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The science is in the medical literature and in the ability of the clinician to interpret that literature buy avalide once a day blood pressure healthy value. Students learn the clinical and basic sciences that are the foundation of medicine during the ﬁrst 2 years of medical school order avalide 162.5mg hypertension lifestyle changes. The art of medicine is in determining to which patients the literature will apply and then communicating the results to the patients discount 150mg clindamycin fast delivery. Students learn to perform an adequate history and physical examination of patients to extract the maximum amount of evidence to use for good medical decision making. Students must also learn to give patients information about their illnesses and empower them to act appropriately to effect a cure or control and moderate the illness. Finally, as pracitioners, physicians must be able to know when to apply the results of the most current literature to patients, and when other approaches should be used for their patients. Evidence- based medicine can be viewed as an attempt to standardize the practice of medicine, but at the same time, it is not “cookbook” medicine. However, it is still up to the clinician to determine whether the individual patient will beneﬁt from that approach. If your patient is very different from those for whom there is evidence, you may be justiﬁed in taking another approach to solve the prob- lem. These decisions ought to be based upon sound clinical evidence, scientiﬁc knowledge, and pathophysiological information. Evidence-based medicine is not a way for managed care (or anyone else) to simply save money. Evidence- based practices can be more or less expensive than current practices, but they should be better. Evidence-based medicine is the application of good science to the practice of health care, leading to reproducibility and transparency in the science support- ing health-care practice. Evidence-based medicine is the way to maximize the beneﬁts of science in the practice of health care. Lord Kelvin, President of the Royal Society, 1895 Learning objectives In this chapter you will learn: r cause-and-effect relationships r Koch’s principles r the concept of contributory cause r the relationship of the clinical question to the type of study The ultimate goal of medical research is to increase our knowledge about the interaction between a particular agent (cause) and the health or disease in our patient (effect). Causation is the relationship between an exposure or cause and an outcome or effect such that the exposure resulted in the outcome. However, a strong association between an exposure and outcome may not be equivalent to proving a cause-and-effect relationship. By the end of this chapter, you will be able to determine the type of causation in a study. Cause-and-effect relationships Most biomedical research studies try to prove a relationship between a partic- ular cause and a speciﬁed effect. The cause may be a risk factor resulting in a disease, an exposure, a diagnostic test, or a treatment helping alleviate suffer- ing.
In 1629 Cardinal Richelieu gave the same advice to the French monarch order avalide in india arteria poplitea, who also hated smokers purchase avalide cheap arteria gastroduodenalis. The attitude of the Church to smoking moved quickly from abhorrence to toleration purchase generic terramycin on-line. Bene- 126 Lifestylism diet had become addicted to nicotine himself, and the Papacy allowed the sale of tobacco and brandy, provided that the contractors paid a reasonable revenue to the Papal States. In less enlightened parts of the world, smokers were per- secuted for their monstrous crime. Reports (not well authenticated) indicate that his father, Ahmed, used to punish the wretches caught smoking in public by having a pipe-stem thrust through their nose and, as a warning to discourage others, were paraded through the streets on a donkey. Soldiers caught smoking on the battlefield were dealt with summarily by beheading, quartering, or just having their hands and feet crushed and being left to their fate. In 17th-century Russia the Tsars had a policy of punishing smokers by slitting their lips or nostrils, or, in the case of tobacco sellers, flogging them to death or castrating them. In Japan, in 1616, the property of smokers was liable to confiscation, and a Chinese law of 1638 threatened tobacco sellers with decapi- tation. In England, however, smoking very quickly became widespread and respectable and it was even believed that smoking protected against the plague. In 1665, at Eton, all boys were obliged to smoke every morning, and, as recalled by Tom Rogers, who was a yeoman beadle at Eton, he was never whipped so much in his life as he was on one morning for not smoking. And in 1976, Mr George Teeling-Smith, Director of the Office of Health Economics in Britain, suggested that cigarettes should be available only on prescription. A German preacher, Jacob Balde wrote in 1658: What difference is there between a smoker and a suicide, except that the one takes longer to kill himself than the other. In 1699, the President of the Paris School of Medicine declared that the act of love was a brief epileptic fit, while smoking was a permanent epilepsy. The revival of anti-smoking agitation in the 19th century had the character of a crusade in which doctors and moralists joined hands. Expanding capitalist industry required masses of workers whose efficiency was not impaired by tobacco or alcohol. In Victorian England, human weaknesses, especially when indulged in by the working class, were seen as a threat to the accumulation of capital. This was in the era when small children were exploited in coal mines, often spending 12-14 hours a day underground, without any objection from the medical and church authorities who backed the newly-formed anti-tobacco leagues and societies. In 1833, James Johnson, the editor of the Medico- Chirurgical Review expressed doubts about the alarmist reports from Germany that tobacco was responsible for 50 per cent of all deaths among men between the ages of 18 and 25. Cor- respondent after correspondent enumerated all the kinds of diseases caused by smoking, including muscular debility, jaundice, cancers of the tongue, lip and throat, the tottering knee, trembling hands, softening of the brain, epilepsy, impairment of the intellect, insanity, impotence, sperma- torrhoea, apoplexy, mania, cretinism, diseases of the pan- creas and liver, deafness, bronchitis, and heart disease. Worries were expressed that the health of England was at stake and that smoking would reduce the English race in the scale of nations to a point which approached the national degeneracy of the Turks.
It is primarily the non-drinking group that causes the U-shaped relationship purchase avalide master card hypertension bp, and this may contain both life-long abstainers and people who stopped drinking because of ill-health discount avalide online amex blood pressure medication leg swelling; this could result in a spurious association suggesting that there is a safe level of alcohol intake 17.5mg lisinopril sale. 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). If the authors’ claim is correct, it implies that there is no level of alcohol consumption that is beneﬁcial with respect to coronary heart disease; rather, risk increases with increasing consumption in a linear fashion. However, subsequent randomized controlled trials have found either no beneﬁt or a harmful association; the earlier results are likely to be due to uncontrolled confounding. It is possible that the protective association between light-to-moderate alcohol consumption and coronary heart disease is also an artefact caused by confounding. It is also important to note that alcohol consumption is associated with a wide range of medical and social problems, including road trafﬁc injuries. Other risks associated with moderate drinking include fetal alcohol syndrome, haemorrhagic stroke, large bowel cancer, and female breast cancer (237, 245). Con- sequently, from both the public health and clinical viewpoints, there is no merit in promoting alcohol consumption as a preventive strategy. Psychosocial factors Issue Are there speciﬁc psychosocial interventions that can reduce cardiovascular risk? Evidence Observational studies have indicated that some psychosocial factors, such as depression and anxiety, lack of social support, social isolation, and stressful conditions at work, independently 38 Prevention of cardiovascular disease inﬂuence the occurrence of major risk factors and the course of coronary heart disease, even after adjusting for confounding factors (246–248). Other psychosocial factors, such as hostility and type A behaviour patterns, and anxiety or panic disorders, show an inconsistent association (249, 250). Rugulies (246), in a meta-analysis of studies of depression as a predictor for coronary heart disease, reported an overall relative risk for the development of coronary heart disease in depressed subjects of 1. This ﬁnding was consistent across regions, in different ethnic groups, and in men and women (247). In a large randomized trial of psychological intervention after myocardial infarction, no impact on recurrence or mortality was found (253). Another large trial that provided social support and treatment for depression also found no impact (254). Depression has a negative impact on quality of life (255, 256), and antidepressant therapy has been shown to signiﬁcantly improve quality of life and functioning in patients with recurrent depression who are hospitalized with acute coronary syndromes (257, 258). The association has been demonstrated in subjects in different countries, and in various age groups (250, 259–262). While these ﬁndings provide some support for a causal interpretation of the associations, it is quite possible that they represent confounding or a form of reporting bias, as illustrated in a large Scottish cohort (263). Well planned trials of interventions to reduce work stress and social isolation are required to elucidate whether there is a true cause–effect relationship and, more importantly, whether inter- vention reduces cardiovascular risk.
This proportion is equal to that due to infectious diseases cheap avalide 162.5 mg otc heart attack jaw pain, nutritional deﬁciencies purchase cheap avalide on-line blood pressure medication excessive sweating, and maternal and perinatal conditions combined (1) order 250 mg terramycin with visa. It is important to recognize that a substantial pro- portion of these deaths (46%) were of people under 70 years of age, in the more productive period of life; in addition, 79% of the disease burden attributed to cardiovascular disease is in this age group (2). Between 2006 and 2015, deaths due to noncommunicable diseases (half of which will be due to cardiovascular disease) are expected to increase by 17%, while deaths from infectious diseases, nutritional deﬁciencies, and maternal and perinatal conditions combined are projected to decline by 3% (1). Almost half the disease burden in low- and middle-income countries is already due to noncommunicable diseases (3). A signiﬁcant proportion of this morbidity and mortality could be prevented through population- based strategies, and by making cost-effective interventions accessible and affordable, both for people with established disease and for those at high risk of developing disease (3–5). In doing so, it placed noncommunicable diseases on the global public health agenda. However, population- wide public health approaches alone will not have an immediate tangible impact on cardiovascular morbidity and mortality, and will have only a modest absolute impact on the disease burden (3, 4). A combination of population-wide strategies and strategies targeted at high risk individuals is needed to reduce the cardiovascular disease burden. The extent to which one strategy should be emphasized over the other depends on achievable effectiveness, as well as cost-effectiveness and availability of resources (1–4). In this context, it is imperative to target the limited resources on those who are most likely to beneﬁt. Thus, as envisioned in the Global Strategy for the Prevention 2 Prevention of cardiovascular disease Table 1 Effect of three preventive strategies on deaths from coronary heart disease over 10 years in Canadians aged 20–74 years* Strategy No. The objective is to reduce the incidence of heart attacks, strokes, and renal failure associated with hypertension and diabetes, as well as the need for amputation of limbs because of ischaemia, by reducing the cardiovascular risk. The focus is prevention of disability and early deaths and improvement of quality of life. This document should be considered as a framework, which can be adapted to suit different political, economic, social, cultural and medical circumstances. Interpretation and implications of recommendations (13, 14) The recommendations included here provide guidance on appropriate care. As far as possible, these are based on clear evidence that allows a robust understanding of the beneﬁts, tolerabil- ity, harms and costs of alternative patterns of care. Recommendations can be deﬁned as being strong when it is certain that their application will do more good than harm or that the net beneﬁts are worth the costs. Strong recommendations apply to most patients in most circumstances, and can be adopted as policy in most situations. Introduction 3 Recommendations can be deﬁned as weak when it is uncertain that their application will do more good than harm or that the net beneﬁts are worth the costs. In this guide, such recommendations include the words “suggest” or “should probably”. In applying weak recommendations, clinicians need to take into account each individual patient’s circumstances, preferences and values. Policy- making related to weak recommendations requires substantial debate and the involvement of a range of stakeholders.