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By Z. Mamuk. Wabash College. 2019.

Genomics tests generic mentax 15 mg amex, for example order mentax 15mg amex, are still focused on traditional genetic conditions versus more common chronic conditions that are seen in the population. However, personalized genomic scans (although they have their critics) are nevertheless available to today’s consumers. The continued role of pharma- cogenomic screening is evident through its association with key drug-metabolizing pathways. As better outcomes-based research becomes available on these associations, tailoring of medications based on pharmacogenomic profiles will become a reality. A handful of targeted therapies, such as imatinib and gefitinib, are currently being used. The above evidence demonstrates that the current role of genomics in healthcare repre- sents the tip of the iceberg – genomics is already here, more is coming (the rest of the iceberg) and it will be a “game changer. Genomics technology will also not occur in isolation, but instead will converge with other innovative technol- ogies such as regenerative medicine, Web 2. Health service organizations and leaders will play a pivotal role in this regard, and can begin by strategizing and planning now for how they will incorporate genomics into healthcare delivery. Take a leadership initiative in genomic literacy by investing in genomic education for key staff. Attract the best people in genomics to raise the innovation bar for your organiza- tion and/or healthcare region. Prepare for the intensely ethical, legal and socio-economic impact of genomics on healthcare. Include genomics in chronic disease management and health and wellness strate- gies and discussions. Adopt sound privacy and security policies and controls (and build staff and consumer awareness of the privacy risks/threat) that can withstand the personal- ized nature of genomics data. He placed bioethics and health care policy within an innovative vision of the phi- losophy of medicine. He recognized that one cannot rightly appreciate the medical humanities, bioethics, the philosophy of medical law, and medical-moral theology unless one also understands the core of the phi- losophy of medicine: the internal morality and the telos of medicine. Pel- legrino’s work compasses important explorations of the healing relation- ship, medicine as a profession, the patient’s good, the role of autonomy, the place of money, and the importance of a virtue-based normative ethics for health care. His work is important in its own right and because of the infuence it has had and continues to have on the philosophy of medicine and bio- ethics. This collection integrates essays scattered among various journals spanning a period of over a quarter of a century. This Pellegrino Reader provides insight into the emergence of a feld, as well as analyses of issues, including the defnition of the philosophy of medi- cine, the role of humanism in medicine, and the place of a virtue ethics in medi cine. The essays explore the philosophy of medicine, the medical humani- ties, and bioethics. Pellegrino’s work has been dedicated to showing that bioethics cannot be understood out- side of the context of the medical humanities, and that the medical hu- manities cannot be understood outside of the context of the philosophy of medicine. Pellegrino correctly appreciates that bioethics should not be narrowly restricted to the usual fare of topics, ranging from abortion, third-party-assisted reproduction, physician-assisted suicide, and eutha- nasia, to genetic engineering, cloning, organ sales, and the allocation of medical resources. He appreciates that all of these issues are shaped by foundational views regarding the nature of the physician-patient relation- ship and the goals of medicine, all of which are the proper focus of the philosophy of medicine. Autonomy, benefcence, non-malefcence, justice, solidarity, property rights, and vulnerability are set within a conceptual and value scafolding that has structured medicine for millennia: medicine’s dedication to the good of the patient. Pellegrino takes seriously medicine as a practice that carries with it its own teleological commitments, internal morality, pre- suppositions regarding the nature and signifcance of the physician/ patient relationship, views concerning the nature of the virtuous physician, and the prerequisites for human fourishing. Because of the implicit role played by understandings of human fourishing, of what it is as a human to live properly and fully, the medical humanities are essential to locating and giving content to bioethics. That is, a particular bioethics presupposes a particular understanding of that which is truly human, the core notion of the humanities. One’s view of what is normatively human, of what con- stitutes the humanum, lies at the roots of culture and morality. Concerns with the humanities bring together an interest in that which is most truly © 2008 University of Notre Dame Press An Introduction human (i. Because this area of scholarship discloses the hidden con-1 tent and implicit presuppositions of bioethics, a bioethics is not under- standable apart from the medical humanities. The humanities disclose the implicit assumptions regarding human fourishing that supply the taken- for-granted content of the ethics at the roots of bioethics. Yet, the medical humanities themselves remain conceptually under- determined and lack a critical self-consciousness absent the philosophy of medicine connecting them to the internal morality of medicine. This is to recognize that philosophy is not just one among the humanities, but the cardinal element of the humanities.

While including these risk factors in risk stratification would improve risk prediction in most populations cheap 15mg mentax overnight delivery, the increased gain would not usually be large buy discount mentax 15mg, and does not warrant waiting to develop and validate further risk stratifica- tion tools. Nevertheless, these (and other) risk factors may be important for risk prediction, and some of them may be causal factors that should be managed. Clinicians should, as in any situa- tion, use their clinical acumen to examine the individual’s lifestyle, preferences and expectations, and use this information to tailor a management programme. The risk prediction charts and the accompanying recommendations can be used by health care professionals to match the intensity of risk factor management with the likelihood of cardio- vascular disease events. The charts can also be used to explain to patients the likely impact of interventions on their individual risk of developing cardiovascular disease. The use of charts will help health care professionals to focus their limited time on those who stand to benefit the most. It should be noted that the risk predictions are based on epidemiological data from groups of people, rather than on clinical practice. However, these objections do not detract from their potential to bring much-needed coher- ence to the clinical dilemmas of how to apply evidence from randomized trials in clinical practice, and of who to treat with a growing range of highly effective but costly interventions. Clinical assessment of cardiovascular risk Clinical assessment should be conducted with four aims: ● to search for all cardiovascular risk factors and clinical conditions that may influence prognosis and treatment; ● to determine the presence of target organ damage (heart, kidneys and retina); ● to identify those at high risk and in need of urgent intervention; ● to identify those who need special investigations or referral (e. Table 4 Causes, clinical features and laboratory tests for diagnosis of secondary hypertension Causes Clinical features and Investigations Renal parenchymal ◆ family history of renal disease (polycystic kidney), hypertension ◆ past history of renal disease, urinary tract infection, haematuria, analgesic abuse ◆ enlarged kidneys on physical examination ◆ abnormalities in urine analysis – protein, erythrocytes, leucocytes and casts ◆ raised serum creatinine Renovascular ◆ abdominal bruit hypertension ◆ abnormal renal function tests ◆ narrowing of renal arteries in renal arteriography Phaeochromocytoma ◆ episodic headache, sweating, anxiety, palpitations ◆ neurofibromatosis ◆ raised catecholamines, metanephrines in 24-hour urine samples Primary aldosteronism ◆ muscle weakness and tetany ◆ hypokalaemia ◆ decreased plasma renin activity and/or elevated plasma aldosterone level Cushing syndrome ◆ truncal obesity, rounded face, buffalo hump, thin skin, abdominal striae, etc. Physical examination A full physical examination is essential, and should include careful measurement of blood pres- sure, as described below. Measuring blood pressure Health care professionals need to be adequately trained to measure blood pressure. In addition, blood pressure measuring devices need to be validated, maintained and regularly calibrated to ensure that they are accurate (84). Two readings should be taken; if the average is 140/90 mmHg or more, an additional reading should be taken at the end of the consultation for confirmation. Blood pressure should be measured in both arms initially, and the arm with the higher reading used for future measurements. If the difference between the two arms is more than 20 mmHg for systolic pressure or 10 mmHg for diastolic pressure, the patient should be referred to the next level of care for examination for vascular stenosis. Patients with accelerated (malignant) hyperten- sion (blood pressure ≥ 180/110 mmHg with papilloedema or retinal haemorrhages) or suspected secondary hypertension should be referred to the next level immediately. Risk stratification is not necessary for making treatment decisions for these individuals as they belong to the high risk category; all of them need intensive lifestyle interventions and appropriate drug therapy (5). Each chart has been calculated from the mean of risk factors and the average ten-year event rates from countries of the specific subregion. They are useful as tools to help iden- tify those at high total cardiovascular risk, and to motivate patients, particularly to change behav- iour and, when appropriate, to take antihypertensive and lipid-lowering drugs and aspirin. An individual’s risk of experiencing a cardiovascular event in the next 10 years is estimated as follows: ● Select the appropriate chart (see Annex 3), depending on whether the person has diabetes or not. The mean of two non-fasting measurements of serum cholesterol by dry chemistry, or one non- fasting laboratory measurement, is sufficient for assessing risk. The strength of the various recommendations, and the level of evidence supporting them, are indicated as follows (13) in Table 5. High quality risk of confounding, bias or chance and a case control or cohort studies with a very significant risk that the relationship is not low risk of confounding or bias and a high causal probability that the relationship is causal 2+ Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal 2− Case control or cohort studies with a high risk of confounding or bias and a signifi- cant risk that the relationship is not causal 3 Non-analytical studies e. A body of evidence, including studies rated as 2++, is directly applicable to the target population and demonstrating overall consistency of results; or extrapolated evidence from studies rated as 1++ or 1+. A body of evidence, including studies rated as 2+, directly applicable to the target popu- lation and demonstrating overall consistency of results; or extrapolated evidence from studies rated as 2++. Low risk does nonfatal vascular nonfatal vascular fatal or nonfatal not mean “no” risk. Conservative Monitor risk profile Monitor risk profile Monitor risk profile management every 3–6 months every 3–6 months every 6–12 months focusing on lifestyle interventions is suggestedb. When resources are limited, individual counselling and provision of care may have to be prioritized according to cardiovascular risk. All smokers should be strongly encouraged to quit smoking by a health professional and supported in their efforts to do so. For individuals in low risk categories, they can have a health impact at lower cost, compared to individual counselling and therapeutic approaches. Total fat intake should be reduced to about 30% of calories, saturated fat intake should be limited to less than 10% of calories and trans-fatty acids eliminated. Most dietary fat should be polyunsaturated (up to 10% of calories) or monounsaturated (10–15% of calories).

They are present in the “diagnosis” and “treatment” sections in medical textbooks purchase 15mg mentax amex. As an example mentax 15mg amex, for the treatment of frostbite on the fingers, a surgical textbook says that operation should wait until the frostbitten part falls off, yet there are no studies backing up this claim. Treatment guidelines for glaucoma state that treatment should be initiated if the intraocular pressure is over 30 mmHg or over a value in the middle 20 mmHg range if the patient has two or more risk factors. It then gives a list of over 100 risk factors but gives no probability estimates of the increased rate of glaucoma attributable to any single risk factor. Clearly these are not evidence- based or particularly helpful to the individual practitioner. In the past, they have been used for good reasons such as hand washing before vaginal delivery to prevent childbed fever or puer- peral sepsis and for bad ones such as frontal lobotomies to treat schizophrenia. One recent example is breast-cancer screening with mammograms in women between 40 and 50 years old. This particular program can cost a billion dollars a year without saving very many lives and can irrationally shape physician and patient behavior for years. A physician in 1916 said “once a Caesarian section, always a Caesarian sec- tion,” meaning that if a woman required a Caesarian section for delivery, all subsequent deliveries should be by Caesarian section. It may have been valuable 85 years ago, but with modern obstetrical techniques it is less useful now. Many recent studies have cast doubts on the validity of this guideline, but a new study sug- gests that there is a slightly increased risk of uterine rupture and poor outcome for mother and baby if vaginal delivery is attempted in these women. Clearly the jury is still out on this one and it is up to the individual patient with her doctor’s input to make the best decision for her and her baby. This should be the best reason for their implementation and use in clinical practice. When evidence-based practice guidelines are written, reviewed, and based upon solid high-quality evidence, they should be implemented by all physicians. However, there are “darker” consequences that accompany the use of prac- tice guidelines. Cur- rently several specialty boards use chart-review processes as part of their spe- cialty recertification process. Performance criteria can be used as incentives in the determination of merit pay or bonuses, a process called Pay for Performance (P4P). In the last 30 years there has been an increase in the use of practice guide- lines in determining the proper utilization of hospital beds. Utilization review has resulted in the reduction of hospital stays, which occurred in most cases 322 Essential Evidence-Based Medicine Table 29. Desirable attributes of a clinical guideline (1) Accurate the methods used must be based on good-quality evidence (2) Accountable the readers (users) must be able to evaluate the guideline for themselves (3) Evaluable the readers must be able to evaluate the health and fiscal consequences of applying the guideline (4) Facilitate resolution of the sources of disagreement should be able to be conflict identified, addressed, and corrected (5) Facilitate application the guidelines must be able to be applied to the individual patient situation without any increase in mortality or morbidity. The process of utilization review is strongly supported by managed care organizations and third-party payors. The guidelines upon which these rules are based ought to be evidence-based (Table 29. Ideally a panel of interested physicians is assembled and collects the evidence for and against the use of a particular set of diagnostic or therapeutic maneuvers. Some guidelines are simply consensus- or expert-based and the results may not be consistent with the best available evidence. When evaluating a guideline it ought to be possible to determine the process by which the guideline was developed. These domains are: scope and purpose of the guideline, stakeholder involvement, rigor of development, clarity and presentation, applicability and editorial independence. This process only indirectly assesses the quality of the studies that make up the evidence used to create the guideline. There are several general issues that should be evaluated when appraising the validity of a practice guideline. They should be those outcomes that will matter to patients and all relevant outcomes should be included in the guideline. This must include explicit descriptions of the manner in which the evidence was col- lected, evaluated, and combined. The magnitudes of benefits and risks should be estimated and benefits com- pared to harms. This must include the interests of all parties involved in provid- ing care for the patient. These are the patient, health-care providers, third-party payors, and society at large. The preferences assigned to the outcomes should reflect those of the people or patients who will receive those outcomes.

On examination his blood pressure is normal generic 15 mg mentax fast delivery, pallor is absent and jugular venous pressure is not raised discount mentax 15mg fast delivery. Key: e Ref: Nephrotic Syndrome (Page 480) Davidson’s Principles and Practice of Medicine. A young girl comes in the cardiology ward with history of breathlessness and palpitations for last one year. After auscultation of precordium cardiology registrar makes diagnosis of mitral stenosis. The most important sign on which this diagnosis is based is: a) Ejection systolic murmur. Key: b Ref: Mitral Stenosis (Page 619) Davidson’s Principles and Practice of Medicine. Key: a Ref: Rheumatic Fever (Page 618) Davidson’s Principles and Practice of Medicine. An old lady presents with history of fever and left sided chest pain for one month. Examination of respiratory system shows decreased chest movements, stony dull percussion note and absent breath sounds on left side. Key: d Ref: Clinical Exam of Respiratory System (Page 649) Davidson’s Principles and Practice of Medicine. A forty year old woman gives history of fever for last three weeks accompanied by dry cough, night sweats and weight loss. Key: a Ref: Tuberculosis (Page 696) Davidson’s Principles and Practice of Medicine. A young girl complains of nocturnal cough and shortness of breath which disturbs her sleep. Key: c Ref: Bronchial Asthma (Page 673) Davidson’s Principles and Practice of Medicine. A fifteen year old girl presents with history of fever, bleeding from gums and pallor for last fifteen days. Key: a Ref: Acute Leukemia (Page 1040) Davidson’s Principles and Practice of Medicine. Which of the following drugs is used in the treatment of hyperkalemia in acute renal failure: a) Amiloride. Key: d Ref: Treatment of Hyperkalemia, Acute Renal Failure Davidson’s Principles and Practice of Medicine. For the patient with history of fever, headache and neck stiffness, the most important investigation is: a) Cerebrospinal fluid examination. Key: a Ref: Meningitis (Page 1224) Davidson’s Principles and Practice of Medicine. The most common risk factor for chronic obstructive pulmonary disease is: a) Air pollution. Key: e Ref: Chronic Obstructive, Pulmonary Disease (Page 678) Davidson’s Principles and Practice of Medicine. Key: a Ref: Cushing’s Syndrome (Page 779) Davidson’s Principles and Practice of Medicine. In a young boy with hypertension, examination of cardiovascular system reveals radio-femoral delay. The most likely cause of hypertension in this patient is: a) Coarctation of aorta. Key: a Ref: Coarctation of the Aorta (Page 637) Davidson’s Principles and Practice of Medicine. The gait of a patient with cog-wheel rigidity and pill rolling tremors is likely to be: a) Drunken. Key: e Ref: Parkinsonism (Page 1218) Davidson’s Principles and Practice of Medicine. An old patient presented in emergency ward with history of weakness of right side of body of rapid onset. The most helpful first line investigation for management of this patient is: a) Cerebral angiography. Key: c Ref: Cerebrovascular Disease (Page 1200) Davidson’s Principles and Practice of Medicine. In a patient of thalessemia peripheral blood film for red cell morphology shows: a) Hypochromic microcytic cells. Key: a Ref: Thalessemia (Page 1038) Davidson’s Principles and Practice of Medicine. Key: b Ref: Pyogenic Liver Abcess (Page 986) Davidson’s Principles and Practice of Medicine.