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By L. Uruk. Syracuse University.

Instead cheap 80mg top avana with mastercard, just stop- spiritual opportunities: to be touched by the unspeakable raw- ping for a few moments and letting ourselves honestly feel our ness of a mother’s grief over her lost child buy 80 mg top avana with amex; to be humbled by frustration and fatigue may be what we really need. We may prefer to avoid or ignore such experiences when they arise and run off When we notice diffcult feelings and still accept ourselves, to write our notes in the chart. Yet, medicine is a challenging without self-criticism or denial, we are developing compassion profession in large part because it directly exposes us to the en- for ourselves. Mindfully listening to a patient’s anxieties is Finding and using practices that connect us with our experi- natural for those who’ve made room in their hearts for their ences, from writing in a journal to contemplation to meditation, own fears. By coming back to our own sense of presence, we are then more able to be present to others. Our willingness to connect with ourselves thus becomes a Refection: Suggestions for spiritual well-being stepping-stone to a deeper connection with our patients and • Connect with your purpose. When you are Case resolution washing your hands between patients, notice the The resident mentions these feelings to a hospital chap- specifc way you move them, the sensation of the lain, with whom a dialogue on death and dying begins. Sense your feet on the ground, and the father’s death and so joins a bereavement group. The resident begins to feel less isolated and fnds when attending to other people and concerns all it easier to relate to what patients and their families are day. The resident now makes a conscious effort write, or just be present, can bring you back to to notice things that they are grateful for. So, rather than being open to ourselves and our life, we of physicians during and following a catastrophe. We fail to get into the program we want; someone we love Newton B, Barber L, Clardy J, Cleveland E, O’Sullivan P. Do I need • explore strategies and resources for obtaining a personal a specialist in family medicine or is it better for me to family physician, and see a surgeon or internist directly? We do not have objective measures of what doctors need from Case their personal physicians, nor do we know whether their needs A third-year resident has used the birth control pill previ- differ from those of other patients. She chooses a package evidence that access to a family physician helps to maximize from the samples that are available at the community health. A family physician considers the whole picture of the health needs of the patient and not just The resident is your colleague and does not have a per- the presenting symptom or concern. Review the regulations or A family physician functions as a personal health care consul- recommendations of your licensing college that relate to tant for you and your family. Your family physician keeps a Now pretend that you are the resident’s personal family record of your personal and family health issues and provides physician. Most importantly, your Introduction personal family physician assists you with decisions about your What factors infuence physicians to consult another physician health and health care services. Are these factors dif- ferent from those that prompt other patients to see a doctor? Contact information is available at: self-care decision may seem straightforward for the physician www. Physicians needing physicians Unlike other patients, physicians can access the health care sys- Research is lacking on the decision-making processes that tem and self-diagnose, self-refer and self-prescribe; traditionally, doctors use to determine when and with whom they should however, they have been implored not to do so, but to behave consult about personal or family health issues. In Canada, ac- like “normal” patients and seek treatment recommendations cess to a family physician is a problem for all patients, including from others rather than directing their own care. These four must do the same and negotiate how much participation from characteristics have always been commonplace in the care of you, the patient, will assist with quality decision-making and physician patients. As physician patients we cannot Building a good family physician relationship help but approach our personal medical issues with an expert Robert Lamberts, a physician based in Augusta, Georgia, perspective. However, physician expertise does not necessarily has written a list of rules to assist him to get along with his assist with decision-making; indeed, clouded by subjective con- patients and for his patients to get along with him. Consider cerns, it can sometimes impair decision-making about personal these as you interact with your family physician, and as you health issues. In family medicine, much of our ability to diagnose and ad- Rules for patients to get along with their doctor: vise is based on a trusting relationship with our patients that • Rule 1: Your doctor can’t do it alone. As in all relationships, there must be doctor does not mean you should not ask support and resolve to permit the relationship to grow. As one commentator has written, for there to be a justifed trust between patient and doctor, “the consultation must be distractible. Case resolution • Rule 5: They want to know what is going to be The resident used the services available through her local done and when. I am a good patient, that the patient must always agree with the physician’s recom- believe it or not. Because one shoe doesn’t patient fnd concordance on an approach to care in illness and ft all: a repertoire of doctor–patient relationships. Objectives that only 14 per cent of the participants consumed the recom- This chapter will mended six to eight glasses of water per day, and the majority • describe some of the barriers to adequate nutrition in the (60 per cent) snacked less than once a day (Winston 2008). A workplace, qualitative study in which physicians were interviewed about • discuss how inadequate nutrition can affect physicians their workplace nutrition habits reported that 19 of the 20 par- personally and professionally, and ticipants expressed that they sometimes have diffculty eating • suggest ways in which individual physicians can infuence and drinking during work hours (Lemaire et al 2008). In particular the usual attention to healthy What is the impact of inadequate nutrition on physi- nutrition has been gradually eroded by long sessions in cians? Poor nutrition for physicians during the work day has the operating room and lengthy work days. The resident signifcant consequences, both for the individual physician and regards the nutrition choices at the hospital as unaccept- for the workplace. Physicians have previously described how able and fnds they are missing meals, losing weight and their inability to eat and drink properly during work hours is generally feeling awful on most days. When considering physicians’ nutrition in the For physicians: workplace, the solution should be simple—just make time to • Eat breakfast. However, the issue is not so straightforward, and • Carry healthy and convenient snacks with you.

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Subjects such as Classics discount top avana 80mg otc, Literature and Art should be funded at a much lower level proven top avana 80mg. These subjects are primarily of interest to the individual, and a wealthy society should give some subsidy to hobby subjects. However, it must be recognised that the future of society lies in the training and development of those people who will contribute the most. A The study at universities of Classics, Literature and Art provides little benefit to society. C Subjects which are of interest to individuals can also provide benefit to society. D A wealthy society should not subsidise subjects which are of interest only to individuals. The training of those people who will contribute most to society requires an increase in E government funding in university education. These trees benefit from coastal fog which is captured by the trees, causing water to drip onto the soil and therefore watering them. Since fog is now 30 percent less frequent than it was 50 years ago the trees will not have this source of water and are therefore likely to begin to die out. The extreme weather last winter was caused by cold air from the Arctic which is normally kept there by strong winds around the pole. A Other regions of the Northern Hemisphere were hotter last winter than in previous years. Although the weather was very cold last winter, the winter before was of average B temperature. The claims that theories of global warming are incorrect are supported by further C evidence. All the people claiming that theories of global warming are incorrect come from areas D that had very cold weather last winter. Some of the people claiming that the theories of global warming are incorrect do not E come from areas that had very cold weather last winter. As two thirds of adults and a third of children are already obese or overweight, with serious risk of heart disease, diabetes and cancer, the need for proper labelling to warn people about the calorie content of these items is urgent. Which one of the following, if true, most strengthens the argument in the passage above? A Trials show that consumers alter their eating habits when food is calorie-labelled. Many people think that the food and drink consumed at the cinema is as important to the D visit as the film. People who are overweight are sometimes more concerned with their looks than the long E term health risks. Additionally, the availability of more formats means that there is more potential for copies of works to be shared with other fans, who do not pay for them. These fans do not show up in the ratings, so the official ratings do not reflect the relative popularity of a work. A The sharing of works with other fans is more widespread for certain types of music. C The calculation of ratings based on downloads and sales together is not difficult. D Artists are not interested in the popularity of their work, just the sales figures. There is a need to save energy usage in all public services and it is time that the government considered turning off street lighting. Modern cars have powerful headlights which provide a clear view of the road ahead even without overhead lighting. There is also evidence to suggest that when drivers move from an area with lighting to an area without they are more likely to have an accident than those drivers who have driven exclusively on roads without lighting. D Research suggests that older drivers find driving without lighting more difficult. There is evidence that there are fewer daytime accidents on those motorways without E lighting. The grey squirrel, a small, tree-dwelling rodent introduced to Britain over a century ago, is breeding so rapidly that the native red squirrel is disappearing. Encouraging the consumption of the grey species as food may help protect the red one, in her view. However, we can challenge this, as it is all just a cheap publicity stunt to increase business in the restaurant. Which one of the following is the best statement of the flaw in the above argument? D It assumes the disappearance of the red squirrel justifies eating the grey squirrel. They need a stable environment and clean water, uncontaminated by perfume or lotions. There should be a complete ban on this type of pedicure, or else there will soon be no garra rufa. Which one of the following is the best statement of the flaw in the above argument? Badgers are animals believed to be responsible for the spread of bovine tuberculosis which results in large numbers of cows having to be destroyed every year. Animal rights supporters have criticised the proposal, but it is clear that the lives of more cattle can be saved by destroying a smaller number of badgers. Which one of the following is the best statement of the flaw in the above argument?

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Studies of new antibiotics are often done against an older antibi- otic that is no longer used as standard therapy buy generic top avana 80 mg line. But purchase top avana 80mg on-line, since the current standard is prevention in the form of influenza vaccine, the correct study should in fact have been comparing the new drug against the strategy of prevention with vaccine. This is a much more complex study, but would really answer the question posed about the drugs. Any study of a new treatment should be com- pared to the effect of both currently available standard therapies and prevention programs. Effect size The actual results of the measurements showing a difference between groups are given in the results section of a scientific paper. The effect size, commonly called δ, is the magnitude of the outcome, association, or difference between groups that one observes. It often can be expressed as either an absolute difference or the percentage with the outcome in each group or the event rate. The effect size for outcomes that are dichotomous can be expressed as percentages that achieved the result of interest in each of the groups. When continuous out- comes are evaluated, the mean and standard deviations of two or more groups 114 Essential Evidence-Based Medicine can be compared. A statistical test will then calculate the P value for the difference between the two mean values, and will show the probability that the difference found occurred by chance alone. If the measure is an ordinal number, the median is the measure that should be compared. In that case, special statistical methods can be used to determine the P value for the difference found. The clinically significant effect size is the difference that is estimated to be important in clinical practice. It is statistically easier to detect a large effect like one representing a 90% change than a small effect like one representing a 2% change. Therefore, it should be easier to detect a difference which is likely to be clinically important. However, if the sample size is very large, even a small effect size may be detected. This effect size may not be clinically important even though it is statisticallysignificant. Event rates In any study, researchers are interested in how many events of interest happen within each of two treatment groups. The outcome of interest must be a dichoto- mous variable for this set of calculations. The most common varilables are sur- vival, admission to the hospital, patients who had relief of pain, or patients who were cured of infection. The reader ought to be able to clearly determine the outcome being measured and the dif- ferences between the groups are usually expressed as percentages. The control group consists of those subjects treated with placebo, comparison, or the cur- rent standard therapy. The experimental group consists of those subjects treated with the experimental therapy. For studies of risk, the control group is those not exposed to the risk factor, while the experimental group is those exposed to the risk factor being studied. This is, in fact, a percentage of a percentage and the reader must be careful when interpreting this result. The signal is the relationship the researcher is interested in and the noise represents random error. Statistical tests determine how much of the difference between two groups is likely due to random noise and how much is likely due to systematic or real differences in the results of interest. The statistical measure of noise for continuous variables is the standard deviation or standard error of the mean (Fig. The confidence of the statistical results of a study can be expressed as pro- portional to the signal times the square root of the sample size (n) divided by the noise. The signal is the effect size and the noise is the standard deviation of the effect size. Confidence in a particu- lar result increases when the strength of the signal or effect size increases. Finally, it increases as the sample size increases, but only in proportion to the square root of the sam- ple size. Standard deviation tells the reader how close individual scores cluster around their mean value. The actual definition is that 95% of such intervals calculated from the same experiment repeated multiple times contain the true value of the variable for that population. This gives more information than a simple P value, since one can see a range of poten- tially likely values. Statistical tests The central limit theorem is the theoretical basis for most statistical tests. It states that if we select equally sized samples of a variable from a population with 2 D. Maintaining standards: differences between the standard deviation and standard error, and when to use each.

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It has a blood cleanser effect (detoxifier) and is nutritive to the liver cheap 80 mg top avana; also mildly diuretic discount top avana 80mg overnight delivery. Dandelion (Taraxacum officinale): Harvest 2nd year roots in the spring or fall; young leaves in the spring for fresh eating. The root has been used for centuries to treat jaundice as it has a powerful alterative effect on the liver. Echinacea (Echinacea angustifolia): Harvest 2nd and 3rd year roots in early winter after the plant has totally died back (see, you do need your map! Echinacea purpurea: Harvest flower heads with seeds before petals drop in late summer. Tincture, water infusion, oil infusion, decoction, poultice, compress, bolus, syrup, capsule. Using these two varieties together gives increases the potency of your treatments. For strengthening the immune system dosage suggested is a dropper full (1/2 tsp) daily for a 10-day course, no herb for 7 days, then repeat the 10-day course, etc. One option now is to purchase 1# of cut and sifted Echinacea angustifolia root (currently $23/lb), tincture half of it right now, and save half for future decoctions and poultices. This will give you some time to gather your own root, and the tincture will be medicinally potent for at least 10 years. Echinacea root tincture has activity against influenza, herpes, and other viruses which includes virus which cause the common colds. Just soak a cotton ball or swab in the decoction and apply directly to the gums twice daily until the disease is resolved. Mullein (Verbascum thapsus): Harvest leaves before flowering taking no more than 1/3 of the total. It has expectorant action, soothes the throat, has bactericidal activity, and helps stop muscle spasms that trigger coughs. It seems to give mucous membranes a protective coating that allergens cannot penetrate. A 1 tsp dose protects against allergy symptoms for 4-5 hours with no negative side effects. Mullein has been stated to have narcotic properties without being habit forming or - 72 - Survival and Austere Medicine: An Introduction poisonous. Plantain is primarily a proven healer of injured skin cells, hence the topical usage. A salve or compress of plantain applied appropriately is known to reduce hemorrhoid swelling and pain. The New England Journal of Medicine carried a study reporting that poultices made from plantain leaves can help control the itching of poison ivy exposures, it is also good for poison oak also. Red clover tea or tincture taken daily is of great benefit in relieving symptoms of menopause as it is estrogenic. It is also of benefit in relieving menstrual cramps by taking daily during the menstrual time. It is very useful for treating children because of its mild sedative effect and excellent for coughs, wheezing, and bronchitis. Willow (Salix, any variety) If you are allergic to aspirin do not use willow in any form as it contains salicin which is converted to salicylic acid Harvest bark and twigs in the fall. If you are taking an aspirin a day for heart attack risk/angina prevention switching to 1 tsp of willow bark made into 1 cup of tea daily provides the same protection. For larger dosage amounts, tincture is most useful keeping in mind the tincture will take about 1 hour to reduce pain. Placing drops of tincture directly on a corn, bunion, or wart daily for 5-7 days usually removes the corn, bunion, or wart. Home-grown/Cultivated Herbs and Botanicals These next herbs are fairly easy to grow in a home garden as they usually do not grow in the wild. You need to start growing these plants now to have them established in case you really might need them. Aloe (Aloe vera): Use fresh leaves as needed; cut a leaf close to the bottom of the plant, split it open, and use the gel inside topically on burns, minor cuts, and even radiation burns. You can buy potted aloe plants at grocery stores, or nurseries, or get your neighbor to give you one. You can separate these shoots from the roots of the mother plant and pot separately at 1-2" tall. They thrive best in light with well-drained soil, and do not require frequent watering. Commonly grown from seed sown in the fall but can be grown from root divisions from a parent plant in the spring. We have never been able to germinate the seed, so purchase starts from the local nursery. Comfrey (Symphytum officinale): Harvest leaves before flowering throughout the growing season. You can harvest 2-3 times from the same plant remembering to take no more than 1/3 the total leaves. Dry or use fresh for poultices, water infusions, oil infusion, salve, compress, and decoction. Apply comfrey as a compress, poultice, decoction soak/wash, or salve to sores or wounds daily until resolved; will also relieve swelling, and inflammation, and pain. Comfrey makes a wonderful water infusion that is extremely gentle yet powerful treatment for stomach, and bowel discomforts. Drink as a water infusion several cups a day or take a dropperful of tincture daily.

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Panel discussion The panel discussion was led by Pierre Meulien quality top avana 80mg, executive director of the Innovative Medicines Initiative order top avana 80 mg otc. Bianca Wittig, a medical director from AbbVie Inc, said the ‘omics disciplines (eg genomics, proteomics and metabolomics) show how signalling pathways work, thereby providing a reservoir of new information for drug targets. These will need to be developed through collaboration and standardisation, and the use of registry data. Raj Long, a senior advisor to the Bill and Melinda Gates Foundation, spoke about the challenges in neuroscience and the need for policymakers to create incentives for new drug development and reimbursement. Alzheimer’s is an example of a disease where, despite much research, there still are no effective treatments. The research community needs to agree on what is known and not known and use existing tools to bridge the gap. Payers need to provide incentives for research and innovation, and regulators need to ask the question: if you put the patient in the middle, what are the essential risks and benefits? The emphasis should be on creating a single ecosystem to personalise the science around the patient. The task is to join the dots among these phases in healthcare by harnessing new data sources and progressively changing the regulatory paradigm. But more could be done to help drug development, for example, by looking at models that simulate the performance of a drug in a preclinical setting to a clinical setting. Mr O’Connor commended Scotland and Estonia for implementing digital health programmes. He told attendees: “Don’t spend time worrying about the problems; implement what you can do at the moment. The key feature is bringing the patient into drug development at the right moment. What is missing from the current initiatives in personalised medicine is a biomarker validation platform. Founded in 2008, the biobank has more than 300,000 biological samples for use in applied medical research. The facility is certified by two separate quality management certification bodies. Dr Meulien fielded questions from the audience which largely revolved around the question of how to influence the strategic decisions of pharma in relation to new drug development. In response, Peter Høngaard Andersen said that pharma needs incentives to develop drugs for small patient populations, where the return on investment is likely to be smaller than for the blockbuster drugs of the past. He suggested that companies receive a longer market exclusivity for personalised medicines. Marisa Papaluca pointed out that companies can elect to have parallel scientific advice at the European Medicines Agency with health technology assessment bodies. These discussions have helped companies get better value from their investments, which itself is an incentive to develop new drugs. Risk-sharing arrangements can also be a tool for helping companies realise an investment return, Raj Long said. This could mean the public authority commits to buying a medicine in advance, in exchange for a company’s agreement to develop it. Dr Meulien concluded the discussions by saying that moving the personalised medicine initiative forward would be like “building a plane while it is flying. He said that personalised medicine represents a change in the paradigm of medicine similar to the introduction of antibiotics at the end of the second world war. Personalised medicine (eg, targeted therapies) have had a big impact on cancer, but the big question is cost. More collaboration among academia, industry and healthcare authorities will be required to address the issue of cost. Coincidentally, it corresponds with a change in demographics whereby older people are becoming a bigger proportion of the population, increasing healthcare costs. Frédérique Nowak, head of the biology, transfer and innovation department at the French National Cancer Institute, explained the challenge of implementing a personalised medicine strategy in an era of targeted cancer therapies. Since 2006, France has been providing molecular testing for all patients with cancer so that they can be prescribed with the most appropriate medicine as soon as possible. Over the years there has been a progressive shift from one-on-one tests for individual patients to a next generation sequencing approach, which has increased the probability that an actionable mutation will be discovered in a patient’s tumour. The cost of the programme has therefore increased because targeted therapies are now available for new subsets of patients. While this has posed challenges, France has nonetheless been able to integrate the stratification of patients into the healthcare system. Andres Metspalu, director of the Estonian Genome Center at the University of Tartu, provided further information on the Estonian heathcare system which has been fully integrated with computers and registries. The practical consequence is that if a citizen shows a risk for cardiovascular disease, he can do something about it by changing his lifestyle. Just as consumers can return a pizza if it is poorly made, perhaps in future patients will be able to return a drug that does not work 17 Panel discussion Mary Harney, a former minister for health and children in Ireland, led the panel discussion. The panellists included Maarten Ijzerman, Professor at the University of Twente in Enschede, the Netherlands; Varda Shalev, Director of the Institute for Health Research and Innovation, Maccabi Health Systems in Tel Aviv, Israel; Maria Aguirre Rueda, Director for Health Research and Innovation, Basque government, Spain; Roberto Salgado, Institut Jules Bordet in Brussels, Belgium and Matthias Perleth of the Gemeinsamer Bundesausschuss in Berlin, Germany. In the discussion, panellists agreed that personalised medicine is an innovation that is here to stay. Technology is transforming the way that we understand the drivers of human health and disease. Using next generation sequencing, scientists can provide information on a person’s genetic susceptibility to disease, or indeed help explain the drivers for good health. Together with information from the environment, it is possible to get a holistic picture of a person’s health. Using information technology, healthcare providers can collect, store and analyse data on whole populations making it possible to identify the most therapeutically effective, and cost effective interventions.

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