By D. Jaffar. Cleveland State University. 2018.

Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www purchase atrovent 20mcg otc. However effective atrovent 20 mcg, there is relatively poor awareness about these infections among health-care providers order 20mcg atrovent visa, social-service providers discount 20 mcg atrovent with amex, and the general public. Lack of aware- ness about the prevalence of chronic viral hepatitis in the United States and about the proper methods and target populations for screening and medical management of chronic hepatitis B and hepatitis C probably contributes to continuing transmission; missing of opportunities for prevention, including vaccination; missing of opportunities for early diagnosis and medical care; and poor health outcomes in infected people. The prevalence of chronic infections remains high for several reasons, and the aging of the chronically infected population has contributed to the tripling of liver-cancer incidence during the last three decades (Altekruse et al. The frst addresses knowledge and awareness about hepatitis B and hepatitis C in health-care providers Copyright © National Academy of Sciences. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Each section begins by describing what is known about the levels of knowledge and awareness about hepatitis B and hepatitis C and how gaps in education about these diseases are affecting prevention, screening and testing, and treatment op- portunities. Those summaries are followed by the committee’s recommen- dations for addressing the gaps and the rationale and supportive evidence for the recommendations. Although there have been no large-scale, controlled studies of health-care providers’ knowledge about chronic hepatitis B and hepatitis C, it is clear that knowledge has been imperfect among providers in all the surveys whose results have been published. Subjects of defcient knowledge include • The prevalence of chronic hepatitis B and hepatitis C in the general and high-risk populations in the United States. However, current studies of provider knowledge about chronic viral hepatitis have not identifed why health-care providers fail to follow national recommended guidelines. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. However, 83% of the respondents were interested in receiving education about chronic viral hepatitis. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. State screening laws do not necessarily translate into higher testing rates, because they often do not include an enforcement mechanism or sanctions for noncompliance (Euler et al. In a study of family physicians in New Jersey, a state with a maternal screening law, Ferrante et al. At the 2009 International Symposium on Viral Hepatitis and Liver Disease, Chao et al. Hepatitis C Health-care providers’ knowledge about hepatitis C appears to be similarly insuffcient, although there is far less published research on this topic (Ascione et al. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. One-fourth incorrectly indicated that blood transfusion continues to be a risk factor, and 19% erroneously be- lieved that casual household contact is a major risk factor. A previous study by the same researchers had also found substantial gaps in primary care providers’ knowledge about hepatitis C (Shehab et al. The gaps persisted even though 95% of the respondents in the 2001 study reported having used at least one educational tool about hepatitis C in the preceding 2 years; this suggests that primary care providers misreport their Copyright © National Academy of Sciences. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Recommendation Many providers are not aware of the high prevalence of chronic hepa- titis B and hepatitis C in some populations. On the basis of the evidence described above, the committee concludes that insuffcient provider knowledge leads to critical missed opportunities for providers to educate patients about prevention of hepatitis B and hepa- Copyright © National Academy of Sciences. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. To address that issue, the committee offers the following recommendation: Recommendation 3-1.

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The infection starts in Urinary schistosomiasis occurs in Africa cheap 20 mcg atrovent otc, the Middle the lower genital tract either as a sexually transmitted East generic 20mcg atrovent amex, Spain buy discount atrovent 20mcg on line, Portugal cheap atrovent 20mcg fast delivery, Greece and the Indian Ocean, par- infection or as a urinary tract infection. Clinical features Pathophysiology Patients present with a greatly enlarged and very tender The eggs of S. Complications include hydronephrosis and 270 Chapter 6: Genitourinary system On examination the swelling is confined to one side Age and the swelling is hot and very tender. Microscopy Sex Thereisextensiveinfiltrationoftheseminiferoustubules M > F (4:1) and interstitium with neutrophils, initial oedema is con- siderable and there is often patchy haemorrhage. Aetiology Risk factors include: dehydration, urinary tract infec- Complications tions, disorders of calcium handling (hypercalcaemia, Infertility is an important complication. Pathophysiology Stone formation usually occurs because compounds of Management low solubility are present in the urine in high concentra- Treatment is with antibiotics, bed rest and scrotal sup- tions. In young adults, erythromycin (to cover Chlamy- such as magnesium, citrate and organic inhibitors such dia)isprobably best, whereas in older individuals or as glycoseaminoglycans and nephrocalcin. Stones commonly contain calcium oxalate (80%) but Urinary stones about half of these also contain hydroxyapatite. Incidence/prevalence The pain is characteristically in sharp, intense waves over Affects about 10% of the population at some time in abackground pain, occurring in the loin, radiating to their lives. Resorptive (primary increased skeletal resorption) Hypercalcaemia Less commonly Oxalate ↑ urinary oxalate levels Uric acid Hyperuricosuria ↑↑ uric acid stones ↑ calcium oxalate stones Cystine Cystinuria Autosomal recessively inherited condition Chapter 6: Urinary stones 271 vomit. Stones within calyces on passing urine, inability to pass urine or the sensation cannot be broken up this way. Subsequent management If the stone obstructs a single functioning kidney, To reduce the risk of recurrence, all patients should be postrenal acute renal failure results. Calcium oxalate stones may also be given to increase urine levels of citrate lookspiky,calciumphosphatestonesareoftensmooth which inhibits calcium stone formation. Uric acid stones are radiolucent and r Oxalate is found in tea, chocolate, nuts, strawberries, cystine stones only slightly radio-opaque. This should be avoided if there is carbonate to alkalinise the urine, or d-penicillamine. Strain all urine to try Despite preventative strategies recurrence rates are as to catch the stone so that it can be analysed. Some recom- Aurinary stone which fills the calyces and pelvis of a mend anti-spasmodic drugs. Ensure adequate fluid in- kidney, these are usually associated with infection and take. Aetiology/pathophysiology Surgical techniques are needed if the stone does not Stag horn calculi are struvite stones (i. It may be necessary to relieve obstruction urgently, vite and calcium carbonate-apatite). Obstruction can be teus or Klebsiella causes increased amounts of ammonia, relieved by retrograde stent insertion (usually requires due to the presence of urease (which breaks down urea general anaesthetic), or percutaneous nephrostomy in- into ammonia and carbon dioxide). Characteristically the patient presents with an acutely tender swollen testis of sudden onset, there may be a Clinical features history of minor trauma or recent vigorous exercise. Later,pain,haema- Nausea and vomiting are common associated symp- turia and impaired renal function. There may be history of previous self-resolving episodes of pain, particularly at night in young boys Investigations (can be associated with nocturnal sexual arousal that As for urinary stones. If <10% renal function the kid- veals a red hemiscrotum, with an asymmetrically high, ney should be removed. If there is >25% function in a swollen testis (pulled up by the shortened, twisted sper- younger patient many would probably try to preserve matic cord). The cremasteric response is absent in tor- sion (stroking or pinching the inside of the thigh should Management cause the ipsilateral testis to rise), but this response is not Open surgery, or very slow gradual breaking up of reliable below the age of 30 months or over 12 years. Nephrectomy is advised for a can be difficult to distinguish particularly as the testis symptomatic stag horn calculus in a poorly functioning can also swell in this condition.

The evidence that underpins the use of risk factor scoring and management comes from a range of sources atrovent 20mcg on-line. There is now increasing evidence that cardiovascular risk factors are associated with clinical 10 Prevention of cardiovascular disease events in a similar way in a wide range of countries (31) purchase atrovent 20 mcg visa. There is also strong epidemiological evidence that combining risk factors into scores is capable of predicting an individual’s total cardiovascular risk with reasonable accuracy buy discount atrovent 20mcg on-line. Finally generic atrovent 20mcg overnight delivery, there is strong evidence from clinical trials that reducing the levels of risk factors has beneficial effects. Risk factor scoring and management have now been widely taken up in cardiovascular prevention guidelines in most high-income countries (36, 41, 43, 44). The risk factors included in current scoring systems are drawn from those used in the original Framingham score. There is currently debate about the inclusion of newer risk factors, such as C-reactive protein, fibrinogen, and waist–hip ratio (49). It is possible that, as more epidemiologi- cal data become available for low- and middle-income countries, a new generation of risk scoring systems may emerge that have greater predictive accuracy. Older age and male sex are powerful determinants of risk; consequently, it has been argued that the use of the risk stratification approach will favour treatment of elderly people and men, at the expense of younger people with several risk factors and women. However, while younger people gain more life years if they have a non-fatal event, older people are a lot more likely to die from an event. When discounting is taken into consideration, the quality adjusted life years gained by preventing events in young people are very similar to those gained in old people (Table 3) (50). Concern about the metabolic syndrome, characterized by central obesity, elevated blood pressure, dyslipidaemia, and insulin resistance (51, 52), has raised the question of whether identifying people with this syndrome should be a priority. There is, as yet, insufficient evidence to justify using metabolic syndrome as an additional risk prediction tool (63, 64). People with metabolic syndrome would, in any case, benefit from weight reduction, higher levels of activity (65–71), lowering of blood pressure, avoidance of drugs that tend to cause hyperglycaemia (72–75), lowering of choles- terol with a statin (76–80), and reduction of hyperglycaemia with metformin. There is insufficient evidence from randomized trials to support more specific management of dyslipidaemias (81). In summary, the great strength of the risk scoring approach is that it provides a rational means of making decisions about intervening in a targeted way, thereby making best use of resources available to reduce cardiovascular risk. Alternative approaches focused on single risk factors, or concepts such as pre-hypertension or pre-diabetes, have been popular in the past, often because they represented the interests of specific groups in the medical profession and professional societ- ies. Such an approach, however, leads to a very large segment of the population being labelled as high risk, most of them incorrectly. If health care resources were allocated to such false-positive individuals, a large number of truly high-risk individuals would remain without medical attention. Risk scoring moves the focus of treatment from the management of individual risk factors to the best means of reducing an individual’s overall risk of disease. It enables the intensity of interven- tions to be matched to the degree of total risk (Figure 2). Further research is required to validate existing subregional risk prediction charts for individual populations at national and local levels, and to confirm that the use of risk stratification methods in low- and middle-income countries results in benefits for both patients and the health care system. These charts are intended to allow the introduction of the total risk stratification approach for management of cardiovascular disease, particularly where cohort data and resources are not readily available for development of population-specific charts. The charts have been generated from the best available data, using a modelling approach (Annex 5), with age, sex, smoking, blood pressure, blood cholesterol, and presence of diabetes as clinical entry points for overall manage- ment of cardiovascular risk. Some studies have suggested that diabetic patients have a high cardiovascular risk, similar to that of patients with established cardiovascular disease, and so do not need to be risk-assessed. In addition, in people with diabetes, there is no gender difference in the risk of coronary heart disease and stroke (82). Therefore, separate charts have been developed for assessment of cardiovascular risk in patients with type 2 diabetes. In many low-resource settings, there are no facilities for cholesterol assay, although it is often feasible to check urine sugar as a surrogate measure for diabetes. Annex 4 therefore contains risk prediction charts that do not use cholesterol, but only age, sex, smoking, systolic blood pressure, and presence or absence of diabetes to predict cardiovascular risk. Obesity, abdominal obesity (high waist–hip ratio), physical inactivity, low socioeconomic position, and a family history of premature cardiovascular disease (cardiovascular disease in a first-degree relative before the age of 55 years for men and 65 years for women) can all modify cardiovascular risk.

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In 1999 purchase 20 mcg atrovent overnight delivery, one of the nation’s largest health plans cheap 20mcg atrovent with visa, United HealthGroup order atrovent 20mcg overnight delivery, abandoned case-by-case prior authorization for all but a handful of extremely costly services because it discovered that this practice was actually costing them more to do it than it saved 20mcg atrovent amex. This decision garnered tremendous positive publicity for United and for health plans generally, because it eliminated a major irritant in the relationship with both doctors and consumers. The Internet will streamline and make much more transparent this key part of health plan operations—its supervision over medical care itself. As it migrates onto the Internet, medical management (that is, determining if the care a physician proposes is covered and 124 Digital Medicine appropriate) will become essentially invisible and instantaneous, embedded directly in electronic claims management. Medical management will thus become an “exception review” process, as the flow of claims will be automatically monitored to identify physician or hospital practices that are inappropriate. Only a small number of very expensive procedures or services will require prior review by the health plan. The fundamental message of the managed care backlash to the health plans is that consumers and physicians would not tolerate the continued intrusion of a finan- cially motivated third party in their relationship. The fact that health plans worked for employers made it im- possible to answer succinctly the question, who is the health plan’s customer? Under “total replacement” coverage, the reality was that the consumer was often not a customer of the health plan at all, but rather its prisoner. Prisoners were referred to in actuarial jargon as “lives” and measured by the thousands. The inability to answer clearly the question of who is the cus- tomer is often fatal to businesses. Technologies that people believe are being used by corporate enterprises to further their own eco- nomic interests almost inevitably become targets of political reac- tion. The reaction of consumers against genetically modified foods, which benefited farmers and agribusiness conglomerates, but not obviously the consumer herself, is a classic example. The problem of defining the consumer’s role also afflicted the health policy proposals on which the Clinton administration gambled Health Plans 125 its presidency. Ellwood’s Jackson Hole, Wyoming, condominium), pro- moted managed care–based reform. The “hole” in the Jackson Hole Group’s so-called “Consumer Choice Health Plan” was the role of the consumer. Most of the tinkering with tax policy and insurance regulation in the Jackson Hole proposals was aimed at compelling consumers to shop for health coverage with their grocery money. Consumers who wished more lavish coverage than a basic, standard benefit package would have been required to use their own money. After selecting the health plan, according to the Jackson Hole proposal, consumers became little lambs, to be shep- herded through the complexities of healthcare by “their” managed care plan. It was up to the managed care plan selected “voluntarily” by the consumer to decide what healthcare was appropriate and who should provide it, and we would all just say “baaaaaah” and go along. Hindsight is always 20/20, but it seems breathtakingly naive in retrospect that health policymakers could assume that consumers (read “baby boom women in charge of their family’s health”) would surrender to shadowy medical directorates with a financial agenda the final say in decisions about what care they or their families needed, let alone who should provide it. Under their version of managed care, Jackson Hole policy advo- cates assumed that medical decisions would ultimately be made by local physician groups themselves, not medical bureaucrats in some glass-fronted corporate office tower in Connecticut. The Jackson Holers did not foresee that the vast majority of growth in man- aged care would be gained through very broad networks where the health plans retained the ultimate decision-making authority about medical necessity for themselves, and continued paying doctors on a (discounted) fee basis. As a result, many consumers got the worst of both worlds: no choice of health plan and corporate medicine managed (cen- 126 Digital Medicine trally and badly) by health plans overwhelmed by rapid enrollment growth. Deprived of a voice in selecting their health plan by total replacement coverage, consumers roared in the press and the polit- ical arena and helped catalyze a flood of state and federal consumer protection legislation. As it does, it will become clear that the real customer of the health plan is, and always was, the family, and its designated representative, the “woman in charge of her family’s health. Information technology, particularly Internet technology, can provide health plans multiple opportunities to create value for their real customers. These opportunities include the following: • Helping consumers minimize the risk of poor-quality care • Delivering disease-management content to high-risk patients • Promoting informed choice through medical decision support software • Offering consumers “do it yourself” network-development tools • Creating customer service portals accessible through the web Helping Consumers Minimize Risk Most consumers are unaware that they may have as much as a fivefold variation in their risk of dying after a surgical procedure, depending on which surgical team or hospital they use or which community they get care in. Consumers naively assume that their physicians will refer them to the safest specialist or hospital.

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