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General information on this matter is as follows: i) Late course registration and addition are only allowed in the first to the third week with the approval of the Dean extra super levitra 100mg cheap. For this purpose purchase extra super levitra 100 mg otc, students must meet the requirements set by the University as follows:- (i) Dropping Course Form must be completed by the student and signed by the lecturer of the course involved and the Dean/Deputy Dean of their respective Schools and submitted to the general office of the School/Centre which is responsible for offering the courses involved order extra super levitra pills in toronto. Lecturers have the right not to certify the course that the student wishes to drop if the student is not serious, such as poor attendance record at lectures, tutorials and practical, as well as poor performance in course work. Students are advised to always check all the information displayed on this website. Normally, confirmation from 79 Academic Advisors will be made known to every student during the first semester in the first year of their studies. Academic Advisors will advice the students under their responsibility on academic-related matters. Among the important advice for the student is the registration planning for certain courses in each semester during the study period. Before registering the course, students are advised to consult and discuss with their Academic Advisor to determine the courses to be registered in a semester. Final year students are advised to consult their respective academic advisors before registering via E-Daftar to ensure they fulfil the graduation requirements. The unit is determined by the scope of its syllabus and the workload for the students. In general, a unit is defined as follows:- Type of Course Definition of Unit Theory 1 unit is equivalent to 1 contact hour per week for 13 – 14 weeks in one semester. To graduate, students must accumulate the total number of credits stipulated for the programme concerned. Students are required to settle all due fees and fulfil the standing requirements for lectures/tutorials/practical and other requirements before being allowed to sit for the examination of courses they have registered for. Course evaluation will be based on the two components of coursework and final examinations. Coursework evaluation includes tests, essays, projects, assignments and participation in tutorials. Students will also be barred from sitting for the final examination if they have not settled the academic fees. However, this opportunity is only given to students who are taking courses that they have attempted before and achieved a grade as stipulated above, provided that the course is being offered. The results will be released and announced after the University Examination Council meeting and is usually two weeks after the provisional results are released. However if the School would like to approve only one course at the diploma level for unit exemption of one course at degree level, the course at diploma level must be equivalent to the degree course and have the same or more units. If a student has undergone industrial training during the period of diploma level study, the student must have work experience for at least one year. The students are also required to produce a report on the level and type of work performed. The form must be approved by the Dean of the School prior to submission to the Examination & Graduation Section for consideration and approval. Courses that can be transferred are only courses that have the same number of units or more. For equivalent courses but with less number of units, credit transfers can be approved by combining a few courses. The most essential values in academia are rooted in the principles of truth- seeking in knowledge and honesty including one’s own rights and intellectual property. Thus, students must bear the responsibility of maintaining these principles in all work done in their academic endeavours. The following are examples of practices or actions that are considered dishonest acts in academic pursuit. There are numerous ways and methods of cheating and they include:  Copying from others during a test or an examination. Tampering with marks /grades after the work has been returned, then re-submitting them for re-marking/re-grading. Plagiarism means to produce, present or copy others’ work without authorization and acknowledgment as the primary source in the form of articles, opinions, thesis, books, unpublished works, research data, conference and seminar papers, reports, paper work, website data, lecture notes, design, creative products, scientific products, music, music node, artefacts, computer source codes, ideas, recorded conversations and others materials. In short, it is the use, in part or whole, of others’ words or ideas and then claiming them as yours without proper attribution to the original author. It includes:  Copying and pasting information, graphics or media from the Internet into your work without citing the source. The non-acknowledgment of an invention or findings of an assignment or academic work, alteration, falsification or misleading use of data, information or citation in any academic work constitute fabrication. Some examples of collusion include:  Paying, bribing or allowing someone else to do an assignment, test/examination, project or research for self-interest. Examples of unfair advantage are:  Gaining access to reproduce or circulate test or examination materials prior to its authorised time. If under any circumstances a student comes to know of any incident that denotes a violation of academic integrity, the student must report it to the relevant lecturer. The lecturer is then responsible for investigating and verifying the violation and then reporting the matter to the Dean of the School. If the investigation reveals that a violation has been committed, the student will be referred to the University Student Disciplinary Committee (Academic Cases). This programme manages psychosocial issues in a more effective manner and finally could improve the well-being of individuals in order to achieve life of better quality. Ideally, students are encouraged to participate in the exchange programme within their third to fifth semester (3 year degree programme) and within the third to seventh semester (4 year degree programme). However, as a condition for the conferment of a degree the student gives this right unconditionally, directly but not exclusively, and free of royalties to the university to use the contents of the work/thesis for teaching, research and promotion purposes. In addition, the student gives non-exclusive rights to the University to keep, use, reproduce, display and distribute copies of the original thesis with the rights to publish for future research and the archives. Students from the School of Medical Sciences and School of Dentistry are required to register for two (2) units of Co- Curriculum course in year Two. Students from the School of Health Sciences are required to register for one (1) unit of Co-Curriculum course. Students may obtain advice from the School of Languages, Literacies and Translation if they have different Bahasa Malaysia qualifications from the above. International students in this category are required to take and pass three Intensive Malay Language courses before they commence their Bachelor’s degree programmes. Note: • Students are required to accumulate four (4) units of English for graduation. They can also take foreign language courses to replace their English language units but they must first obtain written consent from the Dean of the School of Languages, Literacies and Translation. With academic exposure to cultural issues and civilization in Malaysia, it is hoped that students will be more aware of issues that can contribute to the cultivation of the culture of respect and harmony among the plural society of Malaysia.

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Blaser cheap extra super levitra 100 mg otc, New York University Langone Medical Center x Wylie Burke 100 mg extra super levitra visa, University of Washington x Christopher G discount extra super levitra 100 mg free shipping. Chute, University of Minnesota and Mayo Clinic x Sean Eddy, Howard Hughes Medical Institute Janelia Farm Research x Elaine Jaffe, National Cancer Institute x Brian J. Schwartz, University of Washington Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of the report was overseen by Dennis Ausiello, Harvard Medical School, Massachusetts General Hospital and Partners Healthcare and Queta Bond, Burroughs Welcome Fund. Appointed by the National Research Council, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of the report rests entirely with the authoring committee and the institution. We are grateful to those who attended and participated in the workshop “Toward a New st nd Taxonomy of Disease,” held March 1 and 2 , 2011 (Appendix D) and those who discussed data sharing with the Committee during the course of this study. Kelly, Head of Informatics and Strategic Alignment, Aetna x Debra Lappin, President, Council for American Medical Innovation x Jason Lieb, Professor, Department of Biology, University of North Carolina at Chapel Hill x Klaus Lindpaintner, Vice President of R&D, Strategic Diagnostics Inc. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease Summary The Committee’s charge was to explore the feasibility and need for “a New Taxonomy of human disease based on molecular biology” and to develop a potential framework for creating one. Clearly, the motivation for this study is the explosion of molecular data on humans, particularly those associated with individual patients, and the sense that there are large, as-yet- untapped opportunities to use these data to improve health outcomes. The Committee agreed with this perspective and, indeed, came to see the challenge of developing a New Taxonomy of Disease as just one element, albeit an important one, in a truly historic set of health-related challenges and opportunities associated with the rise of data-intensive biology and rapidly expanding knowledge of the mechanisms of fundamental biological processes. Hence, many of the implications of the Committee’s findings and recommendations ramify far beyond the science of disease classification and have substantial implications for nearly all stakeholders in the vast enterprise of biomedical research and patient care. Given the scope of the Committee’s deliberations, it is appropriate to start this report by tracing the logical thread that unifies the Committee’s major findings and recommendations and connects them to its statement of task. The Committee’s charge highlights the importance of taxonomy in medicine and the potential opportunities to use molecular data to improve disease taxonomy and, thereby, health outcomes. Taxonomy is the practice and science of classification, typically considered in the context of biology (e. The Committee envisions these data repositories as essential infrastructure, necessary both for creating the New Taxonomy and, more broadly, for integrating basic biological knowledge with medical histories and health outcomes of individual patients. The Committee believes that building this infrastructure—the Information Commons and Knowledge Network—is a grand challenge that, if met, would both modernize the ways in which biomedical research is conducted and, over time, lead to dramatically improved patient care (see Figure S-1). Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease ʹ Figure S-1: Creation of a New Taxonomy first requires an “Information Commons” in which data on large populations of patients become broadly available for research use and a “Knowledge Network” that adds value to these data by highlighting their interconnectedness and integrating them with evolving knowledge of fundamental biological processes. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease ͵ The Committee envisions this ambitious program, which would play out on a time scale of decades rather than years, as proceeding through a blend of top-down and bottom-up activity. A major top-down component, initiated by public and private agencies that fund and regulate biomedical research, would be required to insure that results of individual projects could be combined to create a broadly useful and accessible Information Commons and to establish guidelines for handling the innumerable social, ethical, and legal issues that will arise as data on individual patients become widely shared research resources. However, as is appropriate for a framework study, the Committee did not attempt to design the Information Commons, the Knowledge Network, or the New Taxonomy itself and would discourage funding agencies from over-specifying these entities in advance of initial efforts to create them. What is needed, in the Committee’s view, is a creative period of bottom-up research activity, organized through pilot projects of increasing scope and scale, from which the Committee is confident best practices would emerge. Particularly given the size and diversity of the health-care enterprise, no one approach to gathering the data that will populate the Information Commons is likely to be appropriate for all contributors. As in any initiative of this complexity, what will be needed is the right level of coordination and encouragement of the many players who will need to cooperate to create the Information Commons and Knowledge Network and thereby develop a New Taxonomy. If coordination is too rigid, much-needed innovation and adaptation to local circumstances will be stifled, while if it is too lax, it will be impossible to integrate the data that are gathered into a whole whose value greatly exceeds that of the sum of its parts, an objective the Committee believes is achievable with effective central leadership. Conclusions The Committee hosted a two day workshop that convened diverse experts in both basic and clinical disease biology to address the feasibility, need, scope, impact, and consequences of creating a “New Taxonomy of human diseases based on molecular biology”. The information and opinions conveyed at the workshop informed and influenced an intensive series of Committee deliberations (in person and by teleconference) over a 6 month period, which led to the following conclusions: 1. Because new information and concepts from biomedical research cannot be optimally incorporated into the disease taxonomy of today, opportunities to define diseases more precisely and to inform health care decisions are being missed. Many disease subtypes with distinct molecular causes are still classified as one disease and, conversely, multiple different diseases share a common molecular cause. The failure to incorporate optimally new biological insights results in delayed adoption of new practice guidelines and wasteful health care expenditures for treatments that are only effective in specific subgroups. Dramatic advances in molecular biology have enabled rapid, comprehensive and cost efficient analysis of clinical samples, resulting in an explosion of disease-relevant data with the potential to dramatically alter disease classification. Fundamental discovery research is defining at the molecular level the processes that define and drive physiology. These developments, coupled with parallel advances in information technologies and electronic medical records, provide a transformative opportunity to create a new system to classify disease. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease 4 3. A New Taxonomy that integrates multi-parameter molecular data with clinical data, environmental data, and health outcomes in a dynamic, iterative fashion, is feasible and should be developed. The Committee envisions a comprehensive disease taxonomy that brings the biomedical-research, public-health, and health-care-delivery communities together around the related goals of advancing our understanding of disease pathogenesis and improving health. Such a New Taxonomy would x Describe and define diseases based on their intrinsic biology in addition to traditional physical “signs and symptoms. The informational infrastructure required to create a New Taxonomy with the characteristics described above overlaps with that required to modernize many other facets of biomedical research and patient care. This infrastructure requires an “Information Commons” in which data on large populations of patients become broadly available for research use and a “Knowledge Network” that adds value to these data by highlighting their interconnectedness and integrating them with evolving knowledge of fundamental biological processes. New models for population-based research will enable development of the Knowledge Network and New Taxonomy. Current population-based studies of disease are relatively inefficient and can generate conclusions that are not relevant to broader populations. Widespread incorporation of electronic medical records into the health-care system will make it possible to conduct such research at “point-of-care” in conjunction with the routine delivery of medical services. Moreover, only if the linked phenotypic data is acquired in the ordinary course of clinical care is it likely to be economically feasible to characterize a sufficient number of patients and ultimately to create a self-sustaining system (i. Redirection of resources could facilitate development of the Knowledge Network of Disease. The initiative to develop a New Taxonomy—and its underlying Information Commons and Knowledge Network—is a needed modernization of current approaches to integrating molecular, environmental, and phenotypic data, not an “add-on” to existing research programs. Enormous efforts are already underway to achieve many of the goals of this report. In the Committee’s view, what is missing is a system-wide emphasis on shifting the large-scale acquisition of molecular data to point-of-care settings and the coordination required to insure that the products of the research will coalesce into an Information Commons and Knowledge Network from which a New Taxonomy (and many other benefits) can be derived. In view of this conclusion, the Committee makes no recommendations about the resource requirements of the new-taxonomy initiative.

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Maintenance Protein Needs Even when mammals consume no protein extra super levitra 100mg free shipping, nitrogen continues to be lost extra super levitra 100mg with mastercard. Provided that the energy intake is adequate order 100mg extra super levitra visa, these “basal” losses are closely related to body weight and basal metabolic rate (Castaneda et al. In man, normal growth is very slow and the dietary requirement to support growth is small in relation to maintenance needs except at very young ages. It follows that maintenance needs are of particular impor- tance to humans and account for a very large majority of lifetime needs for dietary protein. It has been known for decades (Said and Hegsted, 1970) that the body’s capacity to conserve individual amino acids at low intakes varies, so the pattern of amino acids needed in the diet to match their individual catabolic rates does not correspond precisely with the composition of body protein. This implies that there is very effective recycling of indispensable amino acids released continuously from protein degradation back into protein synthesis. Under conditions where the diet is devoid of protein, the efficiency of amino acid recycling is over 90 percent for both indis- pensable and dispensable amino acids (Neale and Waterlow, 1974). While highly efficient, some amino acids are recycled at different rates than others. Physiology of Absorption, Metabolism, and Excretion Protein Digestion and Absorption After ingestion, proteins are denatured by the acid in the stomach, where they are also cleaved into smaller peptides by the enzyme pepsin, which is activated by the increase in stomach acidity that occurs on feed- ing. The proteins and peptides then pass into the small intestine, where the peptide bonds are hydrolyzed by a variety of enzymes. These bond- specific enzymes originate in the pancreas and include trypsin, chymotrypsins, elastase, and carboxypeptidases. The resultant mixture of free amino acids and small peptides is then transported into the mucosal cells by a number of carrier systems for specific amino acids and for di- and tri-peptides, each specific for a limited range of peptide substrates. After intracellular hydrolysis of the absorbed peptides, the free amino acids are then secreted into the portal blood by other specific carrier systems in the mucosal cell or are further metabolized within the cell itself. Absorbed amino acids pass into the liver, where a portion of the amino acids are taken up and used; the remainder pass through into the systemic circulation and are utilized by the peripheral tissues. Thus, a significant portion (at least 50 percent) of fecal nitrogen losses represents the fixation by the colonic and cecal bacteria of nitrogenous substances (urea, ammonia, and protein secretions) that have been secreted into the intestinal lumen. Some authors have argued that the host-colon nitrogen cycle, by which nitrogenous compounds that diffuse into the gut are converted to ammonia by the microflora and are reabsorbed, is a regulated function and serves as a mechanism of nitrogen conservation (Jackson, 1989). The theoretical basis of this proposition has been partly confirmed by the recent demon- stration of the availability to the host of indispensable amino acids synthe- sized by intestinal microbes (Metges et al. However, not all investigators have obtained results indicative of regulated nitrogen cycling (Raguso et al. Although it seems clear that the efficiency of dietary protein digestion (in the sense of removal of amino acids from the small intestinal lumen) is high, there is now good evidence to show that nutritionally significant quantities of indispensable amino acids are metabolized by the tissues of the splanchnic bed, including the mucosal cells of the intestine (Fuller and Reeds, 1998). Thus, less than 100 percent of the amino acids removed from the intestinal lumen appear in the peripheral circulation, and the quantities that are metabolized by the splanchnic bed vary among the amino acids, with intestinal threonine metabolism being particularly high (Stoll et al. Currently, there is a lack of systematic information about the relationship between dietary amino acid intake and splanchnic metabolism, although there are indications that there is a nonlinear rela- tionship between amino acid intake and appearance in the peripheral blood (van der Schoor et al. Intestinal Protein Losses Protein secretion into the intestine continues even under conditions of protein-free feeding, and fecal nitrogen losses (i. Under this dietary circumstance, the amino acids secreted into the intestine as components of proteolytic enzymes and from sloughed mucosal cells are the only sources of amino acids for the maintenance of the intestinal bacterial biomass. In those studies in which highly digestible protein-containing diets have been given to individuals previously ingesting protein-free diets, fecal nitrogen excre- tion increased by only a small amount. The following points support the view that the intestinal route of protein (amino acid) loss is of quantitative significance to maintenance protein needs. First, continued mucosal cell turnover and enzyme and mucin secretion are necessary for maintaining the integrity of the gastrointestinal tract and its normal digestive physiology. Second, animal studies show that the amino acid composition of the proteins leaving the ileum for bacterial fermenta- tion in the colon is quite different from that of body protein (Taverner et al. In particular, the secretions are relatively rich in dispensable amino acids as well as threonine and cysteine (Dekker et al. These two amino acids are of significance in meeting amino acid needs when intake is close to the requirement (Laidlaw and Kopple, 1987). Other routes of loss of intact amino acids are via the urine and through skin and hair loss. These losses are small by comparison with those described above, but nonetheless may have a significant impact on esti- mates of requirements, especially in disease states (Matthews, 1999). From a nutritional and metabolic point of view, it is important to recognize that protein synthesis is a continuing process that takes place in most cells of the body. In a steady state, when neither net growth nor protein loss is occurring, protein synthesis is balanced by an equal amount of protein degradation. Protein Degradation The mechanism of intracellular protein degradation, by which pro- tein is hydrolyzed to free amino acids, is more complex and is not as well characterized at the mechanistic level as that of synthesis (Kirschner, 1999). A wide variety of different enzymes that are capable of splitting peptide bonds are present in cells. However, the bulk of cellular proteolysis seems to be shared between two multienzyme systems: the lysosomal and proteasomal systems. The lysosome is a membrane-enclosed vesicle inside the cell that contains a variety of proteolytic enzymes and operates mostly at acid pH. Volumes of the cytoplasm are engulfed (autophagy) and are then subjected to the action of the protease enzymes at high concentra- tion. This system is thought to be relatively unselective in most cases, although it can also degrade specific intracellular proteins (Cuervo and Dice, 1998). The system is highly regulated by hormones such as insulin and glucocorticoids, and by amino acids (Inubushi et al. The first step is to join molecules of ubiquitin, a basic 76-amino acid peptide, to lysine residues in the target protein. Several enzymes are involved in this process, which selectively targets proteins for degradation by a second component, the proteasome. This is a very large complex of proteins, possessing a range of different proteolytic activities. The ubiquitin-proteasome system is highly selective, so can account for the wide range of degradation rates (half-lives ranging from minutes to days) observed for different proteins. It is thought to be particularly responsible for degrading abnormal or damaged proteins, along with regulatory proteins that typically are synthesized and degraded very rapidly (Ciechanover et al. Protein Turnover The process by which all body proteins are being continuously broken down and resynthesized is known as protein turnover. In the adult human body, upward of 250 g/d of protein is synthesized and degraded (Waterlow, 1984). This compares with a median daily adult intake of about 55 to 100 g/d (Appendix Table E-16). Thus the liver and intestine, despite their rather small contribution to the total protein content of the body, are together believed to contribute as much as 50 percent of whole body protein turnover (McNurlan and Garlick, 1980; Waterlow, 1984). Con- versely, skeletal muscle is the largest single component of body protein mass (43 percent), but contributes only about 25 percent to total body protein turnover (Reeds and Garlick, 1984; Waterlow, 1984).

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When you press “submit order 100 mg extra super levitra,” you will be shown the correct or suggested answer for that question and can proceed to the next question discount 100mg extra super levitra otc. After finishing proven 100 mg extra super levitra, 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. I owe a great debt to the staff at the Cambridge University Press for having the faith to publish this book. Specifi- cally, I want to thank Senior Commissioning Editor for Medicine, Peter Silver, for starting the process, and Richard Marley and Katie James for continuing with the Second Edition. Of course, I am very thankful to my original copy-editor, Hugh Brazier, whose expertise and talent made the process of editing the book actually pleasant. Finally, the First Edition of the book was dedicated to my children: Memphis, Gilah, and Noah. To that list, I want to add my grandchildren: Meira, Chaim, Eliana, Ayelet, Rina, and Talia. George Santayana (1863–1952) Learning objectives In this chapter, you will learn: r a brief history of medicine and statistics r the background to the development of modern evidence-based medicine r how to put evidence-based medicine into perspective Introduction The American health-care system is among the best in the world. Are our citizens who have adequate access to health care getting the best possible care? These questions can be answered by the medical research that is published in the medical literature. When you become an effective and efficient reader of the medical literature, you will be able to answer these questions. This chapter will give you a historical perspective for learning how to find and use the best evidence in the practice of medicine. This is the beginning of a process designed to make you a more effective reader of the medical research literature. The ill person was seen as having a spiritual failing or being possessed by demons. Medicine practiced during this period and for centuries onward focused on removing these demons and cleansing the body and spirit of the ill person. Trephination, a practice in which holes were made in the skull to vent evil spirits or vapors, and religious rituals were the means to heal. With advances in civilization, healers focused on “treatments” that seemed to work. About 4000 years ago, the Code of Hammurabi listed penalties for bad out- comes in surgery. The prevailing medical theories of this era and the next few millennia involved manipulation of various forms of energy passing through the body. It was qi in China, chakras in India, humors in Europe, and natural spirits among Native Americans. Each civilization devel- oped a healing method predicated on restoring the correct balance of these ener- gies in the patient, as described in Table 1. The ancient Chinese system of medicine was based upon the duality of the universe. Yin and yang represented the fundamental forces in a dualistic cosmic theory that bound the universe together. According to the Nei Ching, medical diagnosis was done by means of “pulse diagnosis” that measured the balance of qi (or energy flow) in the body. In addition to pulse diagnosis, traditional Chinese medicine incorporated the five elements, five planets, con- ditions of the weather, colors, and tones. Acupuncture as a healing art balanced yin and yang by insertion of needles into the energy channels at different points to manipulate the qi. For the A brief history of medicine and statistics 3 Chinese, the first systematic study of human anatomy didn’t occur until the mid eighteenth century and consisted of the inspection of children who had died of plague and had been torn apart by dogs. Medical theory included seven substances: blood, flesh, fat, bone, marrow, chyle, and semen. Diet and hygiene were crucial to curing in Indian medicine, and clin- ical diagnosis was highly developed, depending as much on the nature of the life of the patient as on his symptoms. Other remedies included herbal medications, surgery, and the “five procedures”: emetics, purgatives, water enemas, oil ene- mas, and sneezing powders. Anatomy was learned from bodies that were soaked in the river for a week and then pulled apart. Indian physicians knew a lot about bones, mus- cles, ligaments, and joints, but not much about nerves, blood vessels, or internal organs. The Greeks began to systematize medicine about the same time as the Nei Ching appeared in China.

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This chapter addresses both the patient’s and the health-care provider’s role in the communication of evidence buy cheap extra super levitra 100mg. Patient scenario To highlight the communication challenges for evidence-based medicine generic 100 mg extra super levitra visa, we will start with a clinical case purchase 100mg extra super levitra with visa. A patient in clinic asks whether she should take aspirin to prevent strokes and heart attacks. She has worked for at least a year on weight loss and choles- terol reduction through diet and is frustrated by her lack of results. Her family history is significant for stroke in her mother at age 75 199 200 Essential Evidence-Based Medicine Table 18. She is hesitant to take medication, how- ever, she wants to know if she should take aspirin to prevent strokes and heart attacks. Throughout the chapter, we will refer to this case and the dilemma that this patient presents. Steps to communicating evidence Questions like this do not have a simple yes or no answer; therefore more dis- cussion between the provider and the patient is often needed. This discussion provides an opportunity for the provider to encourage the patient to be involved in the decision. Shared or participatory decision making is part of a larger effort toward patient-centered care, where neither the patient nor the provider makes the decision about what to do, rather both parties participate. The provider is responsible for getting the best available evidence to the patient, who must then be assisted in interpreting this evidence and putting it into the context of their life. Very little evidence exists as to the best approach to communicate evidence to patients in either shared or physician-driven decision-making models. However, Epstein and colleagues have proposed a step-wise approach to this discussion using a shared decision model of communication that we have found helpful (Table 18. Step 1: Understand the patient’s experience and expectations Using the patient’s query about aspirin as an example, first determine why the patient is asking, using a simple question such as “What do you know about Communicating evidence to patients 201 how aspirin affects heart attacks and strokes? When communicating evidence, knowing the patient’s baseline under- standing of the question avoids reviewing information of which the patient is already aware. Finding the level of understanding is a sure way to acknowledge that the process of care is truly patient-centered. A patient with a question does not automatically trigger the need for a discussion of the evidence, since a patient may have already decided the course of action and asks the question as a means of validation of her knowledge. For exam- ple, a patient may ask her physician’s opinion about continuing her bisphos- phonate for osteoporosis. When asking her further about her perspective, she tells you that she is concerned about the cost of the treatment. In this case, communication of the benefits of bisphosphonates will not answer her ques- tion directly. For some questions about therapy, there may be no need to discuss evidence, because the patient and the provider may be in clear agreement about the treat- ment. Our patient’s question of aspirin as a preventive treatment against stroke and heart attacks is one that seems to require a discussion of the best available evidence. Though typical office visits are short, taking time to understand the patient’s perspective may help avoid cultural assumptions. For example, when seeing a patient who is culturally different from you, one might assume that the patient’s values are different as well. On the other hand, it is easy to make false assumptions of shared values based on misperceived similarities of backgrounds between the provider and the patient. Understanding the patient’s perspective comes from active questioning of the patient to determine their values and per- spectives and avoids assumptions about similarities and differences. Patients have varying levels of understanding of health-care issues, some with vast and others with limited previous health-care experience and levels of under- standing. The patient’s level of health literacy clearly affects her perspective on the question and how she will interpret any discussion of results and recom- mendations. During the initial phases of the discussion about her question, it is important to understand her health literacy and general literacy level. Asking the patient what she knows about the problem can provide an impression of health literacy. This may be adequate, but asking a question such as: “How comfortable are you with the way you read? For example, if a patient wishes to avoid taking a medication because he or she is more con- cerned about the side effects of treatment than the benefits of treatment, focus the discussion on the evidence in this area. Also, many studies report major morbidity and mortality of treatment, yet, patients may be more concerned about the quality-of-life effects of treatment over many years. In other studies, the use of composite outcomes can make it difficult to directly answer a patient’s question since some of these are more important to the patient than others. The patient in our example wishes to know whether aspirin reduces the risk of heart attack. Although one may find a study that shows a statistically significant reduction of myocardial infarction, if the result is only reported as a composite outcome along with other outcomes such as reduced incidence of angina and heart failure, the result will not directly address your patient’s ques- tion. Since this type of presentation of data is used by authors when an individ- ual outcome is not itself statistically significant, the combination of outcomes is used to achieve statistical significance and get the study published. But, the composite is often made up of various outcomes not all of which have the same value to the patient. The goal of a discussion with the patient is to explain the results of each of the composite components so that she can make up her mind about which of the outcomes are important to her. Recommendations for understanding the patient’s experience and expectations The patient’s perspective on the problem as well as the available evidence deter- mines the true need to proceed with further steps to communicate evidence. It is possible that the patient’s questions relate only to background information, which is clearly defined in the science of medicine and not dependent on your interpretation of the most recent research evidence for an answer. Then, if evi- dence is needed to answer a patient’s question, first check to see whether it truly addresses the patients query about her desired outcomes rather than outcomes that are not important to the patient. Step 2: Build partnerships Taking time for this step is a way to build rapport with the patient. After dis- cussing the patient’s perspective, an impression will have developed of whether one generally agrees or disagrees with the patient. At this point in the discussion, Communicating evidence to patients 203 it should be clear what, if any, existing evidence may be of interest to the patient. The physician will also have a good understanding of whether to spend a major- ity of their time discussing basic or more advanced information. Using phrases such as “Let me summarize what you told me so far” or “It sounds like you are not sure what to do next” can help to build partnership that will allow a transition to the third step in the process of communicating evidence. In the example, the patient who is interested in aspirin for prevention of strokes and heart attacks is frustrated by her lack of reduction of weight or cholesterol after implementing some lifestyle changes. Expressing empathy for her struggles will likely help the patient see you as partner in her care. Step 3: Provide evidence As health-care providers, numbers are an important consideration in our decision-making process.