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Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www cheap renagel 800 mg without prescription. The services should include testing to detect infection generic renagel 400 mg with visa, counseling to reduce alcohol use and secondary transmission, hepatitis B vaccina- tion, and referral for or provision of medical management. Programs should include education about safe drug use (avoiding the shared use of implements to administer drugs by smoking or inhalation) and reduction in sex-related risks, and all participants in the programs should be offered the hepatitis B vaccine. Innovative, effective, multicomponent hepatitis C virus prevention strategies for injection-drug users and non-injection- drug users should be developed and evaluated to achieve greater con- trol of hepatitis C virus transmission. In particular, • Hepatitis C prevention programs for persons who smoke or sniff heroin, cocaine, and other drugs should be developed and tested. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. The programs are administered by state and local public-health departments and vary in reach and intensity. As mentioned in Chapter 2, many programs simply provide surveillance, and others provide comprehensive case management that even includes client home visits by local coordinators. Perinatal hepatitis B programs identify twice as many household and sexual contacts per infant as was reported to the national database, with high rates of programmatic compliance in households of foreign-born people (Euler et al. This gap has a two-fold effect in that chronically infected women do not receive the appropriate medical management and referral and perinatal transmission continues to occur. Those women require followup services to ensure that they are knowledgeable about risks posed by their chronic infection and that they receive appropriate referral for long-term medical management. Cases among household contacts are not uncommon when this risk group is pur- sued aggressively for testing. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Hepatitis B services for foreign-born pregnant women are in need of improved resources that are more culturally and linguistically appropriate. The coordinators are restricted in their ability to fulfll that responsibility in culturally relevant ways, because of inadequate training and resources (Chao et al. The Centers for Disease Control and Prevention should provide additional resources and guidance to perinatal hepa- titis B prevention program coordinators to expand and enhance the capacity to identify chronically infected pregnant women and provide case-management services, including referral for appropriate medical management. Preventing Perinatal Transmission Practice guidelines and additional recommendations focused on vac- cination to prevent perinatal transmission are detailed in Chapter 4. However, the study was small, and large randomized, Copyright © National Academy of Sciences. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. The National Institutes of Health should sup- port a study of the effectiveness and safety of peripartum antiviral therapy to reduce and possibly eliminate perinatal hepatitis B virus transmission from women at high risk for perinatal transmission. Correctional facilities present a unique opportunity to bring viral hepatitis services to at-risk populations. The period of incarceration is opportune for education about hepatitis B and hepatitis C (see Chapter 3). Jails are operated by county and local jurisdictions and house people who have been arrested and are awaiting trial, people who have been convicted of misdemeanor crimes, and people who have been convicted of felony crimes with short- term sentences (usually less than one year). They house people who have been convicted of felony crimes with sentences generally of one year or longer. The high prevalence in this population is not pri- marily a result of incarceration but rather indicative of people who engage in risky behavior and were in risky settings before incarceration. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Correctional systems are constitutionally required to provide necessary health care to inmates that is consistent with the community standard of care. Al- though screening, testing, and treatment could impose an economic burden (Spaulding et al. Texas and Michigan inmate vaccination uptake rates have been reportedly been 60–80% (Vallabhaneni et al. Such prevention interventions save society money because they reduce postincarceration morbidity and mortality (Pisu et al. To capitalize on inmate readiness to participate in hepatitis prevention and control activities, correctional systems and public-health departments need to collaborate to provide targeted testing, appropriate standard-of- care medical management during incarceration, and followup medical ser- vices after release into the community. Health departments and correctional facilities do not always exchange health information, and it can be diffcult to track prisoners once they are released. State registries for hepatitis B and hepatitis C cases are needed so that incarcerated persons with these diseases can be quickly identifed and properly managed once returned into local commu- nities.

If there is the slightest hint that something pleasurable may do harm generic renagel 800mg with mastercard, such evidence is immediately accepted buy renagel 800 mg line, inflated and disseminated. If, however, the same pleasurable activity is shown to be beneficial in any respect, such evidence must be suppressed, ridiculed, or dis- missed. The idea that alcoholism is a disease and alcohol its aetiological agent is again gaining ground. What the medical model misses com- pletely is the question of why some people eat more (or drink more) than is good for them. The medical model simply medicalises problems of living, of which drinking too much is a symptom. The most eloquent refutation of the concept of alcoholism 180 as a disease is provided by Thomas Szasz. While excessive drinking may cause disease, it does not follow that drinking itself is a disease. There is no doubt that pleasures carry risks, but it is equally true that where there is no risk there is no fun. At a meeting sponsored by the Committee of Smoking and Health of the Medical Society of the District of Columbia, an ethicist explained that smoking was inherently immoral since it violated at least three fundamental moral principles. Smoking is a complex behaviour, with little understood neurophysiological and psychological mechanisms. A smoker of 20 cigarettes a day for 50 years will smoke 365,000 ciga- rettes, which, if laid end to end, would stretch 30 kilometres. Assuming an average of 15 puffs per cigarette, the smoker inhales five million puffs. With the alleged 5,000 poisonous substances in smoke, he receives 25 billion doses. What is surprising is that many smokers survive this chronic poisoning relatively unscathed. The awesome intensity of the war against tobacco in all its forms cannot be accounted for simply by referring to certain epidemiological reports which have shown that smokers are more likely to die of lung cancer than of some other diseases. They pose new questions about the relationship between the state and the individual, about the right to privacy and about the legislation of morality. Where is the boundary between information and propaganda, between education and coercion? In 1988, according to a count in the British Medical Jour- nal, Australian newspapers alone carried 1,600 items about 185 smoking, of which 83 per cent disseminated fear. The British Health Education Authority raised objections to films which depicted smokers, even though most of them were portrayed as villains. Health educators regularly complain to news- papers which feature photographs of smokers. Einstein with a pipe will not do: the pipe should be skilfully retouched from the photograph so that young readers will not be cor- rupted. They used to do this with the images of Trotsky in historical photographs from the Soviet Union. The continuous barrage of anti-smoking propaganda uses the promise of better health as its ostensible aim. The cam- paign, however, has gradually degenerated into a single-issue fanaticism. As the majority of smokers now belong to low- income groups, the anti-smoking crusade of the new ruling class, who control media and education, has encountered little resistance among the middle classes, even when its rhet- oric changes from coercive altruism to plain abuse. The shift from medical aspects of smoking to moral exhortation only became possible when smoking declined among the middle classes (the upper classes have generally kept aloof and amused) and was further facilitated by the rise of neopuritanism. Samuel Butler in The Way of All Flesh commented on the absence of any Biblical injunction against smoking: It had not yet been discovered [but] it was possible that God knew Paul would have forbidden smoking, and had purposely arranged the discovery of tobacco for a period at which Paul should no longer be living. According to The Guardian a Harley Street doctor regret- ted warning a chain-smoking Saddam Hussein about the dan- gers of smoking: T honestly believe that without my advice Saddam would have died years ago. A debate periodically flares up in medical journals as to whether smokers should receive the same medical care as non-smokers, especially if they fail to give up their detestable habit. Geoffrey Wheatcroft recalled in The Daily Telegraph that when the historian Sir Raymond Carr had broken his arm while hunting, the attending surgeon confessed that if he had had any moral or legal choice he 122 Lifestylism would have left it untreated, since he hated hunting so 190 much. As doctors still do not refuse treatment to injured drunken drivers or terrorists, why are they so keen to defend discriminatory policies against smokers? The President of the Royal College of Physicians has suggested that smokers and drinkers should be required to contribute towards the cost of their treatment but in fact they have already done so more 191 than adequately through paying tobacco and alcohol tax. In October 1993, a consultant gynaecologist at Billinge Hospital, Wigan, cancelled a fertility operation on a 22-year- old woman when he was told that she smoked 15 cigarettes a day. According to the Sunday Express the mother was lectured by the doctor and told that he would not treat the child until 198 she gave up smoking.

Competing-hypotheses heuristic A way of thinking in which all possible hypotheses are evaluated for their likelihood and final decision is based on the most likely hypothesis modified by secondary evaluations renagel 400 mg on-line. Confidence intervals An interval around an observed parameter guaranteed to include the true value to some level of confidence (usually 95%) cheap renagel 800mg with visa. Continuous test results A test resulting in an infinite number of possible outcome values. Control group The subjects in an experiment who do not receive the treatment procedure being studied. Controlled clinical trial Any study that compares two groups for exposure to different therapies or risk factors. A true experiment in which one group is given the experimental intervention and the other group is a control group. Cost-effectiveness (or cost–benefit) analysis Research study which determines how much more has to be paid in order to achieve a given benefit of preventing death, disability days, or another outcome. Criterion-based validity How well a measurement agrees with other approaches for measuring the same characteristic. Critical value Value of a test statistic to which the observed value is compared to determine statistical significance. The observed test statistic indicates significant differences or associations exist if its value is greater than the critical value. Decision analysis Systematic way in which the components of decision making can be incorporated to make the best possible clinical decision using a mathematical model. Decision node A point on a branching decision tree at which the clinician must make a decision to either perform a clinical maneuver (diagnosis or management) or not. Degrees of freedom (df) A number used to select the appropriate critical value of a statistic from a table of critical values. Dependent variable The outcome variable that is influenced by changes in the independent variable of a study. Descriptive research Study which summarizes, tabulates, or organizes a set of measures (i. Descriptive statistics The branch of statistics that summarizes, tabulates, and organizes data for the purpose of describing observations or measurements. Diagnostic test characteristics Those qualities of a diagnostic test that are important to understand how valuable it would be in a clinical setting. Diagnostic tests Modalities which can be used to increase the accuracy of a clinical assessment by helping to narrow the list of possible diseases that a patient can have. Dichotomous outcome Any outcome measure for which there are only two possibilities, like dead/alive, admitted/discharged, graduated/sent to glue factory. Beware of potentially fake dichotomous outcome reports such as “improved/not improved”, particularly when derived from continuous outcome measures. For example, if I define a 10-point or greater increase in a continuous variable as “improved,” I may show what looks like a tremendous benefit when that result is clinically insignificant. Differential diagnosis A list of possible diseases that your patient can have in descending order of clinical probability. Effect size The amount of change measured in a given variable as a result of the experiment. In meta-analyses when different studies have measured somewhat different things, a statistically derived generic size of the combined result. Effectiveness How well the proposed intervention works in a clinical trial to produce a desired and measurable effect in a well-done clinical trial. Event rate The percentage of events of interest in one or the other of the groups in an experiment. The value of each arm of the decision tree or the entire decision tree (sum of P × U). Experimental group(s) The subjects in an experiment who receive the treatment procedure or manipulation that is being proposed to improve health or treat illness. Explanatory research – experimental Study in which the independent variable (usually a treatment) is changed by the researcher who then observes the effect of this change on the dependent variable (usually an outcome). Explanatory research – observational Study looking for possible causes of disease (dependent variable) based upon exposure to one or more risk factors (independent variable) in the population. A drug, a surgical procedure, risk factor, even a diagnostic test can be an exposure. In therapy, prognosis, or harm studies the “exposure” is the intervention being studied. Framing effect How a question is worded (or framed) will influence the answer to the question. Functional status An outcome which describes the ability of a person to interact in society and carry on with their daily living activities (e. Gold standard The reference standard for evaluation of a measurement or diagnostic test.

The probability of each outcome (P)comes from clinical research studies of patient populations buy renagel 400mg without a prescription. Ideally discount renagel 400 mg on line, they will have the same or similar characteristics as the patient or population that is being treated. These can also come from systematic reviews of many clinical studies or meta- analyses. They are usually not exact, but are only a best approximation, and ought to come with 95% confidence intervals attached. A utility of 1 is assigned to a perfect outcome, usually meaning a complete cure or perfect health. A utility of 0 is usually thought of as a totally unacceptable outcome, usually reserved for death. The quality of life resulting from each intermediate outcome will be less than expected with a total cure but more than death. This outcome state may be wholly or partially unbearable due to treatment side effects or adverse effects of the illness. As research into the development of patient values has continued, it is clear that there are many outcomes that are valued as less than zero. A recent example was a study that requested patients to determine their values in stroke care. A decision tree illustrating treatment options can then be constructed, as seen from the following clinical example. Consider a patient who is a 60-year-old man with sudden onset of weakness of the right arm and leg associated with inability to speak. A stroke is suspected and the physician wants to try this new form of treatment to dissolve the suspected clot in the artery supplying the left parietal area of the brain. For purposes of the exercise we will greatly simplify this process and assume that there are only three possible outcomes. Thrombolytic therapy can result in one of two out- comes, either a cure with complete resolution of the symptoms or death from intracranial hemorrhage, bleeding into the substance of the brain. Traditional medical therapy will result in some improvement in the clinical symptoms in all patients but leave all of them with some residual deficit. Outcome probabilities are obtained from studies of populations of patients with similarities for both the stroke and risk factors for bleeding. The probability of death from thrombolyic therapy is Pd, for complete cure it is Pc, which is equal to 1 – Pd, and for partial improvement with medical therapy in this example only, the probability is 1. The utility of com- plete cure is 1, death is 0, and the unknown residual chronic disability is Ux. These values are obtained from studies of patient attitudes toward each of the outcomes in question and will be discussed in more detail shortly. Mechanics of constructing a decision tree There are three components to any decision tree. A decision node is the point where the clinician or patient must choose between two or more possible options. A probability node is the point where one of two or more possible outcomes can occur by chance. A stationary node is the point where the patient starts, their initial presentation, or finishes, their ultimate outcome. In this sim- plified decision tree for stroke, one arm represents thrombolytic therapy and the other represents standard medical therapy. The thrombolytic therapy arm has a probability node and then two other arms come from that. In the simplified stroke-therapy example calculate the expected values in each arm of the tree by multiplying the utility and probability and summing their val- ues around each node. Therefore, for thrombolytic therapy the expected value E will equal 1(1 – Pd) + 0(Pd). For standard medical therapy, since the utility of chronic residual disability is Ux and since all patients have this intermediate outcome, the expected value E is Ux. The patient should always prefer the strat- egy that leads to the highest expected value. In this example, the patient would always choose standard medical treatment for stroke if the expected value for this arm is 100%, which will occur if Ux = 1 and if there is a measurable death rate for treating with thrombolytic therapy, making the expected value of the throm- bolytic arm 100% – Pd. Final Utility Outcome E = Expected value for each arm of the tree Probabilities E (thrombolytics) = (1 − Pd) × 1+ (Pd × 0) E (medicine) = 1 × Ux Fig. However, the value of a lifetime of chronic neurological disability is not 100%, and lets assume for this example that it is 0. This means that living with chronic neurological disability is somehow equated with living 90% of a normal life. Recalculating the expected value of each arm will determine what probability of death from thrombolytics would result in wanting to choose thrombolytics over medical therapy. For example, if the experience of getting thrombolytics were unpleasant, that may lead to a utility reduction of 0. For the thrombolytic-therapy arm, the clot can be dissolved successfully, there can be residual deficit, or the patient may have an intracranial bleed resulting in death, or have partial improvement but be left with a residual deficit.