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However proven atorlip-20 20 mg, the comparison may sim- ply be for the costs of the treatments only without a specific viewpoint on who is paying for them or how much is being reimbursed proven 20mg atorlip-20. There is a disconnect between costs and charges in health-care finances because of the large amount of uncompensated and negotiated care that is deliv- ered. Costs are the amount of money that is required to initiate and run a particular intervention. However, when using simple costs only, the cost of treating non-insured patients must be fac- tored into the accounting. It should be possible from reading the article’s methods to set up the same pro- gram in any comparable setting. This requires a full description of the process of setting up the program, the costs and effects of the program, and how these were measured. Typically two treatment options or treatment as opposed to non-treatment are considered in a cost- effectiveness analysis. Using treatments that are no longer in common use will give a biased result to the analysis. There should be hard evidence from well-done randomized clinical trials to show that the interven- tion is effective, and this should be explicitly stated. Where not previously done, a systematic review or meta-analysis should be performed as part of the anal- ysis. A cost-effectiveness analysis should not be done based on the assump- tion that because we can do something it is good. Does the analysis identify all the important and relevant costs and effects that could be important? Were credible measures selected for the costs and effects that were incorporated into the analysis? On the cost side this includes the actual costs of organization and setting up a program and continuing operations, addi- tional costs to patient and family, costs outside the health-care system like time lost from work and decreased productivity, and intangible costs such as loss of pleasure or loss of companionship. These costs must be compared for both doing the intervention program and not doing the program but doing the alternatives. On the effect side, the analysis should include “hard” clinical outcomes: mor- tality, morbidity, residual functional ability, quality of life and utility of life, and the effect on future resources. These include the availability of services and future costs of health care and other services incurred by extending life. For example, it may be fiscally better to allow people to continue to smoke since this will reduce their life span and save money on end-of-life care for those people who die prematurely. The error made most often in performing cost-effectiveness analyses is the omission of consideration of opportunity costs that were referred to at the start of this chapter. If you pay for one therapeutic intervention you may not be able to pay for some other one. Cost-effectiveness analyses must include an analysis of these opportunity costs so that the reader can see what equivalent types of programs might need to be cut from the health-care budget in order to finance the new and presumably better intervention. Analyses that do not consider this issue are giving a biased view of the usefulness of the new program and keeping it out of the context of the most good for the greater society. The marginal or incremental gain for both the costs and effects should be cal- culated. This is the number of patients you must treat in order to achieve the desired effect in one additional patient. This is com- pared to the marginal cost of the better treatment to get a cost-effectiveness estimate. The marginal or incremental cost per life saved is then $180 000 [($2000 − $200) × 100 lives]. Also, the effects measured should include lives or years of life saved, improvement in level of function, or utility of the outcome for the patient. This works if the effects of the two interventions are equal or minimally different. For example, when compar- ing inpatient vein stripping to outpatient injection of varicose veins, the results shown in Table 31. Here the cost is so different that even if 13% of outpatients require additional hospitalization (and therefore we must pay for Cost-effectiveness analysis 355 Table 31. Comparing doxycycline to azithromycin for Chlamydia infections Treatment Outcomes Cost to hospital No further Adverse Compliance per patient treatement needed effects rate Doxycycline 3 77% 29% 70% Azithromycin 30 81% 23% 100% Source: Data extracted from A. The cost effective- ness of azithromycin for Chlamydia trachomatis infections in women. Another analysis compared doxycycline 100 mg twice a day for 7 days to azithromycin 1 g given as a one-time dose for the treatment of Chlamydia infec- tions in women.

The media The media buy atorlip-20 20 mg overnight delivery, such as television order 20 mg atorlip-20 fast delivery, radio, newspapers and online news sources, can help get a message to a large number of people quickly and easily. Developing partnerships or good relationships with local or national media can reduce potential for misunderstanding. Ideally, selected personnel should receive media training and be designated spokespersons on behalf of an organisation involved with managing disease, to effectively convey information before, during and after an outbreak or other problem. A community task force that includes health, environmental, civic and business concerns can be valuable in reaching various segments of society and in developing a common message. Community outreach activities should encourage community mobilisation whereby groups take part in actions to prevent and control an outbreak, e. Target audience research Knowing different audiences is critical to putting communication plans into practice. Attitudes to disease management measures may vary considerably by region or section of society. Previous experience with disease prevention and control measures will affect the acceptability of future efforts. Target audience research can identify local attitudes, motivations, barriers to ‘change’, and opportunities to promote desired behaviours. Surveys assessing knowledge, understanding, attitude and practice levels can be of particular value - ideally combining qualitative and quantitative methods. Evaluations, including lessons learned, should be conducted, whenever possible, to measure the efficacy of communications in achieving their aims, and adjustments made accordingly. Emergency communications for a disease outbreak Emergency communications are inevitably focused on managing for the worst case scenario. Above all, a communication plan is a resource of information for those that need it and should be integrated into the overall wetland disease management strategy. All relevant wetland stakeholders, disease control authorities, spokespersons and communications professionals should be involved (e. Crisis Communication: this is used when there is an unexpected disease outbreak and there is a need to quickly communicate about that crisis to wetland stakeholders and the wider public. Issues Management Communication: this is used with the knowledge of an impending crisis and, therefore, the opportunity to choose the timing of the communication to the wetland stakeholders and the wider public. Risk Communication: this is used to prepare people for the possibility of a disease outbreak and to provide appropriate steps to prevent an outbreak and mitigate for its impacts. There will be stages to every outbreak and communication must also evolve with each stage. The following cycle demonstrates the likely stages of an outbreak: Precrisis Initial Maintenance Resolution Evaluation Be prepared. Document lessons consensus about the risk information to those Honestlyexamine learned. Provide emergency Listen to stakeholder Persuade the public courses of action and audience to support public (including how/whereto feedback, and correct policy and resource get more information). Promote the stakeholders and public Empower activities and to continued risk/benefit decision- capabilities of the communication. Disease outbreaks and the media In the case of a significant disease outbreak, it is likely that the media will want information. Tactics for dealing with the media should be covered within a communications plan. Strategies for dealing with the media will vary depending on desired outcomes, for example, the media may be an effective way to communicate with wetland stakeholders. Control of the messages is ceded by adding an additional level between you and your target audience. Sometimes the media can negatively affect a situation either by inaccurate reporting or taking up too much time and resources during a crisis. By being prepared and planning for this scenario, it can be ensured that the attention of the media works to help the situation. The communications plan should cover, for example, whether: a) nominated people within an organisation are a spokesperson and/or field enquiries, or b) enquiries are passed on to other organisations with greater relevant communications resources and experience. When dealing with the media over disease risks, there are a number of guidelines which may be helpful and should be borne in mind. Write the plan in ‘peacetime’, before a disease problem, when it is easy to take time and plan calmly. Clearly assign roles and responsibilities, including a single organisational contact point for media inquiries and spokespeople. In peacetime, train a small number of key spokespeople (exercises can be very useful). Foster good relationships with the media in ‘peacetime’ by briefing them on wetland issues. If dealing with the media does not bring benefits, then do not be afraid to say no to journalists - you will not offend them or ruin your relationship, they are used to hearing no, they respect it and often expect it. It will help to determine scenarios when you will proactively use the media and when you will only react to enquiries. If you are responding to an inquiry, ask beforehand what is the nature and angle of the media story so you have opportunity to prepare and do some background research.

These Arabic medical encyclopedias included sections on women’s dis- eases quality 20mg atorlip-20, based in their substance on thework of the Methodist physician Soranus order 20mg atorlip-20 with visa. But their content was stripped of its overlay of Methodist theory, in whose place were substituted Hippocratic and Galenic principles of the workings of the elements (hot, cold, wet, and dry), the humors (blood, phlegm, yellow or red bile, and black bile), the temperaments (the actual elemental or hu- moral predominance that would characterize any given individual), the facul- ties (physiological processes we would today describe in terms of chemical or muscular action), and so forth. Whereas Soranus had argued that the Meth- odist physician need only know the three states—lax, constricted, or mixed— in a Galenic system disease must be distinguished according to which of the four humors predominates in the body (any imbalance in their proper propor- tion being itself a sign of disease). This fusion of Soranus’s nosographies and therapies with Galenic theory resulted in the creation of a Galenic gynecology, which bore the distinctive stamp of its Arab and Muslim creators, not only for the increased philosophical rigidity of the humoral system (which Galen had never been so formal about), but also for the new, unique Arabic contribu- tions to therapy and especially to materia medica (pharmaceutical ingredients). Thus, for example, when the North African writer Ibn al-Jazzār described the various possible causes of menstrual retention, he distinguished between the faculty, the organs, and the substance (of the menses themselves) as the caus- ative agents, dialectically breaking down each of these three categories into their various subcategories. Whereas in modernWestern medical thought menstruation is seen as a mere by-product of the female reproductive cycle, a monthly shedding of the lining of the uterus when no fertilized ovum is implanted in the uterine wall, in Hippocratic and Galenic gynecology menstruation was a necessary purgation, needed to keep the whole female organism healthy. The Hippocratic writers had been incon- sistent on whether women were hotter or colder than men by nature. In Galenic gynecology, in contrast (which in this respect built on the natural philosophical principles of Aristotle), women were without question constitu-  Introduction tionallycolder than men. Men, moreover, were also able to exude those residues of digestion that did remain through sweat or the growth of facial and other bodily hair. Because (it was assumed) women exerted them- selves less in physical labor even while they produced, because of their insuf- ficient heat, a greater proportion of waste matter, they had need of an addi- tional method of purgation. For if women did not rid their bodies of these excess materials, they would continue to accumulate and sooner or later lead to a humoral imbalance—in other words, to disease. When, too, she did not menstruate because of pregnancyor lactation, she was still healthy, for the excess matter—now no longer deemed ‘‘waste’’—either went to nourish the child in utero or was converted into milk. When, however, in a woman who was neither pregnant nor nursing menstrua- tion was abnormal, when it was excessive or, on the other hand, too scanty, or worse, when it stopped altogether, disease was the inevitable result. Nature, in her wisdom, might open up a secondary egress for this waste material; hence Conditions of Women’s suggestion that blood emitted via hemorrhoids, nosebleeds, or sputum could be seen as a menstrual substitute (¶). In mod- ern western medicine, absence of menstruation in a woman of child-bearing age might be attributable to a variety of causes (e. It might not even be deemed to merit therapeutic intervention, unless the woman desired to get pregnant. In Hippocratic and Galenic thought, ab- sence of menstruation—or rather, retention of the menses, for the waste ma- terial was almost always thought to be collecting whether it issued from the body or not—was cause for grave concern, for it meant that one of the major purgative systems of the female body was inoperative. It is for this reason that the largest percentage of prescriptions for women’s diseases in most early medi- eval medical texts (which reflected the Hippocratic tradition only) were aids for provoking the menses. Between the ages of fourteen (‘‘or a little earlier or a little later, depending on how much heat abounds in her’’)84 and thirty-five to sixty Introduction  (upped to sixty-five in the standardized ensemble), a woman should be men- struating regularly if she is to remain healthy. In overall length, the four sections on menstruation (¶¶– on the general physiology and pathology of menstruation, ¶¶– on menstrual retention, ¶¶– on paucity of the menses, and ¶¶– on excess men- struation) constitute more than one-third of the text of the original Conditions of Women. Throughout these long sections on menstruation, the author is adhering closely to his sources: the Viaticum for overall theory and basic therapeutics and the Book on Womanly Matters for supplemental recipes. In ¶, the author tells us that the menses are commonly called ‘‘the flowers’’ because just as trees without their flowers will not bear fruit, so, too, women without their ‘‘flowers’’ will be deprived of off- spring. This reference to ‘‘women’s flowers’’ has no precedent in the Viaticum (the source for the rest of this general discussion on the nature of the menses) nor in any earlier Latin gynecological texts, which refer to the menses solely as menstrua (literally, ‘‘the monthlies’’). Theterm‘‘flower’’(flos) had been used systematically throughout the Trea- tise on the Diseases of Women (the ‘‘rough draft’’ of Conditions of Women, which had employed frequent colloquialisms), and at least fourteen of the twenty- two different vernacular translations of the Trotula (including Dutch, English, French, German, Hebrew, and Italian) employ the equivalent of ‘‘flowers’’ when translating the Latin menses. But just as a tree which lacks viridity is said to be unfruitful, so, too, the woman who does not have the viridity of her flowering at the proper age is called infertile. Menstrual blood is like the flower: it must emerge before the fruit—the baby—can be born. In the Hippocratic writings themselves, although there is discussion of suffocation caused by the womb, the actual term ‘‘uterine suffocation’’ (in Greek, hysterike pnix) is never used. It was only out of loose elements of Hip- pocratic disease concepts (which were always very vaguely defined and iden- tified) that the etiological entity of uterine suffocation was created, probably sometime before the second century . Such movement was thought to be caused by retention of the menses, excessive fatigue, lack of food, lack of (hetero)sexual activity, and dryness or lightness of the womb (particu- larly in older women). When these conditions obtain, the womb ‘‘hits the liver and they go together and strike against the abdomen—for the womb rushes and goes upward towards the moisture. When the womb hits the liver, it produces sudden suffocation as it occupies the breathing passage around the belly. For example, when the womb strikes the liver or abdomen, ‘‘the woman turns up the whites of her eyes and becomes chilled; some women are livid. If the womb lingers near the liver and the abdomen, the woman dies of the suffocation. Multiple means of treat- ment were employed, including the recommendation that, when the womb moves to the hypochondria (the upper abdomen or perhaps the diaphragm), young widows or virgins be urged to marry (and preferably become preg- nant).

These initiatives produce clear information on risk that acknowledges uncertainty and is readily accessible order 20mg atorlip-20. For day-to-day use in clinical environments effective atorlip-20 20 mg, a scale based on the equivalent number of chest X rays, or that state risk without citing dose, is likely to be adequate. Picano’s graphical approach to dose and risk for different patient groups (including children, adult males, adult females and the elderly) has much to recommend it [1]. Finally, clear transparent public education programmes are essential, where imaging services are marketed directly to the public and to the worried well. This conference devoted a full session to it and recognized it as a major area for attention during the coming decade. The approach derives from an analysis of justification based on ethical considerations. However, the justification may also benefit from approaches that seek to reduce overutilization based on health economic or health technology assessment grounds. There are several compelling reasons: first, it is universally accepted that a significant percentage of imaging worldwide is inappropriate, with both over- and underutilization. This leads to increased health care costs when imaging is overutilized and, in all likelihood, worsened quality of care with both over and under use. The effects of this remain unknown in individuals, but it is inarguable that unnecessary exposure to ionizing radiation should be avoided. These include patient expectations and wishes, the expectation of health care providers that the use of imaging can protect them from malpractice accusations and litigation, financial conflict of interest, lack of specific guidance from imagers, and lack of sufficient knowledge on the part of referring health care providers. Patient expectations are clearly important, and they often have limited or incomplete understanding of the benefits and limitations of imaging, as well as of the costs. Also, they often, legitimately want something concrete done, even if there is no likely benefit. This occurs with the desire for an imaging study as well as in other settings, for example, with the desire for antibiotics for a simple cold. Regarding litigation, in many countries litigation is increasing and anyone can, in fact, sue for anything, regardless of the reality of the medical situation and the outcome. Secondly, health care providers are worried about getting sued, and often do order imaging or laboratory studies or consultations that they believe are unnecessary but will protect them from litigation. These findings have been confirmed in further studies that examined the behaviour of orthopaedists [4], neurosurgeons [5] and specialists in general [6], all in the United States of America. Even though litigation generally is settled in favour of the defendant doctors, and remains unusual, the fear of it has a significant impact on the use of imaging. Inappropriate use of imaging is further complicated by the increasing complexity of modern medicine. Clearly, no health care provider can be fully knowledgeable about more than a small area, and best practice can change very quickly. This adds not only intellectual concerns, but also concern about delivering optimal care. This is further complicated by the increasing role that non-physicians, such as physician assistants and other ‘physician extenders’, play in the delivery of care. These factors taken together make a strong argument that imaging is not likely to be optimally utilized, and this has been shown in many studies. In one, for example, it was shown that a large percentage of patients with advanced cancer underwent screening for other cancer [7]. This screening was very likely to have no benefit in terms of longevity or altered treatment. Medical costs have increased dramatically over the last several decades, in many cases in concert with improved care, and it is clear that imaging has provided major advances in health care. Over the past few years, for a number of reasons, there has been increased concern about the exposure of populations and individuals to ionizing radiation. It is essentially impossible to define the individual risks and population risks are also virtually impossible to define with precision. Recent studies, however, have suggested that limited exposure to ionizing radiation does measurably increase the cancer risk for populations [12, 13]. There are, in summary, two important basic concepts that must be kept in mind: first, there is potential risk of exposure to diagnostic level ionizing radiation, so any use should be based on a risk– benefit analysis, with the possible benefits to be gained through the imaging outweighing the theoretical risks of ionizing radiation. Secondly, the concern about the possible adverse effects of radiation can be used to help educate the lay public, to enable them to consider the risk:benefit ratio whenever imaging (particularly using ionizing radiation) is considered. This concern logically leads to the conclusion that there is need for ongoing education and specific guidance in the optimal use of imaging, and this is probably best achieved and most likely to be successful if it is based on methodologically sound, widely accepted guidelines for the use of imaging. It follows, however, that imaging guidelines are likely to be very difficult to develop and deploy, given the complexity of modern medicine and the wide variations in disease patterns, availability of technology and treatments, and knowledge, but they are also necessary. There has been much discussion about how guidelines should be constructed, but there are several areas of wide consensus. First, clinical guidelines should be based to as large an extent as possible on high quality, peer reviewed literature. The available literature, however, is virtually never sufficient to provide data based guidance, except in very limited areas, so any guidelines must be data driven but supplemented by expert opinion.