietary advice should be strict and specific discount propranolol 40 mg on-line, when sug- gestions for physical activity should be intensified and individualized 40mg propranolol for sale, and when and which drugs should be prescribed to control risk factors generic propranolol 40 mg visa. Such a risk stratification approach is particularly suitable to settings with limited resources, where saving the greatest number of lives at lowest cost becomes imperative (19). In patients with a systolic blood pressure above 150 mmHg, or a diastolic pressure above 90 mmHg, or a blood cholesterol level over 5. If blood pressure was 6 Prevention of cardiovascular disease reduced by 10–15 mmHg (systolic) and 5–8 mmHg (diastolic) and blood cholesterol by about 20% through combined treatment with antihypertensives and statins, then cardiovascular disease morbidity and mortality would be reduced by up to 50% (28). Therefore, targeting patients with a high risk is the first priority in a risk stratification approach. As the cost of medicines is a significant component of total preventive health care costs, it is particularly important to base drug treatment decisions on an individual’s risk level, and not on arbitrary criteria, such as ability to pay, or on blanket preventive strategies. Thus the use of guidelines based on risk stratification might be expected to free up resources for other compet- ing priorities, especially in developing countries. It should be noted that patients who already have symptoms of atherosclerosis, such as angina or intermittent claudication, or who have had a myocardial infarction, transient ischaemic attack, or stroke are at very high risk of coronary, cerebral and peripheral vascular events and death. Risk stratification charts are unnecessary to arrive at treatment decisions for these categories of patients. Thus, it seems reasonable to assume that the evidence related to lowering risk factors is also applicable to people in different settings. Complementary strategies for prevention and control of cardiovascular disease In all populations it is essential that the high-risk approach elaborated in this document is comple- mented by population-wide public health strategies (Figure 1) (11). Although cardiovascular events are less likely to occur in people with low levels of risk, no level of risk can be considered “safe” (32). Population-wide strategies will also support lifestyle modification in those at high risk. The extent to which one strategy is emphasized over the other depends on achievable effectiveness, cost-effectiveness and resource considerations. The cost-effectiveness of pharmacological treatment for high blood pressure and blood cholesterol depends on the total cardiovascular risk of the individual before treatment (29–33); long-term drug treatment is justified only in high-risk individuals. If resources allow, the target population can be expanded to include those with moderate levels of risk; however, lower- ing the threshold for treatment will increase not only the benefits but also the costs and potential harm. People with low levels of risk will benefit from population-based public health strategies and, if resources allow, professional assistance to make behavioural changes. Ministries of health have the difficult task of setting a risk threshold for treatment that balances the health care resources in the public sector, the wishes of clinicians, and the expectations of the public. For example, in England, a 30% risk of developing coronary heart disease over a 10-year period was defined as “high risk” by the National Service Framework for coronary heart disease (34). This threshold would apply to about 3% of men in the population aged between 45 and 75 years. When the cardiovascular risk threshold was lowered to 20% (equivalent to a coronary heart disease risk of 15%), a further 16% of men were considered “high risk” and therefore eligible for drug treatments. Ministries of health or health insurance organizations may wish to set the cut-off points to match resources, as shown below for illustrative purposes. In a state-funded health system, the government and its health advisers are often faced with making decisions about the threshold at which drug and other interventions are affordable. In many health care systems, such decisions must be made by individual patients and their medical practitioners, on the basis of a careful appraisal of the potential benefits, hazards and costs involved. Countries that use a risk stratification approach have tended to reduce the threshold of risk used to determine treatment decisions as the costs of drugs, particularly statins, have fallen and as adequate coverage of the population at the higher risk level has been achieved. In low-income countries, lowering the threshold below 40% may not be feasible because of resource limitations. Nevertheless, use of risk stratification approaches will ensure that treatment decisions are transparent and logical, rather than determined by arbitrary factors or promotional activity of pharmaceutical companies. Risk prediction charts: Strengths and limitations Use of risk prediction charts to estimate total cardiovascular risk is a major advance on the older practice of identifying and treating individual risk factors, such as raised blood pressure (hypertension) and raised blood cholesterol (hypercholesterolemia). Since there is a continuous relationship between these risk factors and cardiovascular risk the concept of hypertension and hyperlipidemia introduces an arbitrary dichotomy. The total risk approach acknowledges that many cardiovascular risk factors tend to appear in clus- ters; combining risk factors to predict total cardiovascular risk is consequently a logical approach to deciding who should receive treatment. Many techniques for assessing the cardiovascular risk status of individual patients have been described (35–40). Most of these techniques use risk prediction equations derived from various sources, most commonly the Framingham Heart Study (35, 41–46). The risk charts and tables produced use different age categories, duration of risk assessment and risk factor profiles. The current New Zealand (43) and Joint British Societies charts (40, 41) are similar in concept. Risk scores have different accuracy in different populations, tending to overpredict in low-risk populations and underpredict in high-risk populations. The threshold for high risk is defined as a risk of death of 5% or greater, instead of the composite fatal and non-fatal coronary endpoint of 20%. The evidence that underpins the use of risk factor scoring and management comes from a range of sources. There is now increasing evidence that cardiovascular risk factors are associated with clinical 10 Prevention of cardiovascular disease events in a similar way in a wide range of countries (31). There is also strong epidemiological evidence that combining risk factors into scores is capable of predicting an individual’s total cardiovascular risk with reasonable accuracy.

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