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By U. Yespas. Brevard College. 2018.
Scientists believe that these changes alter When they first use a drug order micardis 40mg with amex pulse pressure and kidney disease, people may perceive what seem to the way the brain works and may help explain the compulsive be positive effects; they also may believe that they can control and destructive behaviors of addiction. Why do some people become addicted to Over time, if drug use continues, other pleasurable activities drugs, while others do not? In general, the more risk start to feel the need to take higher or more frequent doses, factors a person has, the greater the chance that taking drugs even in the early stages of their drug use. Consider how Risk Factors Protective Factors a social drinker can become intoxicated, get behind the wheel of a car, and quickly turn a pleasurable activity into a tragedy Aggressive behavior Good self-control in childhood that affects many lives. Lack of parental Parental monitoring supervision and support Is continued drug abuse a voluntary Poor social skills Positive relationships behavior? Drug experimentation Academic competence The initial decision to take drugs is typically voluntary. However, Availability of drugs School anti-drug with continued use, a person’s ability to exert self-control can at school policies become seriously impaired; this impairment in self-control is Community poverty Neighborhood pride the hallmark of addiction. Brain imaging studies of people with Children’s earliest interactions within the family are crucial to their healthy development and 8 risk for drug abuse. Risk and protective factors may be either envi- ronmental (such as conditions at home, at school, and in the neighborhood) or biological (for instance, a person’s genes, their stage of development, and even their gender n Genetics n Chaotic home and abuse n Gender n Parent’s use and attitudes or ethnicity). The influence of the home envi- ronment, especially during childhood, is a very impor- tant factor. Parents or older family members who abuse alcohol or drugs, or who engage in criminal behavior, can increase children’s risks of developing their own drug problems. Friends and acquaintances can have Scientists estimate that genetic factors account for between 40 and 60 percent of a an increasingly strong influence during adolescence. Adolescents and people poor social skills can put a child at further risk for with mental disorders are at greater risk of drug abuse and addiction than the general using or becoming addicted to drugs. Smoking a drug or injecting it into 9,10 a vein increases its addictive potential. However, this intense “high” can fade within a few research shows that the earlier a person begins to use drugs, the minutes, taking the abuser down to lower, more normal levels. This may Scientists believe this starkly felt contrast drives some people to reflect the harmful effect that drugs can have on the developing repeated drug taking in an attempt to recapture the fleeting brain; it also may result from a mix of early social and biological pleasurable state. Still, the fact remains that early use is a strong indicator of problems ahead, including addiction. Addiction is a developmental disease— 10 it typically begins in childhood or adolescence. The fact that this critical part of an adolescent’s brain is still a work in progress puts them at increased risk for making poor decisions (such as trying drugs or continuing to take them). Also, introducing drugs during this period of development may cause brain changes that have profound and long-lasting consequences. Remember, drugs change brains—and this can lead to addiction and other serious problems. So, preventing early use of drugs or alcohol may go a long way in reducing A these risks. If we can prevent young people from experimenting with drugs, we can prevent drug addiction. For an adult, a divorce or loss of a job may lead to drug abuse; for a teenag- 12 er, risky times include moving or changing schools. In early adolescence, when children advance from elementary through middle school, they face new and challenging social and academic situations. Often during this period, children are exposed to abusable substances such as cigarettes and alcohol for the first time. When they enter high school, teens may encounter greater availability of drugs, drug use by older teens, and social activities where drugs are used. At the same time, many behaviors that are a normal aspect of their development, such as the desire to try new things or take greater risks, may increase teen tendencies to experiment with drugs. Some teens may give in to the urging of drug-using friends to share the experience with them.
Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease 64 distressingly typical of those seen for patients with chronic diseases throughout our aging population discount 20mg micardis overnight delivery hypertension specialist. The Committee’s assigned task was to “explore the feasibility and need, and develop a potential framework, for creating a ‘New Taxonomy’ of human diseases based on molecular biology. Moreover, the Committee clearly recognized that developing and implementing a Knowledge Network of Disease has the unique potential to go far beyond classification of disease to act as a catalyst that would help to revolutionize the way research is done and patients are treated. Patient 1 has a high likelihood of overcoming her life-threatening disease and going on to live a long, healthy, and productive life. These prospects are a direct result of a new ability to recognize, based on molecular analyses, the precise type of breast cancer she has and to target a rational therapy to her disease. The Committee believes that the best prospects for creating a similarly bright future for Patient 2 lies in achieving a similarly precise understanding of his disease by creating a Knowledge Network of Disease and an associated New Taxonomy. The Committee recognized two key points about its charge: first, development of an improved disease taxonomy is only one facet, albeit an important one, of the challenge of leveraging advances in biomedical research to achieve better health outcomes for patients; secondly, no single stream of activity—led by any single segment of the biomedical research community—can tackle even this limited goal on its own. Both these points suggested that we could best address our charge by framing the “new-taxonomy” challenge broadly. Many of the conclusions and recommendations could apply, as well, to other challenges in “translational research” such as evaluating and refining existing treatments and developing new ones. However, disease classification is inextricably linked to all progress in medicine, and the Committee took the view that an ambitious initiative to address this challenge—and particularly to modernize the “discovery model” for the needed research —is an excellent place to start. The Committee thinks that the key to success lies in building new relationships that must span the whole spectrum of research and patient-care activities that comprise American medicine. As discussed in Chapter 2, the Committee thinks that now is a propitious time to confront the challenge of developing a Knowledge Network of Disease and deriving a New Taxonomy from it because of changes that are sweeping across basic and translational research, information technology, drug development, public attitudes, and the health-care-delivery system. Our recommendations seek to empower stakeholder communities by providing them with informational resources—the Information Commons, the Knowledge Network, and the New Taxonomy itself—that would transform the way they work and make decisions. We make no specific promises about the benefits that would ensue as this transformation occurs but have every confidence that this initiative would be a powerful, constructive force for change throughout a large enterprise that plays an increasingly central role in science, technology, the economy, and each of our lives—and one that is notoriously difficult to reform. At the core of the Committee’s optimism is a conviction that dramatic advances in biological knowledge can be coupled more effectively than they are now to the goal of improving the health outcomes of individual patients. Biology has flourished in the 50+ years since the discovery of the molecular basis of inheritance. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease 65 Genome Project, genetics is in a “golden age” of discovery. Sequence similarity between genes studied in fruit flies and those studied in humans allows nearly instant recognition of the potential medical relevance of the most basic advances in biochemistry and cell biology. Increasingly, this process also works in reverse: unusual human patients call attention to molecules and biochemical pathways whose importance in basic biology had been overlooked or was otherwise inaccessible. Indeed, there are already many areas of basic biology in which human studies are leading the way to deep new insights into the way organisms work. For the simple reason that one can ask a research subject what she sees when looking at a pattern of light—instead of having to develop a crude behavioral test to find out whether she sees anything at all—we know far more about the molecular details of light reception in humans than we could ever have learned from studying mice. Particularly as biomedical research puts an increasing emphasis on unraveling the molecular underpinnings of behavior, the advantages of starting research studies with humans, rather than model organisms, are likely to grow. Experience tells us that translation of intensifying knowledge of basic biology into clinical advances is a daunting task. Furthermore, the Committee shares the sense that basic biology is at an “inflection point” in which there is every reason to expect increasing payoffs from the large investments in basic science that have brought us to this point. However, the grand challenge of coupling basic science more effectively to medicine will require a rethinking of current practices on a scale commensurate with the challenge. The Committee regards the initiative it proposes to develop the tripartite Information Commons, Knowledge Network, and New Taxonomy, as having the potential to rise to this level. Information technology is the key contributor to the technological convergence the Committee perceives. Information technology, quite simply, has made the rise of data-intensive biology possible: molecular biology, as now practiced, could not exist without modern computing systems. In medicine, information technology offers perhaps the best hope of increasing efficiency and improving our collective learning about what works and what does not. In a mere 20 years, people have made the transition from regarding most human knowledge as locked away in the dusty backrooms of research libraries to expecting it to be at their finger tips.
Substantial protec- tion is provided after even one or two of the three doses of the series 80mg micardis mastercard arteriografia. It is important to have a health-record system that tracks immunizations so that the vaccine series can be continued if later incarcerations occur. Ideally, im- munizations administered in jails will be captured in an adult immunization registry (see discussion on immunization-information systems below) so Copyright © National Academy of Sciences. 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. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. The committee did not fnd data on rates of hepatitis B vac- cination of institutionalized developmentally disabled people. Identifying At-Risk Adults As discussed above, recommendations regarding childhood hepatitis B vaccination are aimed at achieving universal coverage, and recommenda- tions regarding adult vaccination focus on the identifcation of risk popula- tions for targeted immunization efforts. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Identifcation of at-risk people is particularly challenging in medical settings in that risks must be assessed in individual patients. In many health-care settings, physicians and other providers might not be comfort- able in asking direct questions to elicit risk history with respect to sexual or percutaneous exposures (Ashton et al. Time constraints during medical appointments and inadequate provider education in the assessment of risk histories also might lead to insuffcient assessment of risk history. In addition, there may be discrepan- cies between a patient’s self-assessment of risk and a health-care provider’s documented assessment (Fishbein et al. Additional federal and state resources should be devoted to increasing hepatitis B vaccination of at-risk adults. Accelerated schedules for vaccine administra- tion should be considered for jail inmates. Health-care providers should routinely seek risk histories from adult patients through direct questioning and self-assessment. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. They also make it possible to generate reminder and recall notifcations and assess vaccination coverage in defned geographic areas. President Clinton established the national Childhood Immunization Initiative by directing the secretary of health and human services to work with states to build “an integrated immunization registry system. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. In addition, a technical work group was established to develop approaches to measuring performance of the systems against 12 functional standards (Hinman et al. States should be encouraged to expand immunization-information systems to include adolescents and adults. Barriers to Hepatitis B vaccination Mistrust of vaccination Like other childhood vaccinations, hepatitis B vaccination is some- times refused because patients or parents of children have concerns about the safety of a vaccine (Allred et al. The committee is unaware of credible evidence of serious harms caused by the hepatitis B vaccine in its many forms. In a 2002 scientifc review by the Institute of Medicine, the hepatitis B vaccine was not found Copyright © National Academy of Sciences. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. The efforts of groups opposed to vaccination present a serious obstacle to comprehensive vaccination coverage, which is essential for the prevention and control of hepatitis B in the United States. Payment for vaccines Insurance Coverage Health-insurance coverage for the nonelderly population (less than 65 years old) is provided by employers (63%) and public programs (11% by the Medicaid/Children’s Health Insurance Program and 2% by other public programs) or is acquired by individuals in the private market (5%) (Holahan and Cook, 2008). Robust coverage for vaccinations, including hepa- titis B vaccination, is provided by public insurance plans (Table 4-5). Pri- vate insurance plans have variable coverage for vaccinations and various degrees of cost-sharing. Insurance coverage for vaccinations also varies substantially with age: children under 5 years old and people 65 years old and over have high rates of private or public coverage (89% and nearly 100%, respectively). Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www.
Such programmes often include physical education order micardis 80 mg fast delivery blood pressure chart low bp, nutrition and food services, health promotion for school personnel and outreach to the community. Many school health programmes focus on preventing the risk factors associated with leading causes of death, disease and disability, such as tobacco, drug and alcohol use, dietary practices, sexual behaviour and physical inactivity. In comparative studies of public health interventions, the World Bank concluded that school health programmes are highly cost-effective. Activities included training health person- as well as some regions of Yunnan Province, nel, health education, health counselling and covering a population of 90 million. The nutrition project was activities in four fields: institutional devel- integrated into the existing three-level health-care opment and policy reform, human resource structure in the Tianjin project area without alloca- development, surveillance and community tion of additional resources. Among the outcomes reported trained to increase their knowledge about the rela- was a reduction in the prevalence of male adult tionship between salt intake and blood pressure, cigarette smokers from 59% to 44%. In Beijing and were taught how to give practical advice to there were substantial increases in high blood patients on this issue. Leaflets disease of more than 15% in the last year of were distributed door-to-door, and posters and the project. Low sodium salt Health has established a total of 32 demonstra- was also introduced, and the project cooperated tion sites for chronic disease prevention and with salt manufacturers and shops to ensure that control across the country. Notable outcomes so far have included edge about salt intake than residents in an area a reduction in the annual heart disease and not taking part. In the intervention area, average stroke deaths in those patients with high blood salt intake was significantly lower in men, and also pressure who were being managed, from 1. In Shenyang, nificant decrease in systolic blood pressure in the there was a reduction in the prevalence of adult intervention area for both men and women. In con- smokers from 29% to 13% between 1997 and trast, both salt intake and systolic blood pressure 2002 and an increase in the proportion of people increased significantly during the same period in participating in planned regular physical activity men who did not take part. It students in decisions related to vending machine was designed to decrease cardiovascular risk factors choices and the maintenance and location of the in children through: machines was important to success (19, 20). Workplace interventions for chronic disease prevention Furthermore, intervention children maintained their and control are a feasible and often successful means results for three years without further interventions. Interven- After five years of follow-up and no further tions tend to focus on chronic diseases and risk fac- intervention: tors that substantially inhibit productivity and incur the » menus from 50% of the former intervention cafete- most serious health and economic burdens. Improvements can be seen in worker produc- time spent in moderate-to-vigorous physical activ- tivity, reduced levels of absenteeism, and employer ity in the intervention schools had been maintained, cost-saving. Staff training is an important factor in institu- Programmes that address multiple risk factors for tionalizing such programmes (18). These programmes allow employees to decide what risk factors they want to improve and define their own goals (22). A seeks to reduce behavioural and psychosocial comprehensive approach including both risk factors, increase healthy behaviours, detect policies and programmes, rather than disease early, and manage chronic diseases. The either in isolation, increases the likeli- programme provides preventive services as well as hood that employees will participate. After almost three years, improvement was seen The most effective workplace tobacco in eight out of 13 risk categories for employees. These savings increased of a test to identify individuals at risk of substantially after the second year (26, 27). The goal is for people who have not sought medical attention to benefit from further investigation or direct preventive action. Effectively implemented medical screening can prevent disability and death and improve quality of life. Screening tests are available for some chronic diseases, including cardiovascular disease, diabetes, and several site- specific cancers (24). The disease or disorder to be considered for screening must be well defined, of public health importance and of known prevalence in the population. An effective, affordable and acceptable treatment must be available to all those who require it (25). In general, the number of proven screening procedures is limited, although notable exceptions include the following: » screening for elevated risk of cardiovascular disease using an overall risk approach; » screening for early detection of breast and cervical cancer, in coun- tries with sufficient resources to provide appropriate treatment. There are a number of highly effective clinical interventions that, when properly delivered, can reduce death Cervical cancer remains a major health problem, and disease and improve the quality of life of particularly in low and middle income countries. Effec- These include supporting behaviour change, the tive screening programmes for cervical cancer in low use of pharmacological agents and surgery.
They will have to contact the when applying for medicine purchase micardis 20 mg blood pressure chart high diastolic, such as the include time periods normally regarded as relevant health registration bodies of their Bachelor of Health Sciences or the Bachelor after hours. This includes (but is not limited to) textbooks, equipment, medical testing, frst aid certifcates and student amenities fees. Students will undertake an advanced research project in nutrition, reproductive health or epidemiology, areas in which the University has an international research reputation. Students taking the Advanced degree will have early opportunities to be involved in the research activities and culture that are hallmarks of a research university. They will gain in-depth understanding of research across the spectrum of knowledge creation, application and translation. Throughout their degree, they will have access to tailored mentoring and career development planning. Students who have not yet completed their Year 12 studies, or a Credit average for tertiary studies. A Aboriginal Education, or studying in the supports the Aboriginal and Torres dedicated study space is provided as a safe Faculty of Health Sciences: Strait Islander students within the and quiet home base for our Aboriginal and Web: www. The Faculty also provides a Telephone: 08 8313 6275 Yaitya Purruna assists Aboriginal and Torres dedicated Student Services Support Offcer Strait Islander students studying nursing, who is co-located in this area to provide medicine, dentistry, oral health, psychology or students with ongoing support. Sitting within the School of Population Health in the Faculty of Health Sciences, the Yaitya Purruna Indigenous health unit is part of the overall Aboriginal and Torres Strait Islander Education Strategy at the University of Adelaide. The unit focuses on the following: > Advocating and providing support for all Aboriginal and Torres Strait Islander students studying in the Faculty of Health Sciences. Group of Eight universities provide opportunities for all students to Open Day offers important information Sunday 00 August 2015 beneft from a world-class education, for future students and parents, as well while enhancing Australia’s wellbeing www. Everyone is invited global challenges, and contributing to to discuss study and career options the global knowledge economy through with the University’s friendly staff and their teaching and research activities. Students with strong interests in more than one area of study may wish to consider a double or combined degree. The application closing date for 2016 entry and how to apply, can be obtained by is 30 September 2015. Bachelor of Medicine contacting us (refer below for details) or and Bachelor of Surgery, and Bachelor of English language visiting the scholarships website: Dental Surgery applicants should refer to www. Students may be required to pay for specialist completion of the International Baccalaureate equipment, reading materials, etc. For more information on Permanent residency Commonwealth supported students studying an other program-related fees and charges, visit equivalent full-time study load were as follows. Program intake For accommodation options and costs please These annual fees are indicative only as actual visit: www. Updated information can be found Please refer to individual programs on Degree on the University website: www. Further information is available at: Adelaide (refer below for details) to check information provided by third parties. If they do not have the answer @uniofadelaide enquirers will be referred to faculty/school/ discipline staff for expert advice. With a growing range of entry pathways, scholarships and support for students, our aim is to ensure the leaders of tomorrow have the opportunity to excel. Setting the Scene for the The conference was held in Bonn, 3–7 December 2012, and aimed, in particular, to: Next Decade • Indicate gaps in current approaches to radiation protection in medicine; • Identify tools for improving radiation protection in medicine; • Review advances, challenges and opportunities in the field of radiation protection in medicine; Proceedings of an • Assess the impact of the International Action Plan for the International Conference Radiation Protection of Patients, in order to prepare new international recommendations, taking into account newer 3–7 December 2012 developments. It resulted in the Bonn Call for Action, which will focus efforts Bonn, Germany in radiation protection in medicine in the next decade, and maximize the positive impact of such efforts. Its principal objective is “to accelerate and enlarge the contribution of atomic energy to peace, health and prosperity throughout the world’’. The copyright has since been extended by the World Intellectual Property Organization (Geneva) to include electronic and virtual intellectual property. Proposals for non-commercial reproductions and translations are welcomed and considered on a case-by-case basis. The copyright has since been extended by the World Intellectual in patient protection worldwide. The Málaga conference, held in March 2001, Property Organization (Geneva) to include electronic and virtual intellectual provided very broad international input on the status of radiation protection of property.
The copyright owners grant third parties the right to use the Internal Medicine Milestones on a non-exclusive basis for educational purposes order micardis 20 mg on-line hypertension journals ranking. He/she is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that includes the delivery of safe, effective, patient-centered, timely, efficient and equitable care. The copyright owners grant third parties the right to use the Internal Medicine Milestones on a non-exclusive basis for educational purposes. An improvement plan is in place to facilitate achievement of competence appropriate to the level of training. Copyright (c) 2012 The Accreditation Council for Graduate Medical Education and The American Board of Internal Medicine. The copyright owners grant third parties the right to use the Internal Medicine Milestones on a non-exclusive basis for educational purposes. The Milestones provide a framework for the assessment of the development of the resident physician in key dimensions of the elements of physician competency in a specialty or subspecialty. They neither represent the entirety of the dimensions of the six domains of physician competency, nor are they designed to be relevant in any other context. They are descriptors and targets for resident performance as a resident moves from entry into residency through graduation. For each reporting period, review and reporting will involve selecting the level of milestones that best describes a resident’s current performance level in relation to milestones, using evidence from multiple methods, such as direct observation, multi-source feedback, tests, and record reviews, etc. Selection of a level implies that the resident substantially demonstrates the milestones in that level, as well as those in lower levels (See the diagram on page v). A general interpretation of levels for emergency medicine is below: Level 1: The resident demonstrates milestones expected of an incoming resident. Level 2: The resident is advancing and demonstrates additional milestones, but is not yet performing at a mid-residency level. Level 3: The resident continues to advance and demonstrate additional milestones; the resident demonstrates the majority of milestones targeted for residency in this sub-competency. Level 4: The resident has advanced so that he or she now substantially demonstrates the milestones targeted for residency. Level 5: The resident has advanced beyond performance targets set for residency and is demonstrating “aspirational” goals which might describe the performance of someone who has been in practice for several years. Answers to Frequently Asked Questions about Milestones are available on the Milestones web page: http://www. For each reporting period, a resident’s performance on the milestones for each sub-competency will be indicated by: selecting the level of milestones that best describes the resident’s performance in relation to the milestones or selecting the “Has not Achieved Level 1” response option Selecting a response box in the middle of a Selecting a response box on the line in between levels level implies that milestones in that level and indicates that milestones in lower levels have been in lower levels have been substantially substantially demonstrated as well as some milestones demonstrated. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. Has not Achieved Level 1 Level 2 Level 3 Level 4 Level 5 Level 1 Knows the different Applies medical knowledge Considers array of drug Selects the appropriate Participates in developing classifications of pharmacologic for selection of therapy for treatment. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. Has not Achieved Level 1 Level 2 Level 3 Level 4 Level 5 Level 1 Identifies pertinent Performs patient assessment, Determines a backup Performs indicated Teaches procedural anatomy and physiology obtains informed consent and strategy if initial attempts procedures on any patients competency and corrects for a specific procedure ensures monitoring equipment is to perform a procedure are with challenging features mistakes in place in accordance with unsuccessful (e.
Finally micardis 80 mg with mastercard blood pressure pregnancy, the inclusion of the all-or-none case series as 1c evi- dence is somewhat controversial. These studies may be helpful for studying new, uniformly fatal, or very rare disorders, but should be viewed with care as they are incapable of proving any elements of contributory cause and are only considered preliminary findings. Also included are 3a, systematic reviews of homoge- neous case–control studies, and 3b, individual case–control studies. Grade C is a recommendation based on the weakest study designs and includes level 4, case series and lower-quality cohort and case–control stud- ies. These studies fail to clearly define comparison groups, to measure expo- sures and outcomes in the same objective way in both groups, to identify or appropriately control known confounding variables, or carry out a suffi- ciently long and complete follow-up of patients. Finally, grade D recommendations are not based upon any scientific studies and are therefore the lowest level of evidence. Also called level 5, they con- sist of expert opinion without explicit critical appraisal of studies. It is based solely upon personal experience, applied physiology, or the results of bench research. Indi- vidual practitioners can modify them in light of a patient’s unique characteris- tics, risk factors, responsiveness, and preferences about the care they receive. A level that fail to provide a conclusive answer can be preceded by a minus sign –. This may occur because of wide confidence intervals that result in a lack of statistical significance but fails to exclude a clinically important benefit or harm. This also may occur as a result of a systematic review with serious and statisti- cally significant heterogeneity. Evidence with these problems is inconclusive and can only generate Grade C recommendations. This stands for the Grading of Recommendations Assessment, Develop- ment and Evaluation Working Group. This group has created a uniform schema for classifying the quality of research studies based on the ability to prove the cause and effect relationship. Strength of results The actual strength of association is the next important issue to consider. All plausible confounders would have reduced the effect (+1) the magnitude of the effect size or the difference found between the two groups studied. The larger the effect size and lower the P value, the more likely that the results did not occur by chance alone and there is a real difference between the groups. Other common measures of association are odds ratios and relative risk: the larger they are, the stronger the association. A relative risk or odds ratio over 5 or over 2 with very narrow confidence intervals should be considered strong. Second, finding no effect size or one that was not statistically significant may have occurred because of lack of power. John Snow performed what is acknowledged as the first modern recorded epi- demiologic study in 1854. Known as the Broad Street Pump study, he proved that the cause of a cholera outbreak in London was the pump on Broad Street. This pump was supplied by water from one company and was associated with a high rate of cholera infection in the houses it fed, while a different company’s pump had a much lower rate of infection. The relative risk of death was 14, suggesting a very strong association between consumption of water from the tainted pump and death due to cholera. A modern-day example is the high strength of associ- ation in the connection between smoking and lung cancer. With such high association, competing hypotheses for the cause of lung cancer are unlikely and the course for the clinician should be obvious. Consistency of evidence The next feature to consider when looking at levels of evidence is the consistency of the results. Overall, it is critical that different researchers in different settings and at different times should have done research on the same topic.
