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The quality of the evidence also needs to be communicated in addition to a discussion of the risks and benefits of treatment purchase 8 mg zofran otc. For example generic 4 mg zofran amex, if the highest level of evidence found was an evidence-based review from a trusted source, the qual- ity of the evidence being communicated is higher and discussions can be done with more confidence. If there is only poor quality of evidence, such as would be available only from a case series, the provider will be less confident in the quality of the evidence and should convey more uncertainty. Pitfalls to providing the evidence The most common pitfall when providing evidence is giving the patient more information than she wants or needs although often the most noteworthy pit- falls are related to the misleading nature of words and numbers. The answer given to the patient is: “Usually headaches like yours are caused by stress. Only in extremely rare circumstances is a headache like yours caused by a brain tumor. In this example, expressing the common nature of stress headaches as “usually” can be very vague. When res- idents and interns in medicine and surgery were asked to quantify this term, they chose a range of percents between 50–95%. In this example stating that headaches due to a brain tumor occurred only in “extremely rare” circum- stances is also imprecise. When asked to quantify “extremely rare” residents and interns chose a range of percents between 1–10%. Knowing that the disease is rare or extremely rare may be consoling, but if there is a 1 to 10% chance that it is present, this may not be very satisfactory for the patient. It is clear that there is a great potential for misunderstanding when converting numbers to words. Unfortunately, using actual numbers to provide evidence is not necessarily clearer than words. For example in a study where the outcomes are reported in binary terms such as life or death, or heart attack or no heart attack, a physician can describe the results numerically as a relative risk reduction, an absolute risk reduction, a number needed to treat to benefit, length of survival or disease-free interval. When describing outcomes, results have the potential to sound quite different Communicating evidence to patients 205 to a patient. The following example describes the same outcome in different ways: r Relative risk reduction: This medication reduces heart attacks by 34% when compared to placebo. This also means that for every 71 patients treated, 70 get no additional benefit from taking the medication. When treatment benefits are described in relative terms such as a relative risk reduction, patients are more likely to think that the treatment is helpful. The description of outcomes in absolute terms such as absolute risk reduction, leads patients to perceive less benefit from the medications. This occurs because the relative changes sound bigger than absolute changes and are, therefore, more attractive. A patient’s ability to understand study results for diagnostic tests may be ham- pered by using percentages instead of frequencies to describe those outcomes. Gigerenzer has demonstrated that for most people, describing results as 2% instead of 1 in 50 will more likely be confusing (see the Bibliography). Using these “natural frequencies” to describe statistical results can make it much easier to understand fairly complex statistics. When describing a diagnostic test using nat- ural frequencies, give the sensitivity and specificity as the number who have dis- ease and will be detected (True Positive Rate) and the number who don’t have the disease and will be detected as having it (False Positive Rate). Then you can give the numbers who have the disease and a positive or negative test as a propor- tion of those with a positive or negative test. The concept of natural frequencies has been described in much more detail by Gerd Gigerenzer in his book about describing risk. Patients’ interpretations of study results are frequently affected by how the results of the study are presented, or framed. For example, if a study evaluated an outcome such as life or death, this can be presented in either a positive way by saying that 4 out of 5 patients lived or a negative way, that 1 out of 5 patients died. The use of positive or negative terms to describe study outcomes does influence a patient’s decision and is described as framing bias. They were asked to imagine they had lung cancer and to choose between surgery and radiation therapy. When the same results were presented first in terms of death and then in terms of life, about one quarter of the study subjects changed their mind about their preference. To avoid confusion associated with use of either percentages or framing biases, using comparisons can be helpful. For example, if a patient is considering whether to proceed with a mammogram, using a statement such as “The effect of yearly screening is about the same as driving 300 fewer miles per year” is helpful, if known. This puts the risk into per- spective with a common daily risk of living and helps the patient put it into per- spective.

Using the Recommended Dietary Allowance The Recommended Dietary Allowances are not useful in estimating the prevalence of inadequate intakes for groups discount 8 mg zofran otc. Human milk and formulas with the same nutrient composition as human milk (after adjustment for bioavailability) provide the appropriate levels of nutrients for full-term infants of healthy generic 4mg zofran with visa, well-nourished mothers. Groups of infants consuming formulas with lower levels of nutrients than that found in human milk may be at some risk of inadequacy, although the prevalence of inadequacy cannot be quantified. A distribution of usual intakes, including intakes from supplements, is required to assess the proportion of the popu- lation that might be at risk of over-consumption. If significant proportions of the population fall outside the range, concern could be heightened for possible adverse consequences. Appendix Table E-6 presents data on the usual daily intake of total fat as a percentage of energy intake and indi- cates that for all groups of children and adolescents, the 5th percentile of intake is at least 25 percent. Intakes at this level ensure that the risk to individuals of not meeting their requirements is very low (2 to 3 percent). Likewise, an infant formula with a nutrient profile similar to human milk (after adjustment for differences in bioavailability) should supply adequate nutrients for an infant. Using the Tolerable Upper Intake Level Tolerable Upper Intake Levels (Uls) were not set for the macronutrients covered in this report. The approach to planning for a low prevalence of inadequacy differs depending on whether or not the distributions of intake and requirements are normally distributed. Additional details are provided in the forth- coming Institute of Medicine report on dietary planning. For example, assume that the goal of planning was to target a 2 to 3 percent prevalence of inadequacy for a nutrient for which both require- ment and intake distributions were statistically normal. Preva- lence of inadequacy more or less than 2 to 3 percent could also be consid- ered. Finally, when it is known that requirements for a nutrient are not normally distributed and one wants to ensure a low group prevalence of inadequacy, it is necessary to examine both the intake and requirement distributions to determine a median intake at which the pro- portion of individuals with intakes below requirements is likely to be low. For example, a meal program for a university dormitory might be planned using the midpoint of the ranges for carbohydrate and fat (for adults, these would be 55 and 28 percent of energy, respectively). Using the univer- sity dormitory example, a dietary pattern might be planned in which the mean intake from fat was 30 percent of energy. Assessment conducted following implementation of the program might reveal that actual fat intakes of the students ranged from about 25 percent to about 35 percent of energy. In other words, the prevalence of intakes outside the acceptable range is low, despite a mean fat intake that is higher than the midpoint of the range. The approach to planning for energy, however, differs substantially from planning for other nutrients. There are adverse effects to individuals who consume energy above their requirements—over time, weight gain will occur. In all cases, however, the equations estimate the energy expen- diture associated with maintaining current body weight and activity level. They were not developed, for example, to lead to weight loss in overweight individuals. However, just as is the case with other nutrients, energy expen- ditures vary from one individual to another, even though their characteris- tics may be similar. Note that this does not imply that an indi- vidual would maintain energy balance at any intake within this range; it simply indicates how variable requirements could be among those with similar characteristics. Usual energy intakes are highly correlated with expenditure when con- sidered over periods of weeks or months. This means that most people who have access to enough food will, on average, consume amounts of energy very close to the amounts that they expend, and as a result, main- tain their weight over extended periods of time. Any changes in weight that do occur usually reflect small imbalances accumulated over a long period of time. In many situations, however, the usual energy intake of an indi- vidual is not known, and the estimated energy requirement equations are useful planning tools. When the goal is to maintain body weight in an individual with specified characteristics (age, height, weight, and activity level), an initial estimate for energy intake is provided by the equation for the energy expenditure of an individual with those characteristics. By definition, the estimate would be expected to underestimate the true energy expenditure 50 percent of the time and to overestimate it 50 percent of the time, leading to corresponding changes in body weight. This indicates that monitoring of body weight would be required when implementing intakes based on the equations that predict individual energy requirements. In some situa- tions the goal of planning might be to prevent weight loss in an individual with specified characteristics. This would lead to an intake that would be expected to exceed the actual energy expenditure of all but 2 to 3 percent of the individuals with similar characteristics. Using the above example for the 33-year-old, low-active woman, one would provide 2,028 + (2 × 160) kcal, or 2,348 kcal. This intake would prevent weight loss in almost all individuals with similar characteristics. Of course, this level of intake would lead to weight gain in most of these individuals. This would lead to an intake that would be expected to fall below the actual energy requirements of all but 2.

Polycythaemia tive pulmonary disease and alcohol or other sedatives (raised haemoglobin and packed cell volume) may occur which exacerbate the problem by causing hypotonia and in advanced cases quality zofran 4 mg. Apnoea can be divided into the following: Management 1 Central apnoea when there is depression of the respi- Non-pharmacological treatment includes weight loss buy 8 mg zofran, ratory drive, e. Snoring arises because of turbulent airflow around the 2 Surgicaltreatmentmaybedifficultaspatientsareoften soft palate with partial obstruction. Thereisareflex the redundant tissues in the soft palate and lateral increase in respiratory drive, which eventually rouses the pharynx is sometimes performed but its benefit in Chapter 3: Restrictive lung disorders 117 true obstructive sleep apnoea is unproven and it changes and the cysts seen in honeycomb lung. It has been reclassified as usual interstitial pneu- Radiation monia, a form of idiopathic interstitial pneumonia. Extrinsic allergic alveolitis Ankylosing spondylitis and other connective tissue diseases (scleroderma, rheumatoid arthritis, sys- Prevalence temic lupus erythematosus) Uncommon. Sarcoidosis, berylliosis (exposure to this industrial al- loy mimics sarcoidosis) Age Tuberculosis Usually late middle age. Cryptogenic fibrosing alveolitis (idiopathic pul- monary fibrosis) Sex Asbestosis Slightly M > F The other main groups of causes are the pneumoco- nioses, which are occupational lung diseases in response Aetiology to fibrogenic dusts such as coal and silicon, and drug- Unknown, but an indistinguishable disease is seen in induced, such as amiodarone. Pathophysiology Antinuclear factor is positive in one third of patients The lung has limited ability to regenerate following a se- and rheumatoid factor is positive in 50%. Fibrosis may be localised, bilateral of patients are current or former smokers, and smoking or widespread depending on the underlying cause. Patients are at an increased risk of secondary infection and even if the original insult is removed may develop progressive Pathophysiology fibrosis and subsequent respiratory failure. The alveo- There appear to be areas of fibroblast activation, which lar wall fibrosis greatly reduces the pulmonary capillary lay down matrix, and healing of these leads to fibrosis. It network, leading to the development of pulmonary hy- is not clear what causes the acute lung injury or the ab- pertension, right ventricular hypertrophy, with eventual normal healing process, but increased levels of cytokines right heart failure (cor pulmonale). They may present with secondary 118 Chapter 3: Respiratory system bacterial infection. Single-lung transplant and fine end-inspiratory crackles in the mid to lower has been shown to be viable, but most patients have lungs. Microscopy Prognosis Characteristically chronic fibrotic, scarred zones with Median survival of 5 years. Forty per cent die of progres- collapsed alveoli and honeycombing alternate with ar- sive respiratory failure, most of the others from acute in- eas of relatively unaffected lung. Newer injury, there are foci of activated fibroblasts with little anti-fibrotic and immunological therapies are being in- inflammation. Complications The disease is progressive and usually unresponsive to Extrinsic allergic alveolitis treatment, and patients develop respiratory failure, pul- Definition monaryhypertensionandcorpulmonale. Anacuteform An immune reaction within the lung to inhaled organic exists (Hamman–Rich syndrome or acute interstitial dusts. Disease Source Antigens r Lung biopsy is indicated if possible, usually trans- Farmer’s lung Mouldy Micropolyspora bronchial via bronchoscopy. Because of the patchy hay/vegetable faeni, nature of the disease, however, surgical lung biopsy material thermophilic of several sites may be needed. A trial of pred- and feathers nisolone 30 mg is indicated if the diagnosis is not well Malt worker’s Germinating Aspergillus established in case there is a responsive interstitial pneu- lung barley clavatus monitis. Azathioprine and ciclosporin have also been Humidifier fever Contaminated Various bacteria humidifiers and/or tried. On 2 High-dose prednisolone is used to cause regression of examination there may be tachypnoea and cyanosis, the early stages of the disease, later stages where there with widespread fine end-inspiratory crackles and is fibrosis are not amenable to treatment. Farmer’s lung is an occupational disease in the United Kingdom with sufferers being entitled to compensation. Definition An acute form of respiratory failure caused by diffuse Complications pulmonary infiltrates and alveolar damage occurring Diffuse fibrosis and formation of honeycomb lung in hours to days after a pulmonary or systemic insult. Investigations Incidence r Chest X-ray shows a diffuse haze initially, which de- Occurs in 20–40% of patients with severe sepsis. This is reversible initially, but becomes r Increasedvascularpermeabilityandepithelialdam- permanent with chronic disease. During this phase, there is alveolar collapse, lung Management compliance falls (i. Increased shunting and 2 Supportive treatment with following: r Ventilatory support – low volume, pressure-limited deadspace occurs (ventilation–perfusion mismatch) and hypoxaemia results. Prognosis Dependant on the underlying cause, mortality can be very high in patients with septic shock who develop Clinical features multi-organ failure. Increasing age and pre-existing dis- The first sign is tachypnoea, followed by hypoxia, wors- ease worsen the outcome.

Kaplan v vi Contents 17 Applicability and strength of evidence 187 18 Communicating evidence to patients 199 Laura J buy zofran 4mg otc. Henry Pohl buy 4 mg zofran, then Associate Dean for Aca- demic Affairs, asked me to develop a course to teach students how to become lifelong learners and how the health-care system works. The first syllabus was based on a course in critical appraisal of the medical literature intended for inter- nal medicine residents at Michigan State University. The basis for the orga- nization of the book lies in the concept of the educational prescription proposed by W. The goal of the text is to allow the reader, whether medical student, resident, allied health-care provider, or practicing physician, to become a critical con- sumer of the medical literature. This textbook will teach you to read between the lines in a research study and apply that information to your patients. For reasons I do not clearly understand, many physicians are “allergic” to mathematics. It seems that even the simplest mathematical calculations drive them to distraction. Although the math content in this book is on a pretty basic level, most daily interaction with patients involves some understanding of mathematical processes. We may want to determine how much better the patient sitting in our office will do with a particular drug, or how to interpret a patient’s concern about a new finding on their yearly physical. Far more commonly, we may need to interpret the information from the Internet that our patient brought in. The math is limited to simple arithmetic, and a handheld calculator is the only computing ix x Preface instrument that is needed. The layout of the book is an attempt to follow the process outlined in the edu- cational prescription. You will be given information about the answer after pressing “submit” if you get the question wrong. When you press “submit,” you will be shown the correct or suggested answer for that question and can proceed to the next question. After finishing, a sample of correct and acceptable answers will be shown for you to compare with your answers. Decisions are made by language and the language includes both words and numbers, but before evidence-based decision-making came along, relatively little consideration was given to the types of statement or proposi- tion being made. Hospital Boards and Chief Executives, managers and clinicians, made statements but it was never clear what type of statement they were mak- ing. Was it, for example, a proposition based on evidence, or was it a proposition based on experience, or a proposition based on values? All these different types of propositions are valid but to a different degree of validity. This language was hard-packed like Arctic ice, and the criteria of evidence- based decision-making smash into this hard-packed ice like an icebreaker with, on one side propositions based on evidence and, on another, propositions based on experience and values. As with icebreakers, the channel may close up when the icebreaker has moved through but usually it stays open long enough for a decision to be made. We use a simple arrows diagram to illustrate the different components of a decision, each of which is valid but has a different type of validity. Evidence-based decision-making is what it says on the tin – it is evidence-based – but it needs to take into account the needs and values of a particular patient, service or population, and this book describes very well how to do that. Foremost, I want to thank my wife, Julia Eddy, without whose insight this book would never have been written and revised. Her encourage- ment and suggestions at every stage during the development of the course, writ- ing the syllabi, and finally putting them into book form, were the vital link in creating this work. At the University of Vermont, she learned how statistics could be used to develop and evaluate research in psychology and how it should be taught as an applied science. She encouraged me to use the “scientific method approach” to teach medicine to my students, evaluating new research using applied statistics to improve the practice of medicine. This group of committed students and faculty has met monthly since 1993 to make constructive changes in the course. Their suggestions have been incorporated into the book, and this invaluable input has helped me develop it from a rudi- mentary and disconnected series of lectures and workshops to what I hope is a fully integrated educational text. I am indebted to the staff of the Office of Medical Education of the Department of Internal Medicine at the Michigan State University for the syllabus material that I purchased from them in 1993. I think they had a great idea on how to intro- duce the uninitiated to critical appraisal. I would especially like to thank the following faculty and students at Albany Medical College for their review of the manuscript: John Kaplan, Ph. Their edi- torial work over the past several years has helped me refine the ideas in this book. I would also like to thank Chase Echausier, Rachael Levet, and Brian Leneghan for their persistence in putting up with my foibles in the production of the manuscript, and my assistant, Line Callahan, for her Herculean effort in typing the manuscript.