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By K. Cyrus. University of California, Santa Cruz.
Appropriate policies might address: agricultural subsidies for fruits and vegetables rumalaya liniment 60 ml mastercard muscle relaxant new zealand; food pricing and avail- ability; labelling of food; public transport; pedestrian- and cyclist-friendly road planning; school health education; and tobacco control measures, including prohibition of advertising and price control. The overall objective should be to make it easy for the population to make healthy choices related to diet, physical activity and avoidance of tobacco. Evidence There is a large body of evidence from prospective cohort studies regarding the beneficial effect of smoking cessation on coronary heart disease mortality (116). However, the magnitude of the effect and the time required to achieve beneficial results are unclear. Some studies suggest that, about 10 years after stopping smoking, coronary heart disease mortality risk is reduced to that of people who have never smoked (109, 110, 117, 118). It has also been shown that cigarette smokers who change to a pipe or cigar (119), and those who continue to smoke but reduce the number of cigarettes, have a greater mortality risk than those who quit smoking (112). A 50-year follow-up of British doctors demonstrated that, among ex-smokers, the age of quitting has a major impact on survival prospects; those who quit between 35 and 44 years of age had the same survival rates as those who had never smoked (120). The benefits of giving up other forms of tobacco use are not clearly established (121–124). General recommendations are therefore based on the evidence for cigarette smoking. Recent evidence from the Interheart study (31) has highlighted the adverse effects of use of any tobacco product and, importantly, the harm caused by even very low consumption (1–5 cigarettes a day). The benefits of stopping smoking are evident; however, the most effective strategy to encourage smoking cessation is not clearly established. All patients should be asked about their tobacco use and, where relevant, given advice and counselling on quitting, as well as reinforcement at follow-up. There is evidence that advice and counselling on smoking cessation, delivered by health profession- als (such as physicians, nurses, psychologists, and health counsellors) are beneficial and effective (125–130). Several systematic reviews have shown that one-time advice from physicians during routine consultation results in 2% of smokers quitting for at least one year (127, 131). Similarly, nicotine replacement therapy (132, 133) can increase the rate of smoking cessation. Nico- tine may be administered as a nasal spray, skin patch or gum; no particular route of administration seems to be superior to others. In combination with the use of nicotine patches, amfebutamone may be more effective than nicotine patches alone, though not necessarily more effective than amfebutamone alone (135, 136). Nortriptyline has also been shown to improve abstinence rates at 12 months compared with a placebo. Both agents have appreciable discontinuation rates because of side- effects (135–137). Data from observational studies suggest that passive cigarette smoking produces a small increase in cardiovascular risk (138–140). Whether reducing exposure to passive cigarette smoke reduces cardiovascular risk has not been directly established. The interventions described above targeted at individuals may be less effective if they are imple- mented in populations exposed to widespread tobacco advertising, sponsorship of sporting activities by the tobacco industry, low-cost tobacco products, and inadequate government tobacco control policies. There is evidence that tobacco consumption decreases markedly as the price of tobacco products increases. Bans on advertising of tobacco products in public places and on sales of tobacco to young people are essential components of any primary prevention programme addressing noncommunicable diseases (140). The cholesterol-raising properties of saturated fats are attributed to lauric acid (12:0), myristic acid (14:0), and palmitic acid (16:0). Stearic acid (18:0) and saturated fatty acids with fewer than 12 carbon atoms are thought not to raise serum cholesterol concentrations (146, 147). The effects of different saturated fatty acids on the distribution of cholesterol over the various lipoproteins are not well known. Trans-fatty acids come from both animal and vegetable sources and are produced by partial hydro- genation of unsaturated oils. Metabolic and epidemiological studies have indicated that trans-fatty acids increase the risk of coronary heart disease (145, 152, 153). It has also been demonstrated that replacing saturated and trans-unsaturated fats with monounsaturated and polyunsaturated fats is more effective in preventing coronary heart disease events than reducing overall fat intake (145, 153, 155). Current guidelines recommend a diet that provides less than 30% of calories from dietary fat, less than 10% of calories from saturated fats, up to 10% from polyunsaturated fats, and about 15% from monounsaturated fats (86, 88, 148).
We can continue to reduce the actual adverse event rate to 1:10 purchase rumalaya liniment 60 ml fast delivery spasms in your sleep, and using the same process we get p(no adverse events in 14 patients) = (0. For example, studies of head-injured patients to date have shown that none of the 2700 low-risk patients, those with laceration only or bump without loss of consciousness, headache, vomiting, or change in neurological status, had any intracranial bleeding or swelling. Therefore, the largest risk of intracranial injury in these low-risk patients would be 3/2700 = 1/900 = 0. General observations on the nature of risk Most people don’t know how to make reasonable judgments about the nature of risk, even in terms of risks that they know they are exposed to. This was articu- lated in 1662 by the Port Royal monks in their treatise about the nature of risk. There 154 Essential Evidence-Based Medicine Table 13. People are more likely to risk a poor outcome if due to voluntary action rather than imposed action. They are likely to smoke and accept the associated risks because they think it is their choice rather than an addiction. Similarly, they will accept risks that they feel they have control over rather than risks controlled by others. Because of this, people are much more likely to be very upset when they find out that their medication causes a very uncommon, but previously known, side effect. One only has to read the newspapers to know that there are more stories on the front page about catastrophic accidents like plane crashes or fatal automo- bile accidents than minor automobile accidents. Patients are more willing to accept the risk of death from cancer or sudden cardiac death than death due to unforeseen complications of routine surgery. If there is a clear benefit to avoiding a particular risk, for example that one shouldn’t drink poison, patients are more likely to accept a bad outcome if they engage in that risky behavior. A major exception to this rule is cigarette smoking, because of the social nature of smoking and the addictive nature of nicotine. They are more willing to accept risk that is distributed to all people rather than risk that is biased to some people. There is a perception that man-made objects ought not to fail, while if there is a natu- ral disaster it is God’s will. Risk that is generated by someone in a position of Risk assessment 155 trust such as a doctor is less acceptable than that generated by someone not in that position like one’s neighbor. We are more accepting of risks that are likely to affect adults than of those primarily affecting children, risks that are more familiar over those that are more exotic, and random events like being struck by lightning rather than catastrophes such as a storm without adequate warning. Irving Fisher, Professor of Economics, Yale University, 1929 Learning objectives In this chapter you will learn: r the essential features of multivariate analysis r the different types of multivariate analysis r the limitations of multivariate analysis r the concept of propensity scoring r the Yule–Simpson paradox Studies of risk often look at situations where there are multiple risk factors asso- ciated with a single outcome, which makes it hard to determine whether a sin- gle statistically significant result is a chance occurrence or a true association between cause and effect. Since most studies of risk are observational rather than interventional studies, confounding variables are a significant problem. Multivari- ate analysis and propensity scores are methods of evaluating data to determine the strength of any one of multiple associations uncovered in a study. They are attempts to reduce the influence of confounding variables on the study results. Multivariate analysis answers the question “What is the importance of one risk factor for the risk of a disease, when controlling for all other risk factors that could contribute to that disease? For example, in a study of lipid levels and the risk for coronary-artery disease, it was found that after adjusting for advancing age, 156 Adjustment and multivariate analysis 157 smoking, elevated systolic blood pressure, and other factors, there was a 19% decrease in coronary heart disease risk for each 8% decrease in total cholesterol level. In studies of diseases with multiple etiologies, the dependent variable can be affected by multiple independent variables. Smoking, advancing age, ele- vated systolic blood pressure, other factors, and cholesterol levels are the inde- pendent variables. The process of multivariate analysis looks at the changes in magnitude of risk associated with each independent variable when all the other contributing independent variables are held fixed. In studies using multivariate analysis, the dependent variable is most often an outcome variable.
Climate change may also exacerbate the spread of non-native species as warmer temperatures may allow currently ‘benign’ non-native species to potentially extend their ranges and become invasive order rumalaya liniment 60 ml with mastercard spasms vitamin deficiency. Invasive species impact native species in a wide range of ways, including competition, predation, hybridisation, poisoning, habitat alteration and disease. With respect to the latter, invasive alien species can carry novel pathogens non-symptomatically, to which native species may have no natural immunity. Crayfish plague], and amphibian chytridiomycosis carried non-symptomatically by introduced species such as American Bullfrogs Lithobates catesbeianus causes population declines and plays a role in amphibian extinctions [►Section 4. There are many parallels between prevention and control of invasive alien species, and of infectious diseases, such as the proactive measures of: Risk analysis and assessment ►Section 3. Communication, education, participation and awareness Training regarding management of those species ►Section 3. In general, to apply the concept of wise use and maintain biodiversity and ecological function i. Although a good understanding of disease dynamics is needed for the most effective proactive disease control strategies, there are some basic generic principles which, if implemented, are likely to reduce risks of disease emergence. For example, strategies for biosecurity (including prevention of introduction of invasive alien species), reduction of stresses on hosts and environment, and prevention of pollution, will bring obvious health benefits. Table 2-1 provides a list of proactive practices for disease prevention and control and the locations of further information in Chapter 3. Practice Section of Manual for further information Healthy wetland management Wise use of wetlands Site-specific risk assessments ►Section 3. Reactive strategies may include determining an evidence base, conducting surveillance, animal movement restrictions and instigating various other control measures. Reactive strategies for complete disease eradication may involve substantial intervention. With such a wide variety of wetland stakeholders, it is important to appreciate that there is the potential for differences in opinions over reactive disease control strategies and thus cross-cutting education, awareness raising and communication about these activities is advisable, particularly where rapid responses to disease emergence are required. Practice Section of Manual for further information Utilisation of multidisciplinary advisory groups in response to ►Section 3. Their application is illustrated in the case studies throughout the Manual and in the ‘Prevention and Control in Wetlands’ sections of the disease factsheets in Chapter 4. Wetland users do not need to become disease experts but communication and awareness raising programmes should aim to increase motivation to become engaged and ‘do the right thing’, with respect to disease management. This will likely only come from becoming informed about the problem, understanding the issues and implications, and participating in the solutions. Developing capacity to undertake disease management may involve formal education and training of key personnel e. Communication networks of key wetland stakeholders, including disease control authorities, should be established in ‘peacetime’ to facilitate rapid disease control responses should the need arise. This Manual aims to provide some of the information as a foundation for communication and public awareness programmes. The concept of ‘One World One Health’ has arisen due to the appreciation of the fundamental connectivity in health of humans, domestic livestock and wildlife. Embracing an ecosystem approach to health in wetlands involves recognising the dependence of health and well-being on ‘healthy wetlands’ which can only be achieved through wise use, most often at a landscape and/or catchment scale. If wetland stakeholders understand both the impacts of diseases and how to prevent and control them, they will feel motivated and empowered to take action. Stakeholder understanding must be built through effective communications or training but action will also be influenced by capacity to respond. To view disease management as separate to other forms of land and wildlife management ensures that opportunities for good disease prevention will be missed. Therefore, integrating disease management into wetland management means putting disease consideration at the heart of the wetland management planning process. Effective management of any disease is dependent on a good understanding of its epidemiology and the ecology of host populations. The dynamics of disease in wildlife populations can be highly complex, and disease management interventions can have unpredictable outcomes. Invasive alien species and novel pathogens and parasites have many parallels in their biology, the risks they pose, and in the measures required to prevent their establishment and control.
