By Z. Gamal. Pepperdine University. 2018.

For example generic lasix 100mg without prescription, some smokers quit smoking just prior to getting sick with lung cancer 100mg lasix for sale. While they may attribute their illness to quitting cheap lasix 40mg with mastercard, the illness was present long before they finally decided to quit proven lasix 40mg. In this case buy lasix 100mg with visa, the cancer may appear to be the cause and the cessation of smoking the effect. The causality may be difficult to determine in many cases, especially with slowly progressive and chronic diseases. Dose–response The dose–response gradient can help define cause and effect if there are varying concentrations of the cause and varying degrees of association with the effect. Usually, the association becomes stronger with increasing amounts of exposure Applicability and strength of evidence 195 to the cause. However, some cause-and-effect relationships show the opposite correlation, with increasing strength of association when exposure decreases. An example of this inverse relationship is the connection between vitamin intake and birth defects. As the consumption of folic acid increases in a population, the incidence of neural tube birth defects decreases. The direction and magnitude of the effect should also show a consistent dose–response gradient. This gradient can be demonstrated in randomized clinical trials and cohort studies but not in case–control or descriptive studies. In general, we would expect that an increased dose or duration of the cause would produce an increased risk or severity of the effect. The risk of lung cancer decreases among former smokers as the time from giving up smoking increases. In these cases, the risk is highest at both increased and decreased rates of exposure while it is lowest in the middle. For example, a recent study of the effect of obesity on mor- tality showed a higher mortality among patients with the highest and lowest body mass index with the lowest mortality among people with the mid-range levels of body mass index. Biological plausibility When trying to decide on applicability of study results, biological plausibility should be considered. The results of the study should be consistent with what we know about the biology of the body, cells, tissues, and organs, and with data from various branches of biological sciences. There should be some basic science in- vitro bench or animal studies to support the conclusions and previously known biologic mechanisms should be able to explain the results. Is there a reason in biology that men and women smokers will have different rates of lung cancer? For some medical issues, gender, ethnicity, or cultural background has a huge influence while for other medical issues the influence is very little. To determine which areas fall into each category, more studies of gender and other differences for medical interventions are required. Coherence of the evidence over time In order to have strong evidence, there should be consistency of the evidence over varying types of studies. The results of a cohort study should be similar to those of case–control or cross-sectional studies done on the same cause-and- effect relationship. Studies that show consistency with previously known epi- demiological data are said to evidence epidemiological consistency. Also, results should agree with previously discovered relationships between the presumed cause and effect in studies done on other populations around the world. An 196 Essential Evidence-Based Medicine association of high cholesterol with increased deaths due to myocardial infarc- tion was noted in several epidemiological studies in Scandinavian countries. Analogy Reasoning by analogy is one of the weakest criteria allowing generalization. Knowing that a certain vitamin deficiency predisposes women to deliver babies with certain birth defects will marginally strengthen the evidence that another vitamin or nutritional factor has a similar effect. When using analogy, the pro- posed cause-and-effect relationship is supported by findings from studies using the same methods but different variables. From this, one could infer that a potent anticoagulant like warfarin ought to have the same effect. However, warfarin may increase mortality because of the side effect of causing increased bleeding. Again, although it is suggested by an initial study, the proposed new intervention may not prove beneficial when studied alone. Common sense Finally, in order to consider applying a study result to a patient, the association should make sense and competing explanations associating risk and outcome should be ruled out.

Besides the physician buy 100mg lasix fast delivery, who obviously is at diagnosis seems to have been mostly a passive haphazard the center of the issue buy discount lasix 100mg line, many other entities potentially in- affair cheap lasix 40 mg without prescription. Every day and are healthcare organizations cheap 100 mg lasix with amex, which bear a clear responsi- in every country 100 mg lasix sale, patients are diagnosed with conditions bility for ensuring accurate and timely diagnosis. Further- ful, however, that physicians and their healthcare organiza- more, patients are subjected to tests they don’t need; alter- tions alone can succeed in addressing this problem. Despite our best intentions to make diag- the help of another key stakeholder—the patient, who is nosis accurate and timely, we don’t always succeed. Patients are Our medical profession needs to consider how we can in fact much more than that. Goals that funding agencies, patient safety organizations, over- should be set, performance should be monitored, and sight groups, and the media can play to assist in the overall progress expected. The authors in this supplement to The American these parties, based on our current—albeit incomplete and untested— understanding of diagnostic error (Table 1). Statement of Author Disclosure: Please see the Author Disclosures section at the end of this article. Healthcare leaders need to expand their concept of prove both the specificity and sensitivity of cancer detection 4 patient safety to include responsibility for diagnostic errors, more than an independent reading by a second radiologist. These resources have substantial poten- aspects of diagnostic error can to some extent be mitigated 5 tial to improve clinical decision making, and their impact by interventions at the system level. Leaders of healthcare will increase as they become more accessible, more sophis- organizations should consider these steps to help reduce ticated, and better integrated into the everyday process of diagnostic error. System-related Suggestions Have Appropriate Clinical Expertise Available When Ensure That Diagnostic Tests Are Done on a Timely It’s Needed. Don’t allow front-line clinicians to read and Basis and That Results Are Communicated to Providers interpret x-rays. Encourage inter- “Morbidity and Mortality (M & M) Rounds on the Web” personal communication among staff via telephone, e-mail, sponsored by the Agency for Healthcare Research and and instant messaging. Establish pathways for physicians who to communicate information verbally and electronically saw the patient earlier to learn that the diagnosis has across all sites of care. Ensure medical prevent, detect, and mollify many system-based as well as records are consistently available and reviewed. Strive to cognitive factors that detract from timely and accurate di- make diagnostic services available on weekend/night/holi- agnosis. Minimize distractions and production pressures help reduce the likelihood of error. For patients to act so that staff have enough time to think about what they are effectively in this capacity, however, requires that physi- doing. Minimize errors related to sleep deprivation by at- cians orient them appropriately and reformulate, to some tention to work hour limits, and allowing staff naps if extent, certain aspects of the traditional relationship be- needed. Two new roles for patients to help reduce the chances for diagnostic error are proposed below. Take advantage of sugges- tions from the human-factors literature on how to improve Be Watchdogs for Cognitive Errors the detection of abnormal results. For example, graphic Traditionally, physicians share their initial impressions with displays that show trends make it more likely that clinicians a new patient, but only to a limited extent. Sometimes the will detect abnormalities compared with single reports or tab- suspected diagnosis isn’t explicitly mentioned, and the pa- ulated lists; use of these tools could allow more timely appre- tient is simply told what tests to have done or what treat- ciation of such matters as falling hematocrits or progressively ment will be used. Computer-aided per- checking for cognitive errors if they were given more in- ception might help reduce diagnostic errors (e. Controlled tri- its probability, and instructions on what to expect if this is als have shown that use of a computer algorithm can im- correct. They should be told what to watch for in the Graber A Safer Future: Measures for Timely Accurate Medical Diagnosis S45 Table 1 Recommendations to reduce diagnostic errors in medicine: stakeholders and their roles Direct and Major Role Physicians ● Improve clinical reasoning skills and metacognition ● Practice reflectively and insist on feedback to improve calibration ● Use your team and consultants, but avoid groupthink ● Encourage second opinions ● Avoid system flaws that contribute to error ● Involve the patient and insist on follow-up ● Specialize ● Take advantage of decison-support resources Healthcare organizations ● Promote a culture of safety ● Address common system flaws that enable mistakes —Lost tests —Unavailable experts —Communication barriers —Weak coordination of care ● Provide cognitive aids and decision support resources ● Encourage consultation and second opinions ● Develop ways to allow effective and timely feedback Patients ● Be good historians, accurate record keepers, and good storytellers ● Ask what to expect and how to report deviations ● Ensure receipt of results of all important tests Indirect and Supplemental Role Oversight organizations ● Establish expectations for organizations to promote accurate and timely diagnosis ● Encourage organizations to promote and enhance —Feedback —Availability of expertise —Fail-safe communication of test results Medical media ● Ensure an adequate balance of articles and editorials directed at diagnostic error ● Promote a culture of safety and open discussion of errors and programs that aim to reduce error Funding agencies ● Ensure research portfolio is balanced to include studies on understanding and reducing diagnostic error Patient safety organizations ● Focus attention on diagnostic error ● Bring together stakeholders interested to reduce errors ● Ensure balanced attention to the issue in conferences and media releases Lay media ● Desensationalize medical errors ● Promote an atmosphere that allows dialogue and understanding ● Help educate patients on how to avoid diagnostic error upcoming days, weeks, and months, and when and how to nated, and all medical records would be available and ac- convey any discrepancies to the provider. Until then, the patient can play a valuable role in If there is no clear diagnosis, this too should be con- combating errors related to latent flaws in our healthcare veyed. Patients can and should function as confidence and certainty, but an honest disclosure of uncer- back-ups in this regard.

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The impact of new treatment technology in radiotherapy is discussed from the viewpoint of patient protection buy lasix 40 mg free shipping. Various new approaches have been proposed and some of them have demonstrated excellent outcomes in the treatment of cancer patients generic 40mg lasix mastercard. Thus trusted lasix 100mg, the introduction of new methods in radiotherapy can be achieved by joint efforts of technology and biology discount lasix 100mg overnight delivery. Considering the complicated properties of radiation and its biological effects cheap lasix 40 mg, collaborative efforts among experts with different professional skills are required for the development of new technology towards safe and secure treatment in cancer patients. Approaches to improving dose distribution in radiotherapy: (a) irradiation from multiple directions; (b) ion beam treatment; (c) brachytherapy; (d) molecular target radiotherapy. In order to provide the maximum benefit to the patient, each procedure must be optimized before the treatment. Protection from accidental exposure Appropriate dose delivery to the target tumour is the most important issue. Not only overexposure but also inappropriate or insufficient dose delivery to the target tumour could cause serious harm to the patient. New technologies have led to substantial improvements to radiotherapy, which is often achieved by complex procedures. There is an increased risk of human error and mistakes in equipment adjustment [2]. Education, sufficient knowledge and training of personnel involved in the treatment procedure are essential for patient protection. Treatment planning and irradiation Imaging technology plays a crucial role for precise localization of the target volume in radiotherapy. High precision radiotherapy is based on the assumption that the tumour boundary can be determined precisely. For this purpose, accurate diagnosis for the precise localization of a tumour is essential, and even a subtle error in diagnosis or misalignment of the tumour boundary could cause substantial harm to the patient. Accurate dose delivery to the target tumour is based on the calculation of physical dose and the estimation of biological effects [3]. For high precision radiotherapy, the patient’s position is important and is verified with orthogonal X ray radiographs in comparison with digital radiographs reconstructed from planning computed tomography images. Immobilization of the patient during the treatment is essential and care should be taken that the patient is comfortable. Respiratory gating is often used to minimize the movement effects of doses in tumours and surrounding organs. Verification of dose delivery to the target volume should be based on experiment before or after treatment. Direct evidence of actual dose to each patient can be obtained only in ion beam treatment with protons or carbon ions, 15 11 where nucleus reactions produce positron decayed nuclei such as O and C. However, significant washout of these radionuclides interferes with accurate estimation [6]. A more challenging approach is to observe the immediate molecular response of radiotherapy during or just after the treatment [7]. The combination of molecular imaging and the unique idea of new scanners provides exciting potential of integration of diagnosis and radiotherapy. Late effects after the treatment The worldwide spread of high precision radiotherapy has led to increased opportunity to treat a variety of cancers. The therapeutic outcome has improved for locally advanced cancers that were not curable with conventional methods. Many of these patients now survive for longer periods and, thus, more attention must be paid to radiation effects from a long term perspective [8]. In the past, radiation oncologists focused mainly on curing cancers with little consideration for secondary cancer. Recently, the situation has been changing; while high precision photon radiotherapy methods are superior to conventional radiotherapy in the dose distribution delivered to the tumour, a large volume of surrounding normal tissues may be exposed to low levels of dose. Ion beam radiotherapy with protons or carbon ions further contributes to localizing the dose to the tumour, and the extra dose received in surrounding normal tissues is further reduced. The increasing use of radiation in young patients requires evidence of age dependent biological effects of radiation [10]. Late deterministic effects after radiotherapy, such as retardation of growth, hormonal deficiencies, organ dysfunctions, and intellectual and cognitive functions are more severe in children than in adults. It should also be noted that children have distinctly different organ susceptibility from adults [12].

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Your Own Perfect Medicine After several unsuccessful surgeries for endometriosis buy 40 mg lasix otc, I was told that I would need more surgery 100mg lasix visa. After my doctor told me that he was scheduling another operation for me purchase lasix 40mg overnight delivery, I canceled the surgery and flew to Mexico to get an alternative treatment for cancer patients that I was told also had possibilities for treating my case order 100mg lasix free shipping. The man in the bed next to mine had a cancerous brain tumor the size of a large grapefruit bulging from his head generic 40mg lasix otc. One of his eyes, nearly eaten away by the cancer, was now just a mass of bloody, unrecognizable tissue. These were hopeless, desperate people, many of them only in their twenties and thirties – but what could they do? It has been reported that: "Nearly two-thirds of all cancer patients will eventually die of their diagnosed cancer, either before or after the arbitrary five-year limit. She told me that in desperation she had gotten into her car and driven 156 from her home in the Midwest to Mexico in hopes of finding some help. She asked me if I knew of any place that she could buy laetrile — she thought that perhaps she could treat herself with it, but I was unable to help her. The bleak look of hopeless despair on her face was horrifying, and I would have loved to have been able to hand her a book on urine thera- 1 py — it was something she could have used herself, for free, in her own home, that undoubtedly would have given her control over her health and, at the very least, an excellent fighting chance. After all, she had everything to gain and nothing to lose by using this safe, proven natural therapy. It is instructive as showing once again that operations merely deal with effects and do not remove the cause of the disease from the body. The lady in question was 45, and had a growth of some size in her left breast, the right one having been removed two years previously for a similar growth. She fasted and was treated according to my method for nineteen days, and then reported that the growth had entirely vanished. Cancer is a frightening disease, but with the assiduous and wise use of natural healing methods such as urine therapy, proper nutrition, herbs, rest, homeopathic remedies, etc. Before you resort to any conventional cancer treatment, go to your local library and research your case by reading material related to different treatment options. After surgery for colon cancer, she called me and said that her oncologist 158 wanted her to take a follow-up course of chemotherapy, "just in case", even though the surgery had taken out all existing non-metastasized tumors. I told her what I had read about the extreme side effects, dangers and inadequacy of chemo, but under pressure from her oncologist, she took the "treatment". Unfortunately, she had a severe allergic reaction to the chemicals, nearly died and spent several totally unnecessary and horribly painful weeks in the hospital recovering from the extremely harmful effects of the chemotherapy, some of which were irreversible. Many doctors themselves are acutely aware of the futility and danger of the conventional cancer treatments: "In 1955, the late Dr. Hardin Jones, professor of medical physics at the University of California, after studying cancer statistics for the previous thirty- three years, concluded that untreated cancer victims lived up to four times longer than treated individuals. Jones pointed out that the cure rates most often cited by doctors were (and continue to be) based only on the conventional treatment of the most favorable cases. She had emergency surgery, and, to her consternation, her oncologist recommended radiation therapy as a follow-up: "To regain some control of her life, Guthrie went straight to the University of Arkansas medical school library in Little Rock. In the end, Guthrie ignored her oncologist and through her research, found a doctor at the M. Anderson Cancer Center in Houston who successfully helped her condition without radiation. Uric acid, which was mentioned previously, has also been discovered to destroy free radicals which are thought to contribute to the development of cancer. Its nutritional benefits alone are phenomenal, not to mention the immense value of its innumerable other health-promoting, therapeutic agents. In 1975, it was reported that urine studies are done on all urology patients at the Mayo Clinic to help detect cancer: "Cancer cells from early-stage urinary system tumors appear in the urine, which allows for detection of such new tumors before they are readily perceived by other diagnostic methods. Your Own Perfect Medicine Cells of urine sediment have been used in the same way that vaginal smears have been used to gain information on ovarian functioning. As a matter of fact, it was reported in 1971 that urine testing was actually shown to detect more cases of abnormal cell activity than the usual cervical Pap smear. Urine testing for urinary tract malignancies is a safe, easy procedure which can replace or supplement other forms of cancer detection. The idea of drinking urine for medicinal purposes certainly takes some getting used to, but consider the facts about urine. While under treatment, patients reported an absence of viral diseases (flu, colds, etc.

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