Emeritus Professor of Paediatrics, Guy?, King?, and
Sr. Thomas?Hospitals School of Medicine, King? College,
University of London
Emeritus Consultant Paediatrician and Paediatric
Nephrologist, Guy? and Sr. Thomas?NHS Foundation Trust,
London, United Kingdom
Expand and increase access to information technology and integrated data systems to promote cross-sector information exchange erectile dysfunction caused by guilt 100 mg silagra. When educational institutions other than schools of public health undertake to train personnel for work in the field erectile dysfunction endovascular treatment buy silagra 50 mg lowest price, careful attention to the scope and capacity of the educational program is essential impotence exercise buy cheap silagra 50 mg online. Reduce barriers to accessing clinical and community preventive services erectile dysfunction needle injection video buy silagra 50mg cheap, especially among populations at greatest risk erectile dysfunction age 27 order 50mg silagra with amex. Enhance coordination and integration of clinical erectile dysfunction age 22 discount silagra 50mg mastercard, behavioral and complementary health strategies. Community coalitions should be formed to facilitate and promote cross-cutting programs and communitywide efforts. Engage and empower people and communities to plan and implement prevention policies and programs. Categories should be selected from a national standard on the basis of health and health care quality issues, evidence or likelihood of disparities, or size of subgroups within the population. The selection of categories should also be informed by analysis of relevant data. In addition, an open-ended option of "Other, please specify:-" should be provided for persons whose granular ethnicity is not listed as a response option. Increase the capacity of the prevention workforce to identify and address disparities. Support research to identify effective strategies to eliminate health disparities. State and community tobacco control programs should supplement the national media campaign with coordinated youth prevention activities. The campaign should be implemented by an established public health organization with funds provided by the Federal government, public-private partnerships, or the tobacco industry (voluntarily or under litigation settlement agreements or court orders) for media development, testing, and purchases of advertising time and space. Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse: Recommendation Statement. They should use universal education interventions, as well as selective and indicated approaches with relevant populations. Appendix 5 Justification for Evidence-Based Recommendations Recommendation Support policies and programs that promote breastfeeding. Smoking cessation interventions in pregnancy need to be implemented in all maternity care settings. Given the difficulty many pregnant women addicted to tobacco have quitting during pregnancy, population-based measures to reduce smoking and social inequalities should be supported. These systems should involve individuals, families, schools, justice systems, health care systems, and relevant community-based programs. Such approaches should build on available evidence-based programs and involve local evaluators to assess the implementation process of individual programs or policies and to measure community-wide outcomes. Partnership for Sustainable Communities: A Year of Progress for American Communities. New the Guide to Community Preventive Services, Task Force York: Oxford University Press; 2005. Multiple Chronic Conditions-A Strategic Framework: Optimum Health and Quality of Life for Individuals with Multiple Chronic Conditions. Department of Health and Human Services, Agency for Health care Research and Quality. Health literacy online: A guide to writing and designing easy-to-use health Web sites. Eliminating Racial and Ethnic Health Disparities: A Business Case Update Health Disparities: A Business for Employers. National Standards on Culturally and Linguistically Appropriate Services in Health Care. Reducing Tobacco Use: A Report of the Surgeon Report of the Surgeon General General. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2000. Best Practices for Comprehensive Tobacco Control Programs Centers for Disease Control and Prevention. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; October 2007. Department of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention. Department of Health and Human Services, Office of the Surgeon General, January 2010. Solving the Problem of Childhood Obesity within a Generation: the White House Task Force on Childhood Obesity Report to the President. Essential Elements of Effective Workplace Programs and Policies for Improving Worker Health and Well-Being. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health. Department of Health and Human Services Action Plan for the Prevention, Care and Treatment of Viral Hepatitis U. Combating the Silent Epidemic: Action Plan for the Prevention, Care and Treatment of Viral Hepatitis. Committee on the Prevention of Mental Disorders and Substance Abuse Among Children, Youth, and Young Adults: Research Advances and Promising Interventions. Board on Children, Youth, and Families, Division of Behavioral and Social Sciences and Education. National Prevention Strategy Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, National Healthcare Expenditures Data, We Can Do Better Improving the Health of the American People, N Engl J Med 2007; 357: 1221-28. Urban sprawl and public health: designing, planning, and building for healthy communities. Current housing reports, series H150/05, American Housing Survey for the United States: 2005. Racial and ethnic disparities in health-related early childhood home routines and safety practices. Perceptions of neighborhood characteristics and leisure-time physical inactivity- Austin/Travis County, Texas. Impact of changes in transportation and commuting behaviors during the 1996 Summer Olympic Games in Atlanta on air quality and childhood asthma. Air pollution and development of asthma, allergy and infections in a birth cohort. Air pollution and cardiovascular disease: a statement for healthcare professionals from the expert panel on population and prevention science of the American Heart Association. Effect of exposure to traffic on lung development from 10 to 18 years of age: a cohort study. Stroke mortality associated with living near main roads in England and wales: a geographical study. Locally generated particulate pollution and respiratory symptoms in young children. Firearm storage practices and rates of unintentional firearm deaths in the United States. Unintentional nonfire-related carbon monoxide exposures-United States, 20012003. A review of household drinking water intervention trials and an approach to the estimation of endemic waterborne gastroenteritis in the United States. Linking public health, housing and indoor environmental policy: successes and challenges at the local and federal agencies in the United States. Biological monitoring survey of organophosphorous pesticide exposure among preschool children in the Seattle metropolitan area. Growing the field of health impact assessment in the United States: an agenda for research and practice. On exposure and response relationships for health effects associated with exposure to vehicular traffic. Economic determinants of urban form - Resulting trade-offs between active and sedentary forms of travel. Obesity relationships with community design, physical activity, and time spent in cars. Walking and cycling to school: predictors of increases among children and adolescents. Active transportation to school over 2 years in relation to weight status and physical activity. Social capital and the built environment: the importance of walkable neighborhoods. Epidemiology and prevention of traffic injuries to urban children and adolescents. Potential health effects associated with residential proximity to freeways and primary roads: review of scientific literature, 1999-2006. Cardiovascular health and particulate vehicular emissions: a critical evaluation of the evidence. Improving health through neighbourhood environmental change: Are we speaking the same language? Numerical evaluation of tree canopy shape near noise barriers to improve downwind shielding. Investment in safe routes to school projects: public health benefits for the larger community. Income and racial disparities in access to public parks and private recreation facilities. Neighborhood resources for physical activity and healthy foods and their association with insulin resistance. Potential health effects associated with residential proximity to freeways and primary roads: Review of scientific literature, 1999-2006. Transportation Research Record: Journal of the Transportation Research Board 2008; 2046:45-52. Psychosocial effects of community noise: cross sectional study of school children in urban center of Skopje, Macedonia. Updated Guidelines for Evaluating Public Health Surveillance Systems: Recommendations from the Guidelines Working Group. The Benefits Of Health Information Technology: A Review Of the Recent Literature Shows Predominantly Positive Results. Action Plan to Reduce Racial and Ethnic Health Disparities A National Free of Disparities in health and health care. Statewide community-based health promotion: a North Carolina model to build local capacity for chronic disease prevention. Accessed May 17, 2011 Health in All Policies Task Force Report to the Strategic Growth Council. Routine Preventive Services for Women: a Composite Measure Highlights Gaps in Delivery. Preventing Chronic Disease: Public Health Research, Practice, and Policy 2005;2(3). Department of Health and Human Services, Public Health Service, Office of the Surgeon General; 2001. Prevalence, awareness, treatment, and control of hypertension among United States adults 1999-2004. Prevalence, awareness, treatment, and control of hypertension among United States adults 19992004. United States cancer statistics: 1999-2006 incidence and mortality web-based report. Effect of diuretic-based antihypertensive treatment on cardiovascular disease risk in older diabetic patients with isolated systolic hypertension. Overcoming clinical inertia improves glycemic control in patients with type 2 diabetes. Incorporating diabetes care into a health maintenance organization setting: a practical guide. Organized personal care-an effective choice for managing diabetes in general practice. Renal assessment practices and the effect of nurse case management of health maintenance organization patients with diabetes. A nurse-coordinated intervention for primary care patients with non-insulin-dependent diabetes mellitus: impact on glycemic control and health-related quality of life. Veterans Affairs Cooperative Study Group on Primary Care and Hospital Readmission. Nurse case management to improve glycemic control in diabetic patients in a health maintenance organization. Diabetes care organization, process, and patient outcomes: effects of a diabetes control program. Improvements in diabetic care as measured by HbA1c after a physician education project. Diabetes managed care and clinical outcomes: the Harbor City, California Kaiser Permanente diabetes care system. Nationwide program for improving the care of diabetic patients in Israeli primary care centers.
Syndromes
Bargaining (for instance "If I am cured of this cancer, I will never smoke again.")
In an artery to monitor blood pressure
Blood in urine
Speech may sound odd because too much air is escaping through the hose (hypernasality) or too little air is coming out through the nose (hyponasality)
Fluid from the vagina that gets into the urine
Clove cigarettes
It is also unclear how to set the retraining schedule male erectile dysfunction age quality silagra 100mg, and what information should guide that decision impotence versus erectile dysfunction purchase silagra 50mg overnight delivery. The issues of model surveillance and implementation are more deeply addressed in Chapter 6 erectile dysfunction caused by ptsd order silagra 100 mg otc. For example impotence kegel buy silagra 50mg online, the software for data retrieval erectile dysfunction radiation treatment order silagra 50mg mastercard, preprocessing erectile dysfunction caused by vasectomy buy silagra 100 mg on-line, and cleaning is often lost or not maintained, making it impossible to re-create the same dataset. In addition, the data from the source system(s) may have been discarded or may have changed. The problem is further compounded by fast-changing data sources or changes over time in institutional data stores or governance procedures. Finally, silos of expertise and access around data sources create dependence on individual people or teams. When the collection and provenance of the data that a model is trained on is a black box, researchers must compensate with reliance on trusted individuals or teams, which is suboptimal and not sustainable in the long run. Consider, for example, that race and ethnicity information is simply not recorded, is missing, or is wrong in more than 30 to 40 percent of the records at most medical centers (Huser et al. Given the poor quality of these data, arguments about unfairness of predictive models for ethnic groups remain an academic discussion (Kroll, 2018). As a community, we need to address the quality of data that the vast majority of the enterprise is collecting. The quality is highly variable and acknowledging this variability as well as managing it during model building is essential. The quality of these data practices affects the development of models and the successful implementation at the point of care. However, the assessment of the quality of data that are available and the methodology to create a highquality dataset are not standardized or often are nonexistent. Ideally, data should be cross validated from multiple sources to best determine trustworthiness. Also, multiple subject matter experts should be involved in data validation (for both outcome and explanatory variables). In manually abstracted and annotated datasets, having multiple trained annotators can provide an accurate assessment of the ambiguity and variability inherent in data. For example, when tasked with identifying surgical site infection, there was little ambiguity whether infection was present or not; however, there was little agreement about the severity of the infection (Nuttall et al. Insufficiently capturing the provenance and semantics of such outcomes in datasets is at best inefficient. At worst, it can be outright dangerous, because datasets may have unspecified biases or assumptions, leading to models that produce inappropriate results in certain contexts. Another critical point is that the acquisition of the data elements present in the training data must be possible without major effort. When computationally defined phenotypes serve as the basis for downstream analytics, it is important that computational phenotypes themselves be well managed and clearly defined and adequately reflect the target domain. Researchers in molecular biology and bioinformatics put forth these principles, and, admittedly, their applicability in health care is not easy or straightforward. The soon-to-be in-clinic promise of genomic data further complicates the problems of maintaining data provenance, timely availability of data, and knowing what data will be available for which patient at what time. It stands to reason that any predictive or classification model operating at a given point in the patient time line can only expect to use data that have come into being prior to the time at which the model is used (Jung et al. Limited attention has been given to the significant risk of harm, from wasting resources as well as from relying on evaluation strategies decoupled from the action they influence (Abrams, 2019) or relying evaluation regimes that avoid simple and obvious baseline comparisons (Christodoulou et al. At present, most of the existing discussion focuses on evaluating the model from a technical standpoint. After the potential utility has been established, model developers and model users need to interact closely during model learning because many modeling choices are dependent on the context of use of the model (Wiens et al. For example, the need for external validity depends on what one wishes to do with the model, the degree of agency ascribed to the model, and the nature of the action triggered by the model. It is well known that biased data will result in biased models; thus, the data that are selected to learn from matter far more than the choice of the specific mathematical formulation of the model. Model builders need to pay closer attention to the data they train on and need to think beyond the technical evaluation of models. For decision making in the clinic, additional metrics such as calibration, net reclassification, and a utility assessment are necessary. The topic of interpretability deserves special discussion because of ongoing debates around interpretability, or the lack of it (Licitra et al. To the model builder, interpretability often means the ability to explain which variables and their combinations, in what manner, led to the output produced by the model (Friedler et al. To the clinical user, interpretability could mean one of two things: a sufficient enough understanding of what is going on, so that they can trust the output and/or be able to get liability insurance for its recommendations; or enough causality in the model structure to provide hints as to what mitigating action to take. An often-overlooked detail is when and where certain data become available and whether the mechanics of data availability and access are compatible with the model being constructed. In parallel, we need to educate the different stakeholders, and the model builders need to understand the datasets they learn from. This subtlety is not new to recent technological advancements, and in fact was brought up decades ago (Berg, 2010). The model builders need to better understand the datasets they choose to learn from. The decision makers need to look beyond technical evaluations and ask for utility assessments. Implementing electronic health care predictive analytics: Considerations and challenges. Statistical modeling: the two cultures (with comments and a rejoinder by the author). A systematic review shows no performance benefit of machine learning over logistic regression for clinical prediction models. Comorbidity clusters in autism spectrum disorders: An electronic health record time-series analysis. Learning (predictive) risk scores in the presence of censoring due to interventions. Cardiovascular disease risk factors, type 2 diabetes mellitus, and the Framingham Heart Study. Comparing the performance of propensity score methods in healthcare database studies with rare outcomes. Potential biases in machine learning algorithms using electronic health record data. Opportunities and challenges in developing risk prediction models with electronic health records data: A systematic review. Improving coronary heart disease risk assessment in asymptomatic people: Role of traditional risk factors and noninvasive cardiovascular tests. The impact of health information technology on the quality of medical and health care: A systematic review. A longitudinal analysis of data quality in a large pediatric data research network. The Artificial Intelligence Clinician learns optimal treatment strategies for sepsis in intensive care. A clinical score for predicting atrial fibrillation in patients with crytogenic stroke or transient ischemic attack. The inter-rater reliability of the diagnosis of surgical site infection in the context of a clinical trial. Creating value in healthcare through big data: Opportunities and policy implications. Phenomapping for novel classification of heart failure with preserved ejection fraction. Detection of clinically important colorectal surgical site infection using Bayesian network. Assessing the performance of prediction models: A framework for some traditional and novel measures. The importance of interpretability and visualization in machine learning for applications in medicine and health care. Clinical implications of revised pooled cohort equations for estimating atherosclerotic cardiovascular disease risk. Using smartphones and machine learning to quantify Parkinson disease severity: the mobile Parkinson disease score. At this time in the development cycle, methods to estimate the requirements, care, and maintenance of these tools and their underlying data needs remain a rudimentary management science. Decision support generally refers to the provision of recommendations or explicit guidance relating to diagnosis or prognosis at the point of care, addressing an acknowledged need for assistance in selecting optimal treatments, tests, and plans of care along with facilitating processes to ensure that interventions are safely, efficiently, and effectively applied. The nature of regulation is evolving but will need to account for changes in clinical practice, data systems, populations, etc. A complex array of people and services are necessary to support direct care and they tend to consume and generate massive amounts of data. Diagnostic services such as laboratory, pathology, and radiology procedures are prime examples and are distinguished by the generation of clinical data, including dense imaging, as well as interpretations and care recommendations that must be faithfully transmitted to the provider (and sometimes the patient) in a timely manner. In addition, the data necessary to train models in these settings are often more easily available than in clinical settings. For example, in a hospital, these tasks might include the management of billing, pharmacy, supply chain, staffing, and patient flow. This might include freestanding, urgent care facilities or pharmacies, or our homes, schools, and workplace. Although some of these may be considered traditional point-of-care environments, the availability of information may be substantially different in these environments. However, these types of tools may be used to link health metrics to purchasing recommendations. This poses a challenge for traditional health systems because some research suggests that only a small fraction of overall health can be attributed to health care (see Figure 6-1) (McGinnis et al. Nevertheless, other research suggests that health systems have a major role to play in improving population health that can be distinguished from those of traditional medical care and public health systems (see Figure 6-2). Promoting healthy behaviors and self-care are major focuses of population health management efforts (Kindig and Stoddart, 2003). Much of the work of health management in this context is conducted outside of regular visits and often involves more than one patient at a time. In addition, an essential component of these initiatives involves contacting large numbers of patients, which can occur through a variety of automated, readily scalable methods, such as text messaging and patient portals (Reed et al. One such example in a weight loss program among prediabetic patients is the use of Internet-enabled devices with an application to provide educational materials, a communication mechanism to their peer group and health coach, and progress tracking, which showed that completion of lessons and rate of utilization of the tools were strongly correlated with weight loss over multiple years (Sepah et al. Such communication may be as basic as asynchronous messaging of reminders to obtain a flu shot (Herrett et al. Higher order activities, such as for psychosocial support or chronic disease management, might entail use of a dedicated app or voice or video modalities, which could also be delivered through encounters using telemedicine, reflecting the fluidity and overlap of technological solutions (see Chapter 3 for additional examples) (Xing et al. These predictions are starting to be used to prioritize provision of care management within these populations (Rumsfeld et al. The patient- and caregiver-facing application domain merges health care delivery with publicly available consumer hardware and software. It is defined as the space in which applications and tools are directly accessible to patients and their caregiver. Tools and software in this domain enable patients to manage much of their own health care and facilitate interactions between patients and the health care delivery system. In particular, smartphone and mobile applications have transformed the potential for patient contact, active participation in health care behavior modification, and reminders. These applications also hold the potential for health care delivery to access new and important patient data streams to help stratify risk, provide care recommendations, and help prevent complications of chronic diseases. This trend is likely to blur the traditional boundaries of tasks now performed during face-toface appointments. Proliferation of these applications will continue to amplify and enhance data collected through traditional medical activities. Mobile applications are increasingly able to cross-link various sources of data and potentially enhance health care. In addition to being used by patients, the technology will likely be heavily used by their family and caregivers. Unfortunately, the use of technologies intended to support self-management of health by individuals has been lagging as has evaluation of their effectiveness (Abdi et al. Although there are more than 320,000 health apps currently available, and these apps have been downloaded nearly 4 billion times, little research has been conducted to determine whether they improve health (Liquid State, 2018). In all, 11 of the 23 trials showed a meaningful effect on health or surrogate outcomes attributable to apps but the overall evidence of effectiveness was deemed to be of very low quality (Byambasuren et al. In addition, there is a growing concern that many of these apps share personal health data in ways that are opaque and potentially worrisome to users (Loria, 2019). Both information generated by medical science and clinical data related to patient care have burgeoned to a level at which clinicians are overwhelmed. This is a critically important problem because information overload not only leads to disaffection among providers but also to medical errors (Tawfik et al. Although clinical cognitive science has made advances toward understanding how providers routinely access medical knowledge during care delivery and the ways in which this understanding could be transmitted to facilitate workflow, this has occurred in only very limited ways in practice (Elstein et al. Further, these features would enhance the quality and safety of care because important information would be less likely to be overlooked. Health care is increasingly delivered by teams that include specialists, nurses, physician assistants, pharmacists, social workers, case managers, and other health care professionals. Each of them brings specialized skills and viewpoints that augment and complement the care a patient receives from individual health care providers.
If the intake of dietary vitamin K1 increases erectile dysfunction treatment injection cost discount 50mg silagra, the synthesis of the blood clotting factors begins to return to normal erectile dysfunction nervous purchase 100mg silagra amex. The natural coumarins present in alfalfa are not considered to be anticoagulants smoking weed causes erectile dysfunction trusted 100mg silagra, because they do not have the structural requirements for this activity erectile dysfunction causes young males generic 50 mg silagra with amex. Importance and management Patients should be counselled on the effects of dietary vitamin K and the need to avoid dramatic dietary alterations while taking warfarin erectile dysfunction enlarged prostate proven silagra 50mg. It would be prudent to avoid large doses of alfalfa leaf supplements as a precaution when taking warfarin or other coumarin anticoagulants low testosterone erectile dysfunction treatment order 100 mg silagra with amex. Available evidence suggests that it is unlikely that infusions prepared with water, or alfalfa seeds, would pose any problem, due to the lower vitamin K1 content. Dietary vitamin K influences intra-individual variability in anticoagulant response to warfarin. Role of dietary vitamin K intake in chronic oral anticoagulation: prospective evidence from observational and randomized protocols. Patients with unstable control have a poorer dietary intake of vitamin K compared to patients with stable control of anticoagulation. Controlled vitamin K content diet for improving the management of poorly controlled anticoagulated patients: a clinical practice proposal. Constituents Aloe vera gel is contained in the mucilaginous tissue that is found in the inner leaf, and should not be confused with aloes, page 27, which is the latex stored in tubules along the leaf margin. Aloe vera gel may be produced by a handfilleted technique to remove the inner leaf, or by a whole-leaf extraction process where the aloes constituents (anthraquinones) are now usually subsequently removed. The principal constituents of the gel are polysaccharides consisting mainly of polymannans, of which acemannan is the major one. Other constituents include glycoproteins such as aloctins, and various carboxypeptidases, sterols, saponins, tannins, organic acids, vitamins and minerals. It is reported to possess anti-inflammatory, antitumour, immunomodulatory and antibacterial properties. Internally, aloe vera is thought to be immunostimulatory and to have mild analgesic, antioxidant and antidiabetic effects. Interactions overview Aloe vera contains only traces of anthraquinone glycosides, and would therefore not be expected to have any of the interactions of aloes, page 27, or similar herbal medicines, which occur, or are predicted to occur, as a result of their anthraquinone content. Aloe vera may have blood-glucose-lowering properties and may therefore be expected to interact with conventional drugs that have the same effect. Aloe vera appears to enhance the absorption of some vitamins but the clinical significance of this is not clear. Use and indications Aloe vera is used topically to aid wound healing from cuts 24 Aloe vera 25 Aloe vera + Antidiabetics Aloe vera juice reduces blood-glucose levels in patients with diabetes taking glibenclamide. Clinical evidence In placebo-controlled clinical studies, aloe vera juice (80%), one tablespoonful twice daily for 42 days, reduced blood-glucose in patients with diabetes, either taking glibenclamide,1 or not taking oral antidiabetic drugs,2 from an average of 14 to 16 mmol/L down to 8 mmol/L over a period of 6 weeks. However, it should be noted that, in the study in patients taking glibenclamide, there was, unexpectedly, no response to the use of glibenclamide alone. In these studies, the aloe vera juice (80%) was prepared from aloe gel and additional flavours and preservatives. Experimental evidence There is extensive literature (not cited here) on the possible bloodglucose-lowering effect of various extracts of aloe vera in animal models of diabetes, with some studies showing an effect and others not. Importance and management It seems possible that some oral preparations of aloe vera might have a clinically important blood-glucose-lowering effect. It might therefore be prudent to increase the frequency of blood-glucose monitoring if patients taking antidiabetic medication wish to try oral aloe vera preparations. The authors suggest that a possible interaction between sevoflurane and aloe vera contributed to the excessive bleeding seen. Experimental evidence Aloe vera gel extracts inhibited prostaglandin synthesis in vitro,2 and might therefore have antiplatelet activity. Mechanism Sevoflurane can inhibit platelet aggregation by inhibiting thromboxane A2, and aloe vera affects prostaglandin synthesis, which may also impair platelet aggregation. Therefore additive antiplatelet effects may have contributed to the excessive bleeding. A Aloe vera + Vitamins Aloe vera might delay, and enhance, the absorption of vitamin C and vitamin E. However, this difference was not statistically significant: it was attributed to the large interindividual differences. There was a second maximum plasma ascorbate level at 8 hours with the gel, and plasma ascorbate was still detectable at 24 hours, suggesting that aloe vera gel might delay, as well as enhance, absorption. Conversely, aloe vera whole leaf extract 60 mL had no significant effect on the absorption of vitamin C. However, the only statistically significant difference was the increase in plasma tocopherol at 8 hours, which occurred with both aloe vera extracts. The time to maximum level was delayed from 4 hours to 8 hours for the gel and to 6 hours for the leaf extract, suggesting that aloe vera might delay, as well as enhance, absorption. Mechanism the authors suggest that the vitamins may be protected from degradation in the intestine by flavonoid antioxidants in the aloe Aloe vera + Sevoflurane An isolated case report tentatively attributed increased surgical bleeding to the concurrent use of aloe vera and sevoflurane. Clinical evidence A 35-year-old woman, who had taken four aloe vera tablets (exact constituents and dose unknown) daily for 2 weeks before undergoing a procedure to excise a haemangioma from her left thigh, lost more than double the amount of blood estimated before surgery. Effect of Aloe vera preparations on the human bioavailability of vitamins C and E. A vera extracts and by polysaccharides that may bind to the vitamins, delaying and increasing their absorption. Use and indications Aloes has mainly been used internally as a laxative (although, note that this use has generally been superseded) and, in low concentrations, as a flavouring ingredient in food and drink. Pharmacokinetics the anthraquinone, emodin, is present in aloes (and similar plants) principally as the inactive glycoside. It travels through the gut, and is then metabolised by microflora to produce the active aglycone emodin, some of which is absorbed. Constituents Not to be confused with Aloe vera, page 24, which is the gel contained in the mucilaginous tissue that is found in the inner leaf. Aloes is derived from the latex that is stored in tubules along the margin of the leaf. When the outer leaf is cut, latex exudes from the leaf and this exudate, when dried, is aloes. Anthraquinone glycosides are major components of aloes and include barbaloin, a glycoside of aloe-emodin to which it may be standardised, and minor glycosides such as aloinosides A and B. Aloe-emodin, chrysophanol, chromones including aloesin, aloeresin E, isoaloeresin D and furoaloesone are also present in small amounts, as are resins. Interactions overview Although aloes have been predicted to interact with a number of drugs that lower potassium levels (such as the corticosteroids and potassium-depleting diuretics), or drugs where the effects become potentially harmful when potassium is lowered (such as digoxin), there appears to be little or no direct evidence that this occurs in practice. Biotransformation of the anthraquinones emodin and chrysophanol by cytochrome P450 enzymes. However, note that, if anthraquinone laxatives are used as recommended (at a dose producing a comfortable soft-formed motion), then this interaction would not be expected to be clinically relevant. Consider also Senna + Digitalis glycosides, page 350, for the effects of anthraquinones on digoxin absorption. A Aloes + Corticosteroids Theoretically, the risk of hypokalaemia might be increased in patients taking corticosteroids, who also regularly use, or abuse, anthraquinone-containing substances such as aloes. Clinical evidence Chronic diarrhoea as a result of long-term use, or abuse, of stimulant laxatives such as aloes can cause excessive water and potassium loss; this has led to metabolic acidosis in one case. The effect of the over-use of aloes combined with systemic corticosteroids is not known, but, theoretically at least, the risk of hypokalaemia might be increased. Although this is mentioned in some reviews2 there do not appear to be any reports describing clinical cases of this effect. Mechanism In theory the additive loss of potassium, caused by anthraquinonecontaining substances and systemic corticosteroids, may result in hypokalaemia. Importance and management the interaction between aloes and corticosteroids is theoretical, but be aware of the potential in patients who regularly use, or abuse, anthraquinone-containing substances such as aloes. Aloes + Diuretics; Potassium-depleting Theoretically, patients taking potassium-depleting diuretics could experience excessive potassium loss if they also regularly use, or abuse, anthraquinone-containing substances such as aloes. Chronic diarrhoea caused by long-term use, or abuse, of stimulant laxatives such as aloes, may also lead to excessive water loss and potassium deficiency. This interaction is sometimes mentioned in reviews;1,2 nevertheless, there is little, if any, direct evidence. There appears to be one case describing a myopathic syndrome related to potassium deficiency (potassium level 1. However, even this case may not have occurred as a result of an interaction as the patient also had gastroenteritis, causing profuse diarrhoea. Aloes + Digitalis glycosides Theoretically, digitalis toxicity could develop if patients regularly use, or abuse, anthraquinone-containing substances such as aloes. Clinical evidence Chronic diarrhoea caused by the long-term use, or abuse, of stimulant laxatives such as aloes can cause excessive water and potassium loss, which may cause hypokalaemia that could lead to the development of digitalis toxicity. Although this is often mentioned in reviews1,2 there do not appear to be any reports describing clinical cases of this effect. However, for mention of a case of digoxin toxicity and mild hypokalaemia in a patient stabilised on digoxin and furosemide, who started to take a laxative containing rhubarb and liquorice, see Liquorice + Digitalis glycosides, page 274. The risk of development of digitalis toxicity, including cardiac arrhythmias, is increased by hypokalaemia, which can be induced by the excessive use of anthraquinone laxatives. Importance and management this is a theoretical interaction, but it may be prudent to exercise Mechanism Possible pharmacodynamic interaction involving additive loss of potassium and water by anthraquinone-containing substances and potassium-depleting diuretics. Importance and management this is a theoretical interaction, but be aware of the potential for hypokalaemia in patients who are taking potassium-depleting diuretics and who regularly use, or abuse, anthraquinone-containing substances such as aloes. However, note that, if anthraquinone laxatives are used as recommended (at a dose producing a comfortable soft-formed motion), then this interaction is not clinically relevant. See also Senna + Diuretics; Potassium-depleting, page 350, for the effects of anthraquinones on furosemide absorption. An evaluation of the biological and toxicological properties of Aloe barbadensis (Miller), Aloe Vera. Aloes 29 Aloes + Herbal medicines; Liquorice Consider Liquorice + Laxatives, page 275, for the potential additive effects of anthraquinone-containing laxatives and liquorice. Aloes + Quinidine Consider Senna + Quinidine, page 351 for a potential interaction between anthraquinone-containing laxatives and quinidine. A A Andrographis Andrographis paniculata Nees (Acanthaceae) Synonym(s) and related species Bhunimba, Green chiretta, Kalmegh. Constituents the whole plant contains diterpene lactone glycosides, collectively termed andrographolides, which are based on the aglycone andrographolide and its derivatives, such as neoandrographolide, deoxyandrographolide, andrographiside, andropaniside and others. Interactions overview Andrographis may have antidiabetic and antihypertensive effects, and limited evidence suggests that it may interact with conventional drugs with these properties. Andrographis may also have antiplatelet effects, and so it may interact with conventional antiplatelet drugs and anticoagulants, although evidence is sparse. Jarukamjorn K, Don-in K, Makejaruskul C, Laha T, Daodee S, Pearaksa P, Sripanidkulchai B. Impact of Andrographis paniculata crude extract on mouse hepatic cytochrome P450 enzymes. Use and indications Used in Ayurvedic medicine particularly for jaundice as a general liver and digestive system tonic, and as an immune system stimulant for treatment and prevention of infections. It is also used as an anti-inflammatory and antimalarial, and for cardiovascular disorders and diabetes. When used for the common cold, it is commonly combined with Eleutherococcus senticosus (Siberian ginseng), page 219, or echinacea, page 167. Experimental evidence Kan Jang (a standardised fixed combination of extracts from Andrographis paniculata and Eleutherococcus senticosus (Siberian ginseng), page 219) caused a modest increase in warfarin exposure, but did not alter the effect of warfarin on prothrombin time, in a study in rats. One group of animals was given an aqueous solution of Kan Jang orally for 5 days, at a dose of 17 mg/kg daily of the active principle andrographolide (a dose about 17-fold higher than that recommended for humans). Sixty minutes after the final daily dose of Kan Jang or water, an aqueous solution of warfarin was given orally, at a dose of 2 mg/kg. This may increase the risk or severity of bleeding if over-anticoagulation with warfarin occurs. Importance and management A very high dose of andrographis does not appear to directly affect prothrombin time, but may modestly increase warfarin exposure. As this study suggested that the pharmacodynamic effects of warfarin were not altered, any pharmacokinetic interaction would not be expected to be clinically relevant. However, if the antiplatelet effects of andrographis are confirmed to be clinically important, then an increased risk of bleeding would be anticipated in patients also taking warfarin, as occurs with low-dose aspirin. Therefore, until more is known, some caution is appropriate if andrographis is given in high doses for a long period of time with any anticoagulant. The effect of Kan Jang extract on the pharmacokinetics and pharmacodynamics of warfarin in rats. However, if a patient taking antidiabetic drugs wants to take andrographis it may be prudent to discuss these potential additive effects, and advise an increase in blood-glucose monitoring should an interaction be suspected. Antihyperglycemic effect of andrographolide in streptozotocin-induced diabetic rats. Anti-diabetic potentials of Momordica charantia and Andrographis paniculata and their effects on estrous cyclicity of alloxan-induced diabetic rats. A Andrographis + Antihypertensives Limited evidence suggests that andrographis may have hypotensive properties that may be additive if given with conventional antihypertensives. Clinical evidence Anecdotal evidence suggests that some patients have experienced hypotensive effects while taking andrographis. Andrographis may have antihypertensive effects, and a slight additive reduction in blood pressure is possible if it is given with conventional antihypertensives. Importance and management these experimental studies provide limited evidence of the possible hypotensive properties of andrographis. Because of the nature of the evidence, applying these results to a general clinical setting is difficult and, until more is known, it would be unwise to advise anything other than general caution. Yoopan N, Thisoda P, Rangkadilok N, Sahasitiwat S, Pholphana N, Ruchirawat S, Satayavivad J.
The average of these values would be used as the planning goal for maintenance of current weight and activity level what age does erectile dysfunction happen silagra 50mg fast delivery. However erectile dysfunction what age buy silagra 50mg lowest price, because intakes and expenditures are highly correlated erectile dysfunction and heart disease order 50 mg silagra with mastercard, and assuming that all members of the group have free access to food erectile dysfunction quiz test purchase silagra 50mg line, most members of the group will consume an amount of energy equal to their expenditure erectile dysfunction incidence age 100mg silagra overnight delivery. Thus erectile dysfunction drugs free sample cheap silagra 50mg without a prescription, planning for an intake that approximates the mean energy expenditure should allow the group to meet energy needs for weight maintenance and current activity levels. As with other planning applications, it should be emphasized that the planning goal is for energy intakes. The above approach requires the assumption that free access to food is available, that each member of the group consumes an amount of energy that approximates their individual expenditure, and that food is not wasted or spoiled. As with other planning examples, food waste and to what extent the amount of energy offered would need to exceed the target median intake need to be considered. Assessing the plan following its implementation would lead to further refinements. Assessing Energy Intakes As was true for planning, the approach to assessing the adequacy of energy intakes differs from that described for other nutrients. Perhaps more importantly though, it is related to the fact that for energy, unlike most nutrients, a readily observable, accurate biological indicator-body weight-can be used to assess the long-term adequacy of energy intake. The availability of a biological indicator to assess the adequacy of energy intake becomes particularly critical because of the effect of dietary underreporting on the assessment of adequacy. It is now widely accepted, and supported by a large body of literature, that underreporting of food intake is pervasive in dietary surveys (Black et al. Underreporters can constitute anywhere from 10 to 45 percent of the total sample, depending on the age, gender, and body composition of the sample. Underreporting tends to increase in prevalence as children age (Livingstone et al. Both the prevalence and severity of underreporting is greater among obese individuals compared with lean individuals (Bandini et al. In addition, those of low socioeconomic status (characterized by low incomes, low educational attainment, and low literacy levels) are more likely to report low energy intakes (Johnson et al. Theoretically, one could compare the usual energy intake of an individual to his or her requirement to maintain current weight and activity level, as estimated using the equations developed to estimate energy expenditure. Excessive intake must be interpreted as being excessive in relation to energy expenditure. In many cases, intake may not be excessive in absolute terms; instead, inadequate energy expenditure may be the primary factor in contributing to long-term positive energy balance. This has important implications for how this issue is best addressed at the population level. There are a number of reasons why increased energy expenditure may be a more appropriate solution than decreased energy intake to long-term positive energy balance. First, restricting energy intake also decreases the ability to meet requirements of many nutrients. Increasing physical activity, thereby improving fitness, improves health outcomes of overweight individuals irrespective of changes in relative weight (Blair et al. In addition to the major impact of underreporting on assessment of the adequacy of energy intake, it also has potential implications for other macronutrients. If it is assumed that underreporting of macronutrients occurs in proportion to underreporting of energy intake, macronutrients expressed as a percentage of energy would be relatively accurate. Underreporting would, however, overestimate the prevalence of dietary inadequacy for protein, indispensable amino acids, and carbohydrate. It could also lead to an overestimate of the percentage of energy derived from carbohydrate. Added Sugars Added sugars are defined as sugars and syrups that are added to foods during processing or preparation. Specifically, added sugars include white sugar, brown sugar, raw sugar, corn syrup, corn-syrup solids, high-fructose corn syrup, malt syrup, maple syrup, pancake syrup, fructose sweetener, anhydrous dextrose, and crystal dextrose. Since added sugars provide only energy when eaten alone and lower nutrient density when added to foods, it is suggested that added sugars in the diet should not exceed 25 percent of total energy intake. Usual intakes above this level place an individual at potential risk of not meeting micronutrient requirements. To assess the sugar intakes of groups requires knowledge of the distribution of usual added sugar intake as a percent of energy intake. Once this is determined, the percentage of the population exceeding the maximum suggested level can be evaluated. Dietary, Functional, and Total Fiber Dietary Fiber is defined in this report as nondigestible carbohydrates and lignin that are intrinsic and intact in plants. Instead, it is based on health benefits associated with consuming foods that are rich in fiber. Fiber consumption can be increased by substituting whole grain or products with added cereal bran for more refined bakery, cereal, pasta, and rice products; by choosing whole fruits instead of fruit juices; by consuming fruits and vegetables without removing edible membranes or peels; and by eating more legumes, nuts, and seeds. For example, whole wheat bread contains three times as much Dietary Fiber as white bread, and the fiber content of a potato doubles if the peel is consumed. For most diets (those that have not been fortified with Functional Fiber that was isolated and added for health purposes), the contribution of Functional Fiber is minor relative to the naturally occurring Dietary Fiber. Because there is insufficient evidence of deleterious effects of high Dietary Fiber as part of an overall healthy diet, a Tolerable Upper Intake Level has not been established. For example, a person whose energy expenditure was 2,300 kcal/day should aim for an energy intake from fat of 460 to 805 kcal/ day. Likewise, when assessing fat intakes of individuals, the goal is to determine if usual energy intake from total fat is between 20 and 35 percent. As illustrated above, this is a relatively simple calculation assuming both usual fat intake and usual energy intake are known. However, because dietary data are typically based on a small number of days of records or recalls, it may not be possible to state with confidence that a diet is within this range. If planning is for a confined population, a procedure similar to the one described for individuals may be used: determine the necessary energy intake from the planned meals and plan for a fat intake that provides between 20 and 35 percent of this value. If the group is not confined, then planning intakes is more complex and ideally begins with knowledge of the distribution of usual energy intake from fat. Then the distribution can be examined, and feeding and education programs designed to either increase, or more likely, decrease the percent of energy from fat. Assessing the fat intake of a group requires knowledge of the distribution of usual fat intake as a percent of energy intake. Thus, there are several considerations when planning and evaluating n-3 and n-6 fatty acid intakes. However, with increasing intakes of either of these three nutrients, there is an increased risk of coronary heart disease. Chapter 11 provides some dietary guidance on ways to reduce the intake of saturated fatty acids, trans fatty acids, and cholesterol. For example, when planning diets, it is desirable to replace saturated fat with either monounsaturated or polyunsaturated fats to the greatest extent possible. This implies that requirements and recommended intakes vary among individuals of different sizes, and should be individualized when used for dietary assessment or planning. However, this method requires a number of assumptions, including that the individual requirement for the nutrient in question has a symmetric distribution. Thus, determining a recommended protein intake based on current body weight may not be appropriate for those who are significantly underweight or overweight. A patient weighing 40 kg, whose body weight when healthy was 55 kg, could thus have a recommended protein intake of 44 g/day (55 kg Ч 0. Conversely, protein intakes recommended for individuals who are morbidly obese could be based on the amounts recommended for those with more normal body weights. In other words, it was not necessary to assess or plan for intakes of indispensable amino acids. The simplest scenario for answering this question relates to dietary planning for individuals. Data in Table 13-2 suggest that although most protein sources provide recommended amounts of threonine, tryptophan, and sulfur-containing amino acids, this is not true for lysine. Even then, diets could be marginal, as the data in Table 13-2 regarding amino acid composition do not account for the apparent lower digestibility of some plant protein sources. Thus, it appears that, in addition to assessing and planning total protein intakes, it is also necessary to assess and plan for intakes of the amino acid lysine in individuals consuming proteins with low levels of lysine. The example that follows illustrates how these considerations might be addressed in planning the macronutrient intake of an individual. Her job is not physically active, and she does little planned exercise, so it might appear that activity level would be classified as sedentary. However, to provide a more reliable indication of her activity level, she keeps a 7-day record of her activities using a chart similar to that provided in Chapter 12 (Table 12-3), and this also confirms that she is sedentary. Energy Because recommended intakes of at least some nutrients relate to energy requirements, the first step would be to estimate her energy expenditure. Assuming it was appropriate to maintain her current weight and activity level, the Estimated Energy Requirement for a woman with her characteristics would be about 2,000 kcal/day. Of course, her individual energy expenditure could be above or below this amount, but it provides a starting point. An additional consideration would be that her current activity level is less than the recommended of "active. Therefore, her diet should provide these levels of fatty acids, which would provide 9. In addition, she would need to meet recommended intakes of indispensable amino acids, of which lysine is most likely to be limiting. Energy Distribution the amount of energy provided by the recommended intakes of essential fatty acids, protein, and carbohydrate totals only 818 kcal/day, yet her estimated requirement is approximately 2,000 kcal/day. Her energy intake might be allocated among macronutrients as shown in Table 13-3 for an overall healthy diet. Because the estimated energy expenditure of 2,000 kcal/day may differ from actual energy expenditure (and lead to changes in weight that may not be desirable), her weight should be monitored over time and energy intake adjusted as appropriate. Comparison of high-calorie, low-nutrient-dense food consumption among obese and nonobese adolescents. Number of days of food intake records required to estimate individual and group nutrient intakes with defined confidence. Physical activity, physical fitness, and all-cause mortality in women: Do women need to be active? Use of semiquantitative food frequency questionnaires to estimate the distribution of usual intake. Evaluation of true status requires clinical, biochemical, and anthropometric data. Infants consuming formulas with the same nutrient composition as human milk consume an adequate amount after adjustments are made for differences in bioavailability. As such, it is below the needs of half the individuals with specified characteristics and exceeds the needs of the other half. Correlates of over- and underreporting of energy intake in healthy older men and women. Database and quick methods of assessing typical dietary fiber intakes using data for 228 commonly consumed foods. The relation between energy intake derived from estimated diet records and intake determined to maintain body weight. Inaccuracies in self-reported intake identified by comparison with the doubly labelled water method. This chapter describes the approach used to develop the research agenda, briefly summarizes gaps in knowledge, and presents a prioritized research agenda. Sections at the end of Chapters 5 through 10 and Chapter 12 presented prioritized lists of research topics. Identify gaps in knowledge to understand the role of macronutrients in human health, functional and biochemical indicators to assess macronutrient requirements, methodological problems related to the assessment of intake of these macronutrients and to the assessment of adequacy of intake, relationships of nutrient intake to chronic disease, and adverse effects of macronutrients. Examine data to identify major discrepancies between intake and recommended intakes and consider possible reasons for such discrepancies. Consider the need to protect individuals with extreme or distinct vulnerabilities due to genetic predisposition or disease conditions. For some of the macronutrients considered in this report, such as n-6 and n-3 polyunsaturated fatty acids, there is a dearth of information on the biochemical values that reflect abnormal function. A priority should be to determine if there is a correlation between existing status indicators and clinical endpoints in the same subjects. For some macronutrients, such as indispensable amino acids, more data are needed using clinical endpoints or intermediate endpoints of impaired function to determine their requirements in regard to long-term health. For determining energy requirements, more information is needed on the form, frequency, intensity, and duration of exercise that is consistent with a healthy body weight for all age groups. The number of doubly labeled water studies for the determination of total energy expenditure in certain life stage and gender categories is limited and should be expanded. For many of the essential macronutrients, useful data are seriously lacking for setting requirements for infants, children, adolescents, pregnant and lactating women, and the elderly. As an example, more information is needed on the role of n-3 polyunsaturated fatty acids in the neurodevelopment of term infants. Studies should use graded levels of nutrient intake and a combination of response indexes, and they should consider other points raised above. For some of the macronutrients, studies should examine whether the requirement varies substantially by trimester of pregnancy. Data are lacking about gender issues with respect to metabolism and requirements of macronutrients. Methodology For some macronutrients, serious limitations exist in the methods available to analyze laboratory values indicative of energy balance and macronutrient status. For instance, biological markers of risk of excess weight gain in children and young adults are needed, as are the standardization and validation of indicators in relation to functional outcome.
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