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M. Kurt. Thomas Jefferson University.

Following the test • Subjects should continue to walk slowly round the course a further four times to avoid any syncopal attacks associated with abrupt cessation of exercise buy 200 mcg levothroid free shipping. If they report continuing breathlessness or angina then a further rest period should follow during which they may receive sub- lingual nitrates order levothroid 100mcg without prescription, have an ECG or be seen by a doctor as appropriate. Estimated metabolic equivalents (METs) for each stage of a shuttle-walking assessment Test stage Walking speed (km/hr) VO (ml·kg·1-min-1) METS 2 1 1. Cycle ergometer estimated metabolic equivalents (METs) Body Body 25 50 75 100 125 150 175 200 Weight Weight Watts Watts Watts Watts Watts Watts Watts Watts (kg) (lbs) 50 110 3. Then guide the patient’s activities that equate to this MET value as outlined by Ainsworth, et al. Similar principles for cycle ergometry can be applied as with the stepping and walking above. Cycle ergometers with accurate readings in Watts are required with MET values summarised in Table 3. Rowing ergometry, especially the Concept II models, is now being used in rehabilitation settings (Buckley, et al. The oxygen uptake of rowing on the Concept II ergometer can be determined using the regression equations developed by Lakomy and Lakomy (1993). OBSERVATION Observation of the exerciser by the exercise leader and assistants is a vital aspect of monitoring. The leader and assistants should monitor the CR exer- ciser continuously for quality of movement, excessive sweating, shortness of breath, skin colour and general fatigue. As part of the teaching skills the leader and assistants should scan the group and also maintain face and eye contact. These can be indicators of overexertion and a need to adapt or reduce exer- cise intensity. It is important that there is continuity of exercise leader to ensure that the leader/s becomes familiar with the participants and how they react to exercise. Estimated metabolic equivalents (METs) for a given rowing on a Concept-II Ergometer. Rowing speed is described as the 500-meter split time, which is the largest value displayed on the ergometer console Rowing speed 60kg 70kg 80kg 90kg 100kg 500-m split time 132lbs 154lbs 176lbs 198lbs 220lbs 4:30 2. Furthermore, the patient’s psychological state may be an important factor that holds back or advances too quickly the patient from exercising at the physiologically ben- eficial intensity. The RPE provides a channel through which the patient’s psycho- logical status influences the appropriate exercise intensity. In the initial stages of rehabilitation, if an MET value and HR are known from an ETT, to show the intensity at which any critical cardiac events occur, these should be used to guide exercise intensity. RPE should be used imme- diately to link with these, but its reliability to represent these levels should be Exercise Physiology and Monitoring of Exercise 87 Heart rate Related METs Rate Pressure Safe and Beneficial Exercise Intensity Psychological state RPE Observation Figure 3. Framework of the integrated components in monitoring exercise intensity in cardiac patient rehabilitation. It has been reported that patients tend to inflate their RPE in an initial exercise ETT compared to subsequent exercise at the same intensity in the CR exercise class, with only a few days separating the two sessions (Buckley, et al. If the exercise sessions involve the use of exercise machines, then either HR or METs, relative to the peak measurements from the exercise test, can be used to set intensity. If the exercise is a class, circuit or home-based activity then HR will be the obvious choice initially, but giving patients advice about what activities they can or should do based on the MET value is an important adjunct. Models of good practice for home-based pro- grammes involve either having a few instructional sessions with the patients as part of an outpatient clinic before patients exercise at home, and/or supporting this with a video (see the British Heart Foundation: www. For monitoring exercise subsequent to more practical assessments (step test, cycle test, shuttle walk) the appropriate level should be one that equates to the intensity that the patient can sustain. These tests are designed to raise intensity incrementally to a level which elicits an HR of £60%HRRmax or 75%HRmax and an RPE of 13 to 15 as per the upper limit guidelines in Table 3. From the MET level or 75%HRmax that corresponds with the end of the test, subsequent exercise intensities can be monitored relative to this. This principle can be used even when patients are beta-blocked, but the HR has to be adjusted, as recommended in Table 3. The cue to progressing intensity in all the above cases is when, for a given -1 work rate, there is a noticeable decrease in both HR (>5 beats. If there is a noticeable decrease in HR there should be a 88 Exercise Leadership in Cardiac Rehabilitation corresponding decrease in RPE.

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The effect of panel m em bership and feedback on ratings in a two-round D elphi survey: results of a random ized controlled trial purchase 100 mcg levothroid visa. An econom ic analysis can be defined as one that involves the use of analytical techniques to define choices in resource allocation 100 mcg levothroid mastercard. M ost of what I have to say on this subject com es from advice prepared by Professor M ichael D rum m ond’s team for authors and reviewers of econom ic analyses1 and three of the "U sers’ guides to the m edical literature" series,2, 3, 4 as well as the excellent pocket sized sum m ary by Jefferson and colleagues,5 all of which em phasise the im portance of setting the econom ic questions about a paper in the context of the overall quality and relevance of the study (see section 10. The first econom ic evaluation I ever rem em ber was a TV advertisem ent in which the pop singer Cliff Richard tried to persuade a housewife that the m ost expensive brand of washing up liquid on the m arket "actually works out cheaper". It was, apparently, stronger on stains, softer on the hands, and produced m ore bubbles per penny than "a typical cheap liquid". W hy should the effectiveness of a washing up liquid be m easured in term s of bubbles produced rather than plates cleaned? Forgive m e for sticking with this trivial exam ple but I’d like to use it to illustrate the four m ain types of econom ic evaluation which you will find in the literature (see Table 10. In term s of quality adjusted housewife hours (a com posite score reflecting tim e and effort needed to scrub plates clean and hand roughness caused by the liquid), Sudso provides 29 units per pound spent whereas Jiffo provides 23 units. The net overall cost (reflecting direct cost of the product, indirect cost of tim e spent washing up, and estim ated financial value of a clean plate relative to a slightly grubby one) of Sudso per day is 7. Cost utility analysis is unnecessary since, in this exam ple, we are interested in very little else apart from the num ber of plates cleaned per unit of washing up liquid; in other words, our outcom e has only one im portant dim ension. Cost benefit analysis is, in this exam ple, an absurdly com plicated way of telling you that Sudso cleans m ore plates per penny. There are, however, m any situations where health professionals, particularly those who purchase health care from real cash lim ited budgets, m ust choose between interventions for a host of different conditions whose outcom es (such as cases of m easles prevented, increased m obility after a hip replacem ent, reduced risk of death from heart attack or likelihood of giving birth to a live baby) cannot be directly com pared with one another. Controversy surrounds not just how these com parisons should be m ade (see section 10. These essential, fascinating, and frustrating questions are beyond the scope of this book but if you are interested I would recom m end you look up the references listed at the end of this chapter. From the hospital’s point of view, the cost of m y care included m y board and lodging for five days, a proportion of doctors’ and nurses’ tim e, drugs and dressings, and investigations (blood tests and a scan). I was off work for three weeks and m y dom estic duties were tem porarily divided between various friends, neighbours, and a nice young girl from a nanny agency. And, from m y point of view, there were several intangible costs, such as discom fort, loss of 153 H OW TO READ A PAPER independence, the allergic rash I developed on the m edication, and the cosm etically unsightly scar which I now carry on m y abdom en. On the benefit side, the operation greatly increased m y chances of staying alive. In addition, I had a nice rest from work and, to be honest, I rather enjoyed all the attention and sym pathy. I would be less likely to brag about m y experience if m y hospital adm ission had been precipitated by, say, an epileptic fit or a nervous breakdown, which have negative social stigm ata. Avoidance of hospital adm ission Investigations Return to paid work Staff salaries Indirect Clinical W ork days lost Postponem ent of death or disability Value of "unpaid" Relief of pain, nausea, breathlessness, etc. Intangible Quality of life Pain and suffering Increased m obility and independence Social stigm a Im proved wellbeing Release from sick role In the appendicitis exam ple, few patients (and even fewer purchasers) would perceive m uch freedom of choice in deciding to opt for the operation. But m ost health interventions do not concern definitive procedures for acutely life threatening diseases. M ost of us can count on developing at least one chronic, disabling, and progressive condition such as ischaem ic heart disease, high blood pressure, arthritis, chronic bronchitis, cancer, rheum atism , prostatic hypertrophy or diabetes. At som e stage, alm ost all of us will be forced to decide whether having a routine operation, taking a particular drug or m aking a com prom ise in our lifestyle (reducing our alcohol intake or sticking to a low-fat diet) is "worth it". But when the choices are about other people’s care, subjective judgem ents are the last thing that should enter the equation. M ost of us would want the planners and policym akers to use objective, explicit, and defensible criteria when m aking decisions such as "N o, M rs Brown m ay not have a kidney transplant". A num ber of questionnaires have been developed which attem pt to m easure overall health status, such as the N ottingham H ealth Profile, the SF-36 general health questionnaire (widely used in the U K) and the M cM aster H ealth U tilities Index Questionnaire (popular in N orth Am erica).

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J Neurocytol 22:342–381 Zhang X order levothroid 50mcg online, Verge V buy levothroid 50 mcg visa, Wiesenfeld-Hallin Z, Ju G, Bredt D, Snyder SH, Hökfelt T (1993b) Nitric oxide synthase-like immunoreactivity in lumbar dorsal root ganglia and spinal cord of rat and monkey and effect of peripheral axotomy. J Comp Neurol 335:563–575 Zhang X, Bean AJ, Wiesenfeld-Hallin Z, Xu XJ, Hökfelt T (1995a) Ultrastructural studies on peptides in the dorsal horn of the rat spinal cord. Neuroscience 64:893–915 Zhang X, Bean AJ, Wiesenfeld-Hallin Z, Hökfelt T (1995b) Ultrastructural studies on pep- tides in the dorsal horn of the rat spinal cord. Effects of peripheral axotomy with special reference to neuropeptide Y and vasoactive intestinal polypeptide/peptide histi- dine isoleucine. Neuroscience 64:917–941 References 115 Zhang X, Kostarczyk E, Giesler GJ (1995c) Spinohypothalamic tract neurons in the cervical enlargement of rats: descending axons in the ipsilateral brain. J Neurosci 15:8393–8407 Zhang X, Bao L, Shi TJ, Ju G, Elde R, Hökfelt T (1998) Down-regulation of mu-opioid receptorsinratandmonkeydorsalrootganglionneuronsandspinalcordafterperipheral axotomy. Neuroscience 82:223–240 Zhang X, Wenk HN, Gokin AP, Honda CN, Giesler GJ (1999) Physiological studies of spinohypothalamictractneuronsinthelumbarenlargementofmonkeys. JNeurophysiol 82:1054–1058 Zhou XF, Deng YS, Chie E, Xue Q, Zhong JH, McLachlan EM, Rush RA, Xian CJ (1999) Satellite-cell-derived nerve growth factor and neurotrophin-3 are involved in noradren- ergic sprouting in the dorsal root ganglia following peripheral nerve injury in the rat. Eur J Neurosci 11:1711–1722 Subject Index allodynia 44, 49–53, 61, 64, 69 density, postsynaptic 13, 15, 18 AMPA 3, 13, 17 diabetes, diabetic 49, 61, 69 – receptor subunits (GluR1, GluR2/3) disk, intervertebral 7 13–19, 53–54, 56–58, 68 amygdala 39–41, 46 efficacy, synaptic 51, 56 antinociception, antinociceptive 43, EPSP 13 48 area fiber –preoptic 40 –Aα 6 – pretectal 38, 48 –Aβ 49, 50, 62 astrocyte, astrocytic 9, 13, 58, 59 –Aδ 4, 6, 9, 62 axotomy 50, 58 – C 4, 6, 9, 11, 12, 43, 50, 62, 67, 68 – postsynaptic 42, 43 bone – sympathetic 7, 51, 63 – cancer 58, 62 fMRI 44, 66 – innervation 7 brain derived neurotrophic factor GABA, GABAergic 10, 11, 16, 17, 25, (BDNF) 3, 58 48, 56, 65, 69 calcitonin gene-related peptide (CGRP) galanin 3,4,52 3–6, 8, 52, 55, 63 ganglion cerebellum 11, 43, 44 – spinal (SG, DRG) 1–4, 7, 12, 42, 50, cholecystokinin 3 58, 59, 61, 66–68 colliculus – trigeminal (TG) 2–4, 6, 10, 59 –inferior 38 glia, glial 9, 58, 62, 63 – superior 38, 41 globus pallidus 40, 41 cornea 4–7, 11 glomerulus cortex – type 1 (C1) 12, 15, 17, 18, 54, 56, 68 – anterior cingulate (ACC) 25, 44, – type 2 (C2) 12, 15, 17, 18, 54–56, 68 46, 67, 69 glutamate, glutamatergic 2, 3, 11–14, – insular (IC) 25, 45, 47 16, 17, 23, 25, 38, 45, 48, 52–56 – motor 47 gold particles 15–18, 54–56 – prefrontal (PC) 44, 46, 66, 69 – primary somatosensory (SI) 44, herpes zoster (HZ) 59 47, 69 – ophthalmicus 60 – secondary somatosensory (SII) 44, –oticus 60 45, 47, 69 –pathology 60 hyperalgesia 17, 49, 51, 53, 56, 58, 69 damage 1, 4, 8, 17, 49, 60, 62, 64, 66, 67 hypersensitivity 53, 64, 66 degeneration 50, 51, 60, 67, 69 hypothalamus 39–41 118 Subject Index immunocytochemistry 13, 14, 53 neuropeptide Y (NPY) 3, 52 inflammation, inflammatory 3, 8, 48, neurotrophins 8, 51, 58 52, 53, 58–61, 63, 66 nitric oxide (NO) 4, 8, 11 nitric oxide synthase (NOS) 4, 11, 16, junction, spinomedullary 27, 69 23, 52 NMDA 3, 13, 17 kainate 3, 13, 16 – receptor subunits (NMDAR1, NMDAR2) 13, 18, 19, 56 lamina, basal 5, 6 nociceptor 2–5, 7, 8, 50, 68 laminae (dorsal horn of spinal cord) – silent 8 – I (nucleus postero-marginalis) nucleus/nuclei 9–11, 14, 18, 23, 24, 26–28, 38–40, 48, –accum bens 41 66 – basal, of Meynert 41 – II (substantia gelatinosa) 9–12, 14, – centralis lateralis (CL) 24, 26 15, 18, 50–56, 68 – cuneate (Cu) 11, 25, 40, 42, 43 – III 9, 14, 50, 67 – cuneiformis 38 – IV 9, 23, 28, 38, 39, 42, 50, 67, 68 – Darkschewitsch 38 – V 9, 23, 24, 26, 28, 38, 39, 50, 67, 68 – gigantocellularis 39 – VI 9, 23, 28, 38, 50, 67, 68 – gracile (Gr) 25, 42, 43 – VII 23, 28, 39 – interstitialis (Cajal) 38 – VIII 23, 28, 39 – intralaminar 24, 26, 27, 40, 46, 65 – IX 23, 28 – lateral cervical (LCN) 28 – X 14, 23, 28, 38, 43 – lateral spinal (LSN) 28 lesion 53 – parabrachial 39 – cortex 44, 46 – pretectal 41, 48 – sciatic nerve 52, 54–56 – principal trigeminal (PTN) 10, 26, – spinal 62, 64 27 – thalamus 44, 64, 66 – raphe 47, 69 locus coeruleus 39, 48 – reticularis dorsalis 39 malignancy 49, 69 pontis oralis et caudalis 39 medulla oblongata 10, 39, 47, 69 –ruber 38 modulation 11, 25, 39, 44, 48, 49 – solitarius 39, 40 muscle 3, 6, 53 – spinal trigeminal (STN) 9–11, 23, 27, 38, 68 nerve ending caudalis (STNc) 11, 26, 27 – free, localization 2, 4, 5, 7, 68 interpolaris (STNi) 11, 26, 27 – galanin 5 oralis (STNo) 11, 26, 27 – sensory 2, 4–7, 61, 68 – spional trigeminal (STN) 47 neuralgia – ventral posteromedial thalamic –geniculate 60 (VPM) 11, 26, 45, 48 – postherpetic (PHN) 48–52, 59, 60, – ventralis lateralis (VL) 25 66, 67, 69, 70 – ventralis medialis, posterior (VMpo) –trigem inal 47 24, 25, 45, 46, 66 neurokinin A (NKA) 3, 5, 8 – ventralis posterior inferior (VPI) neuron, primary afferent (PA) 1–4, 42, 24, 45, 66 49, 52, 59, 63 – ventralis posterior lateralis (VPL) –Acells 2,68 24–26, 43, 45, 48 – Bcells 2,3,68 –num ber 2 opiates, opioid 12, 48, 52, 69 Subject Index 119 PAG (periaquaductal gray) 38, 46–48, skin 3, 5–7, 59, 61 69 somatostatin 3 pain sprouting 50, 51, 58, 67, 70 – cancer 52, 60, 62 stimulation 4, 8, 46, 48, 49 – central 51, 63–65 –electrical 43 – chronic 1, 47, 49, 59, 61, 66, 68, 69 – motor cortex 47 – diabetic 62 – noxious 11, 39, 43, 46 – first 4,9,68 –PAG 47 –m uscle 44 – visceral 44 – neuropathic 49, 56, 69 substance P (SP) 3, 7, 10, 12, 42, 43, 55 – neuropathic (NP) 1, 62, 66–69 substantia innominata 40, 41 – neurophatic (NP) 53, 63 sympathectomy 51 – persistent 52, 61, 66 synapse 12, 14, 15, 17, 25, 53–56, 64, 68 – phantom limb 49, 67 – asymmetric 15, 18, 25, 55 – post-stroke 47, 64, 69 – number of receptors 16 – second 4,9,68 – symmetric 12, 15, 16, 18 –skin 9 – visceral 42 teeth 6 PET 44, 66 tract plasticity 51, 52, 66, 69 – spinal trigeminal (STrT) 11 postembedding 14, 53 – spinohypothalamic (SHT) 40 preembedding 13 – spinomesencephalic (SMT) 38 prostaglandins 8, 63 – spinoparabrachial (SPbT) 38 – spinoreticular (SRT) 38–40 rash 60 – spinothalamic (STT) 23, 24, 26, 28, receptors 38, 42, 48, 64–66 – endothelin 58 – trigeminohypothalamic (THT) 40, – GABA 56 41 – glutamate 3, 12–14, 16, 17, 23, – trigeminothalamic (TTT) 11, 26, 53–56, 68 27 – NK1 10, 38, 48, 49 – vanilloid 6, 8 varicella (chickenpox) 59, 60 regulation varicella-zoster virus (VZV) 59 – down-regulation 52, 53, 63 vasoactive intestinal polypeptide (VIP) – up-regulation 52–57, 59, 63 3, 52 reticular formation (RF) 10, 11, 38–40 vesicle 8, 12 root, dorsal 1, 9, 66 – clear 5, 12, 18, 54, 55 – dense core 4, 12, 18 satellite cell 51, 58–60 – pleomorphic 12 Schwann cell 5, 6, 58, 62 –synaptic 4,25 sensitization 4, 8, 50–53, 56 signaling 26, 58 zoster sine herpete 60 . Cassel, MD Professor and Dean, Oregon Health & Science University, School of Medicine, Portland, Oregon Deputy Editor Rosanne M. Leipzig, MD, PhD Vice-Chair for Education, Gerald and May Ellen Ritter Professor of Geriatrics, Brookdale Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York, New York Associate Editors Harvey Jay Cohen, MD Director, Center for the Study of Aging and Human Development, and Chief, Geriatrics Division, Duke University Medical Center; Director, Geriatric Research, Education, and Clinical Center, Veterans Affairs Medical Center, Durham, North Carolina Eric B. Larson, MD, MPH Director, Center for Health Studies, Group Health Cooperatives; Professor of Medicine, University of Washington Medical Center, Seattle, Washington Diane E. Meier, MD Director, Hertzberg Palliative Care Institute; Catherine Gaisman Professor of Medical Ethics; Professor, Brookdale Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York, New York Managing Editor Carol F. Capello, PhD Assistant Professor of Geriatric Education, Division of Geriatrics and Gerontology, Weill Medical College of Cornell University, New York, New York 1 3 Christine K. Cassel, MD, Professor and Dean, Oregon Health & Science University, School of Medicine, Portland, OR, 97201-3098, USA Rosanne M. Leipzig, MD, PhD, Vice-Chair for Education, Gerald and May Ellen Ritter Professor of Geriatrics, Brookdale Department of Geriatrics and Adult Devel- opment, Mount Sinai School of Medicine, New York, NY 10029, USA Harvey Jay Cohen, Director, Center for the Study of Aging and Human Development, and Chief, Geriatrics Division, Duke University Medical Center; Director, Geriatric Research, Education, and Clinical Center, Veterans Affairs Medical Center, Durham, NC 27710, USA Eric B. Larson, MD, MPH, Director, Center for Health Studies, Group Health Coop- eratives; Professor of Medicine, University of Washington Medical Center, Seattle,WA 98195–6330, USA Diane E. Meier, MD, Director, Hertzberg Palliative Care Institute; Catherine Gaisman Professor of Medical Ethics, Professor, Brookdale Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York, NY 10029, USA Carol F. Capello, PhD, Assistant Professor of Geriatric Education, Division of Geriatrics and Gerontology, Weill Medical College of Cornell University, New York, New York 10021, USA Library of Congress Cataloging-in-Publication Data Geriatric medicine: an evidence-based approach/editors, Christine K. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer-Verlag New York, Inc. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now know or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. At the most basic level, the successful mapping of the human genome was declared complete in the fall of 2000. Understanding the map of the human genome is as important as understanding the map of genomes of important laboratory species, ranging from the microscopic worms and fruitflies used in most classic genetic studies to rodents such as laboratory mice, and eventually to primates, on which much of the research on the aging human brain is done. The genetic maps of all of these species, including our own, does not answer clinical questions, but it does open the door to dramatic, rapid, and efficient answers to questions about the genetic polymorphisms related to diseases in humans. Telomerase is an enzyme responsible for maintaining the telomeres—the redundant DNA portions at the end of chromosomes—whose shortening seems to be linked directly to cell senescence, apop- tosis,and the control over cell death,which,at the level of the individual cell,seems to be linked to the decline of organ function and eventually aging and death within the organ- ism. The potential for genetic manipulations by which telomerase maintains and restores telomere length within individual tissue cultures gives great promise for potential approaches to restoring function lost through degenerative diseases, such as macular degeneration and other disorders related to epithelial aging. In addition, the mainte- nance of telomeres has been intriguingly associated with the malignant immortality of cancer cells,and yet it appears possible to prevent degeneration without creating uncon- trolled growth or malignancy. Understanding this single genetic mechanism may give us clues not only to degenerative neurological and epithelial disease, but also perhaps to cancer,another age-related human disease. Scientists have also discovered that stem cells from embryonic and adult tissues can potentially create new tissues and new organs.

We a prognosis of the outcome someone like me (my situ- also need a forum of peers and those skilled at ation being similar to screening) would expect buy generic levothroid 50mcg on line. It evidence based medicine in which test out our ideas so suggested that I was unlikely to have a serious that we can reassure ourselves that we are not condition that was amenable to cure buy levothroid 50 mcg visa. If health authorities are serious this may be an overestimate of the benefits of about promoting evidence based medicine in clinical screening. Perhaps those three people would have practice, they may have to consider providing a service developed symptoms such as frank haematuria or (perhaps like pathology, radiology, or referred special- dysuria sufficiently early to negate the beneficial effect ist opinions) to help clinicians to take these steps. Paul Glasziou constructively read earlier drafts and checked, Another study was done in California. In: outcome of people whose dipstick test was not positive; Fauci AS, Braunwald E, Isselbacker KJ, Wilson JD, Martin JB, et al, eds. New York: McGraw Hill, their probability of developing urological cancer was 1998:258-62. Dipstick urinalysis screening, asymptomatic microhematuria, and subsequent urological cancers in a population- were probably the best match with my situation that I based sample. The second study, particularly, seemed 7 Froom P, Gross M, Froom J, Caine Y, Margaliot S, Benbassat J. Is the net benefit of Health Policy, Summary points Oxfordshire Health investigation worth the cost? At a recent discussion in Authority,Oxford our general practice it soon became apparent that our OX3 7LG Chlamydia infection is the commonest treatable views and practices varied widely. Was there any N R Hicks, sexually transmitted disease in the United consultant evidence to help us reach a consensus? We resolved to Kingdom; it is most common in sexually active Hollow Way try and find out. D Goldman, The discharge was slight, clear, watery, and non- 60-80% of genital chlamydia infections in women general practitioner offensive, and she had no abnormal vaginal bleeding. J Hamling, may be asymptomatic Ms A had changed her sexual partner two months pre- general practitioner viously. Soon after this she had contracted genital In one randomised trial, screening high risk L J Hicks, general practitioner thrush, which responded to topical clotrimazole. She women and treating those found to be infected Correspondence to: uses a combined contraceptive pill and does not use reduced the incidence of pelvic inflammatory DrNRHicks condoms. Ms A has no other sexual partners, and disease by about half in 12 months nicholas. Access to the internet allows valid, relevant BMJ 1999;318:790–2 The only noteworthy finding at vaginal examina- information to be identified and retrieved tion was that Ms A’s cervix bled easily when swabbed. A quickly—but appraising the evidence and deciding high vaginal swab was taken from the posterior fornix, how best to reflect it in practice takes considerably and two swabs were taken from the endocervix and the longer urethra—a standard cotton swab and a plastic shafted chlamydia swab respectively. Ms A was prescribed doxycycline (200 mg for seven days) and metronida- ated with proactive case finding or whether any net zole (400 mg three times daily for seven days). Ms A was invited back to the surgery and was upset to be told that she might Search for evidence have had a sexually transmitted disease. She and her It is frequently written that the first step in evidence partner were referred to the local sexually transmitted based practice is to turn the clinical problem into an diseases clinic for further investigation and follow up. This proved more difficult than we first thought, as we wanted answers to several Our uncertainty questions: The case of Ms A prompted discussion in the practice x Is genital chlamydia an important cause of clinically about who we should investigate and treat for chlamy- important morbidity? Of course, we all wanted to prevent our patients x Does antibiotic treatment reduce subsequent mor- suffering avoidable morbidity—for example, pelvic bidity in asymptomatic, sexually active women infected inflammatory disease, infertility, and ectopic with chlamydia? But some of us cost effective way of reducing clinically important thought there was no place for chlamydia investigation morbidity? However, textbooks held in logical diagnosis wherever possible, and, as chlamydial libraries are now more difficult to access from general infection can be asymptomatic, thought we should be practitioners’ homes and surgeries than are online searching for asymptomatic cases—for example, electronic databases. In addition, traditional textbooks among sexually active women attending for cervical are rarely written in a way that is sufficiently smears or for contraceptive advice.

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