Presentación realizada por Holger Schünemann, profesor y director del Departamento de Epidemiología Clínica y Bioestadísticas en la Universidad McMaster de Hamilton, Canadá, en las Jornadas Científicas "Guías de Práctica Clínica y Pluripatología" de GuíaSalud, Madrid, 21 de febrero de 2013.
Typhoid perforation is a serious complication of typhoid fever, a bacterial infection caused by Salmonella typhi. It occurs when the infection causes a hole to form in the wall of the intestine, leading to the leakage of contents from the intestine into the abdominal cavity. This can cause severe infection and inflammation of the abdominal cavity, known as peritonitis.
The symptoms of typhoid perforation may include severe abdominal pain, fever, nausea and vomiting, diarrhea or constipation, and signs of shock such as low blood pressure and rapid heart rate. In some cases, there may also be visible signs of a perforation, such as a palpable abdominal mass or signs of fluid accumulation in the abdomen.
The diagnosis of typhoid perforation is typically made through a combination of physical examination, laboratory tests, and imaging studies such as X-rays or CT scans. Treatment typically involves surgical repair of the perforation and aggressive management of the infection and inflammation. This may include antibiotics, intravenous fluids, and other supportive care measures such as pain management and nutritional support.
It is important to seek prompt medical attention if you suspect you or someone you know may have typhoid fever or typhoid perforation. Early diagnosis and treatment are essential for a successful outcome and to prevent further complications.
In the vedio you can see how the presentation was supposed to be
The link :
http://www.youtube.com/watch?v=MFBdaSF-JqM
To download my Animated presentation vist
https://www.dropbox.com/s/qg6ie3mpcbvp793/Gastric.Ulcer.ToPost.pptx
Thanks for watching
Typhoid perforation is a serious complication of typhoid fever, a bacterial infection caused by Salmonella typhi. It occurs when the infection causes a hole to form in the wall of the intestine, leading to the leakage of contents from the intestine into the abdominal cavity. This can cause severe infection and inflammation of the abdominal cavity, known as peritonitis.
The symptoms of typhoid perforation may include severe abdominal pain, fever, nausea and vomiting, diarrhea or constipation, and signs of shock such as low blood pressure and rapid heart rate. In some cases, there may also be visible signs of a perforation, such as a palpable abdominal mass or signs of fluid accumulation in the abdomen.
The diagnosis of typhoid perforation is typically made through a combination of physical examination, laboratory tests, and imaging studies such as X-rays or CT scans. Treatment typically involves surgical repair of the perforation and aggressive management of the infection and inflammation. This may include antibiotics, intravenous fluids, and other supportive care measures such as pain management and nutritional support.
It is important to seek prompt medical attention if you suspect you or someone you know may have typhoid fever or typhoid perforation. Early diagnosis and treatment are essential for a successful outcome and to prevent further complications.
In the vedio you can see how the presentation was supposed to be
The link :
http://www.youtube.com/watch?v=MFBdaSF-JqM
To download my Animated presentation vist
https://www.dropbox.com/s/qg6ie3mpcbvp793/Gastric.Ulcer.ToPost.pptx
Thanks for watching
Natural History of Disease & Levels of preventionsourav goswami
I have tried to explain the National History of Disease taking the example of a disease condition. Similarly, the different prevention levels are also explained in a similar manner. The presentation also includes few newer concepts of screening like lead time and length time bias.
N.B: Please download to see all the animations.
Contains bullet-point summary of questions to be asked in medical interview / consultation based on the presenting complaint or system. Contains additional information on clinical reasoning and developing a differential diagnosis
This is a presentation which gives you a basic idea about clinical application of tuberculosis including pathology,clinical features,investigations and management.
Elaboración de recomendaciones en GPC. Sistema GRADE 2GuíaSalud
Presentación realizada por Pablo Alonso Coello, miembro del Centro Cochrane Iberoamericano sobre la utilización del sistema GRADE para la elaboración de recomendaciones en guías de práctica clínica. Presentación realizada en la Jornada Cienfífica de GuíaSalud 2011 "Avances en el desarrollo de Guías de Práctica Clínica"
Portal GuíaSalud http://www.guiasalud.es
¿Cómo elaborar e implementar GPC dirigidas a pacientes con enfermedades cr…GuíaSalud
Presentación realizada por Javier Gracia San Román, Director del Comité Científico de GuíaSalud, en las Jornadas Científicas "Guías de Práctica Clínica y Pluripatología" de GuíaSalud, Madrid, 21 de febrero de 2013.
Natural History of Disease & Levels of preventionsourav goswami
I have tried to explain the National History of Disease taking the example of a disease condition. Similarly, the different prevention levels are also explained in a similar manner. The presentation also includes few newer concepts of screening like lead time and length time bias.
N.B: Please download to see all the animations.
Contains bullet-point summary of questions to be asked in medical interview / consultation based on the presenting complaint or system. Contains additional information on clinical reasoning and developing a differential diagnosis
This is a presentation which gives you a basic idea about clinical application of tuberculosis including pathology,clinical features,investigations and management.
Elaboración de recomendaciones en GPC. Sistema GRADE 2GuíaSalud
Presentación realizada por Pablo Alonso Coello, miembro del Centro Cochrane Iberoamericano sobre la utilización del sistema GRADE para la elaboración de recomendaciones en guías de práctica clínica. Presentación realizada en la Jornada Cienfífica de GuíaSalud 2011 "Avances en el desarrollo de Guías de Práctica Clínica"
Portal GuíaSalud http://www.guiasalud.es
¿Cómo elaborar e implementar GPC dirigidas a pacientes con enfermedades cr…GuíaSalud
Presentación realizada por Javier Gracia San Román, Director del Comité Científico de GuíaSalud, en las Jornadas Científicas "Guías de Práctica Clínica y Pluripatología" de GuíaSalud, Madrid, 21 de febrero de 2013.
El papel de las guías de práctica clínica en el abordaje del paciente con …GuíaSalud
Presentación realizada por Pilar Román Sánchez (Presidente de la Sociedad Española de Medicina Interna y Coordinadora del Abordaje de la Cronicidad del SNS) en las Jornadas Científicas "Guías de Práctica Clínica y Pluripatología" de GuíaSalud, Madrid, 21 de febrero de 2013.
Presentación realizada por Victor M. Montori, Profesor de Medicina, Mayo Clinic, en las Jornadas Científicas "Guías de Práctica Clínica y Pluripatología" de GuíaSalud, Madrid, 21 de febrero de 2013.
¿Cómo elaborar e implementar GPC dirigidas a pacientes con enfermedades cr…GuíaSalud
Presentación realizada por Rafael Rotaeche, médico de familia en el Centro de Salud Alza, del Servicio Vasco de Salud - Osakidetza en las Jornadas Científicas "Guías de Práctica Clínica y Pluripatología" de GuíaSalud, Madrid, 21 de febrero de 2013.
Diseminando recomendaciones a clínicos, pacientes/publico y decisores en saludGuíaSalud
"Diseminando recomendaciones a clínicos, pacientes/publico y decisores en salud" presentación realizada por Pablo Alonso Coello, investigador del Centro Cochrane Iberoamericano (CIBERESP-IIB Sant pau) en las Jornadas Científicas de GuíaSalud (Madrid, 4 abril 2016)
Elaborando Guías de Práctica Clínica innovadoras para el Sistema Nacional de ...GuíaSalud
"Elaborando Guías de Práctica Clínica innovadoras para el Sistema Nacional de Salud (II)" presentación realizada por Rafael Rotaeche del Campo, Médico de familia de Osakidetza en las Jornadas Científicas de GuíaSalud (Madrid, 4 abril 2016)
Estrategias para Implementación de las Guías de Práctica ClínicaGuíaSalud
"Estrategias para Implementación de las Guías de Práctica Clínica" presentación realizada por Andrew D. Oxman, investigador del Norwegian Institute of Public Health en las Jornadas Científicas de GuíaSalud (Madrid, 4 abril 2016)
"Formulando recomendaciones implementables" presentación realizada por por Andrew D. Oxman, investigador del Norwegian Institute of Public Health en las Jornadas Científicas de GuíaSalud (Madrid, 4 abril 2016)
Investigación en multimorbilidad. El Papel de las guías de práctica clínic…GuíaSalud
Presentación realizada por Alexandra Prados Torres (grupo investigación en enfermedades crónicas EpiChron) del IACS en las Jornadas Científicas "Guías de Práctica Clínica y Pluripatología" de GuíaSalud, Madrid, 21 de febrero de 2013.
Elaborando Guías de Práctica Clínica innovadoras para el Sistema Nacional de ...GuíaSalud
"Elaborando Guías de Práctica Clínica innovadoras para el Sistema Nacional de Salud (I)" presentación realizada por Javier Gracia San Román, Director del Comité Científico de GuíaSalud en las Jornadas Científicas de GuíaSalud (Madrid, 4 abril 2016)
Guías de Práctica Clínica: Actualización continuaGuíaSalud
"Guías de Práctica Clínica: Actualización continua" presentación realizada por Laura Martínez García, investigadora del Centro Cochrane Iberoamericano (IIB Sant Pau) en las Jornadas Científicas de GuíaSalud (Madrid, 4 abril 2016)
GuíaSalud. Programa de Guías de Práctica Clínica en el Sistema Nacional de Sa...GuíaSalud
"GuíaSalud. Programa de Guías de Práctica Clínica en el Sistema Nacional de Salud: Pasos para el cambio" presentación realizada por Sandra García Armesto, Directora Gerente del Instituto Aragonés de Ciencias de la Salud en las Jornadas Científicas de GuíaSalud (Madrid, 4 abril 2016)
Evidence based decision making in periodonticsHardi Gandhi
INTRODUCTION TO EVIDENCE BASED DENTISTRY
EVIDENCE BASED PERIODONTOLOGY
NEED, PRINCIPLES, GOALS AND ADVANTAGES OF EBDM
SKILLS NEEDED FOR EBDM
ASSESING THE EVIDENCE
INCORPORATING INTO THE PRACTICE
This is the handout version of a lecture I give to medical residents and fellows on the basics of clinical research designs and the inherent issues that go along with each one. I give this lecture as part of a multi-module lecture series on research design and statistical analysis.
Validity and bias in epidemiological studyAbhijit Das
Validity and bias are essential aspects of any research—a brief description of internal and external validity and different types of bias related to the epidemiological study.
Systematic (non-random) error that results in an incorrect estimate of the association between exposure and risk of disease.
Can occur in all stages of a study
Not affected by study sample size
Difficult to adjust for afterwards, but can be reduced by adequate study design.
•Can never be totally avoided, but we must be aware of it and interpret our results accordingly
Study of the distribution and determinants of
health-related states or events in specified populations and the application of this study to control health problems.
John M. Last, Dictionary of Epidemiology
Nonverbal Communication: Eye contact between physicians and older-patients i...rgbhat
This PP presentation delineates the nature of eye contact in anxiety-provoking interactions (e.g. cancer, acute medical visits) and compares it with eye contact in routine medical visits.
La participación de los pacientes en la elaboración y difusión de GPC. GuíaSalud
Jesusa Izquierdo Izquierdo. Paciente de Distrofias Hereditarias de Retina, Federación de Asociaciones de Retinosis Pigmentaria de España (FARPE), miembro del Grupo Elaborador de la GPC sobre Distrofias Hereditarias de Retina.
Información de las GPC para los pacientes. GuíaSalud
Xavier Krauel Vidal. Neonatólogo, ilustrador de la Guía para madres y padres de la GPC sobre Encefalopatía Hipóxico-Isquémica Perinatal en el Recién Nacido.
Utilización de la evidencia cualitativa para mejorar la inclusión de las pref...GuíaSalud
Tercera intervención de la Mesa 1 de la Jornada científica GuíaSalud 2017: La implicación de pacientes en el desarrollo de GPC. Una estrategia necesaria para mejorar la toma de decisiones. Simon Lewin
La participación de pacientes en las GPC del Programa de GPC en el SNS de Guí...GuíaSalud
Segunda intervención de la Mesa 1 de la Jornada científica GuíaSalud 2017: La implicación de pacientes en el desarrollo de GPC. Una estrategia necesaria para mejorar la toma de decisiones. Yolanda Triñanes Pego
GPC y Herramientas de Ayuda para la Toma de Decisiones (HATD). Un trabajo col...GuíaSalud
Tercera intervención de la Mesa 2 de la Jornada científica GuíaSalud 2017: Toma de decisiones compartidas, un largo camino por recorrer. Lilisbeth Perestelo-Pérez
Profesionales y pacientes. Tomando juntos decisiones.GuíaSalud
Segunda intervención de la Mesa 2 de la Jornada científica GuíaSalud 2017: Toma de decisiones compartidas, un largo camino por recorrer. Ana Carvajal de la Torre.
Primera intervención de la mesa 1 de la Jornada científica GuíaSalud 2017: La implicación de pacientes en el desarrollo de GPC. Una estrategia necesaria para mejorar la toma de decisiones. Pilar Pazos Casal
Diferencias entre el Programa de GPC en el SNS y el Catálogo de GPC en el SNS...GuíaSalud
A menudo se suelen confundir estos dos productos que se ofrecen desde GuíaSalud. Esta infografía trata de resolver este problema de forma sintética y visualmente
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...
Integrating multiple co-morbidities in guidelines
1. Holger Schünemann
Professor and Chair, Dept. of Clinical Epidemiology & Biostatistics
Professor of Medicine
Michael Gent Chair in Healthcare Research
McMaster University, Hamilton, Canada
Madrid, February 21, 2013 (recorded slides)
Integrating multiple co-morbidities in
guidelines
Acknowledgment
Mr. W. Wiercioch
Dr. Pablo Alonso
Co-authors
2.
3. Disclosure
• No direct/personal for-profit payments to me or my
research group
• Co-chair of GRADE working group
• Cochrane Collaboration
– Co-convenor of the Applicability and Recommendations
Methods Group
– Various other functions
• IQWiG Scientific Board
4. Content
1. Intro to considering multiple co-morbidities
2. How important are multiple comorbidities for guidelines?
3. How have other organizations involved in the
development of guidelines for single chronic disease
approached the problem of multiple comorbidities?
4. What are the implications of multiple comorbidities for
pharmacological treatment?
5. What are the potential changes induced by multiple
comorbidities in guidelines?
6. What are the implications of considering a population of
older patients with multiple comorbidities in designing
clinical trials?
6. Framing a foreground question
Population: Patients with COPD
Intervention: Respiratory rehabilitation
Comparison: No respiratory rehabilitation
Outcomes: Mortality, hospitalizations,
resource use, adverse
outcomes
Schunemann, Hill et al., The Lancet ID,
2007
7. Importance of multiple comorbidities for
guidelines
• COPD commonly exists in patients who often have
multiple comorbidities:
– e.g. heart failure, coronary artery disease,
hypertension, diabetes mellitus, metabolic syndrome,
cancer, depression
• These comorbidities affect the epidemiology,
pathophysiology, and care of COPD, as well as
that of the comorbid disease(s)
• For example, COPD and cardiovascular disease
(a non-respiratory comorbidity):
– Symptoms of COPD and comorbidities may overlap
– Underlying pathology may be shared
– Treatments may interact
– Natural history of conditions may be altered
9. Indirectness - population
Outpatient respiratory
rehabilitation in patients with
COPD
COPD and heart
COPD and heart failure
failure
No concerns about directness (transferability) Concerns about directness
No lowering of confidence Lower confidence
Same recommendation Separate recommendation
10. Indirectness - population
Outpatient respiratory
rehabilitation
in patients with COPD
COPD and heart
failure
Is the effect the same
in patients who also
have heart failure
No concerns about directness (transferability) Concerns about directness
No lowering of confidence Lower confidence
Same recommendation Separate recommendation
13. Determinants of confidence:
GRADE
• Any evidence
• 5 factors that can lower confidence
1. limitations in detailed study design and execution
(risk of bias criteria)
2. Inconsistency (or heterogeneity)
3. Indirectness (PICO and applicability)
4. Imprecision
5. Publication bias
• 4 factors can increase confidence
1. Randomization
2. large magnitude of effect
3. opposing plausible residual bias or confounding
4. dose-response gradient
14. Lowering confidence in RCTs
Table: GRADE's approach to rating quality of evidence (aka confidence in effect estimates)
For each outcome based on a systematic review and across outcomes (lowest quality across the outcomes critical for decision making)
1. 2. 3.
Establish initial Consider lowering or raising Final level of
level of confidence level of confidence confidence rating
Study design Initial Reasons for considering lowering Confidence
confidence or raising confidence in an estimate of effect
in an estimate across those considerations
of effect Lower if Higher if*
High Risk of Bias Large effect High
Randomized trials
confidence
Inconsistency Dose response
Indirectness All plausible Moderate
confounding & bias
Imprecision would reduce a
Low demonstrated effect Low
Observational studies Publication bias
confidence or
would suggest a
spurious effect if no Very low
effect was observed
*upgrading criteria are usually applicable to observational studies only.
15. 1. How important are multiple comorbidities for
guidelines? K
2. How have other organizations involved in the
ey questions
development of guidelines for single chronic
disease approached the problem of multiple
comorbidities?
3. What are the implications of multiple
comorbidities for pharmacological treatment?
4. What are the potential changes induced by
multiple comorbidities in guidelines?
5. What are the implications of considering a
population of older patients with multiple
comorbidities in designing clinical trials?
16. Importance of multiple comorbidities for
guidelines
• Increase in the prevalence of multiple
comorbidities with advanced age
– 33% in 65-69 year-old age group, and ≥50% in 85+
year-old age group, have 3 or more chronic
conditions
• Multiple comorbidities influence the clinical
manifestations and natural history of a chronic
disease
• Multiple comorbidities must be taken into account
in considering diagnosis, assessment of severity,
prognosis, and management of a chronic disease
(i.e. the topics covered in a clinical guideline)
• Implementing single disease guidelines presents a
challenge to clinicians treating the average
population of patients with multiple comorbidities
17. 1. How important are multiple comorbidities for
guidelines? K
ey questions
2. How have other organizations involved in the
development of guidelines for single chronic
disease approached the problem of multiple
comorbidities?
3. What are the implications of multiple
comorbidities for pharmacological treatment?
4. What are the potential changes induced by
multiple comorbidities in guidelines?
5. What are the implications of considering a
population of older patients with multiple
comorbidities in designing clinical trials?
18. Approaches of other organizations in
addressing problem of multiple comorbidities
• Recent guidelines for COPD:
– Acknowledge the importance of considering multiple
comorbidities in diagnosis, prognosis, and management
– Acknowledge the lack of evidence and specific guidance for
clinicians to make these considerations
– Provide few recommendations on how to modify care based
on multiple comorbidities
• Recent guidelines for other common chronic diseases
– CHF, hypertension, and diabetes mellitus guidelines address
poorly some comorbidities, including COPD, one at a time,
failing to address coexistence of multiple comorbidities at the
same time
– Underrepresentation of individuals 80 years and older
– Few adequately address issues directly related to elderly
patients with comorbidities
19. Approaches of other organizations in
addressing problem of multiple comorbidities
• There are some examples of collaborative guideline
development that may serve as a model for future work
• European Society of Cardiology participating in joint
development of cardiovascular disease prevention
recommendations with 9 other societies
• American Geriatrics Society/California HealthCare Foundation
guideline for care of the older patient with diabetes mellitus:
– Selected six chronic conditions common in people with
diabetes mellitus and reviewed literature on each topic
– Limited availability of data specific to older adults for most
topic areas
– Extrapolation of findings based on data for persons of younger
ages
– Example Recommendation Statement: “The older adult who
has diabetes mellitus is at increased risk for major depression
and should be screened for depression during the initial
evaluation period (first 3 months) and if there is any
unexplained decline in clinical status. (IIA)” Brown AF, Mangione CM, Saliba D, Sarkisian CA.
Guidelines for improving the care of the older
person with diabetes mellitus. J Am Geriatr Soc
2003;51:S265–S280.
20. Approaches of other organizations in
addressing problem of multiple comorbidities
• All chronic disease guidelines should have
a separate section on comorbidities, with a
summary of basic recommendations on
diagnosis, assessment of severity, and
treatment of each comorbid condition that
can be derived from other high-quality
guidelines or developed de novo
21. 1. How important are multiple comorbidities for
guidelines? K
ey question
2. How have other organizations involved in the
development of guidelines for single chronic
disease approached the problem of multiple
comorbidities?
3. What are the implications of multiple
comorbidities for pharmacological treatment?
4. What are the potential changes induced by
multiple comorbidities in guidelines?
5. What are the implications of considering a
population of older patients with multiple
comorbidities in designing clinical trials?
22. Implications of multiple comorbidities for
pharmacological treatment
• Primary focus on the management of a single
disease may inadvertently lead to
undertreatment, overtreatment, or
inappropriate treatment:
– Excess medication administration from adding
treatments for the same condition when other
causes are not considered and there is a lack of
response to therapy
– Therapeutic efficacy of a medication is often
evaluated for treatment of a single index condition
and the medication may have unanticipated
effects on patients with other illnesses
23. Implications of multiple comorbidities for
pharmacological treatment
• Problem of adverse effects of
pharmacological agents in patients with
COPD:
– Systemic steroids are recommended for
treatment of exacerbations of COPD, but
increase risk of hyperglycemia in patients with
COPD and diabetes mellitus, and may worsen
osteoporosis
– Beta-blockers are recommended for treatment
of CHF, but can exacerbate respiratory
symptoms in patients with COPD who also
have asthma
24. Implications of multiple comorbidities for
pharmacological treatment
• Strategies can be used to account for possible effect
modification and interaction of different
pharmacological agents:
– Demonstrate whether the effects will differ in the
population for whom the recommendation is intended
from that in whom the evidence is obtained
– Or, demonstrate that there is evidence of an interaction
between different interventions that would change the
benefit-downside profile compared with when the
interventions are administered alone
• Key Message: Evidence that is less direct,
compared with evidence that directly supports the
recommendations, influences the confidence in how
the obtained effects relate to the population of
interest.
25. Population indirectness:
Does the recommendation apply to the
population treated/managed by the
decision maker?
Relative effect Assumed & described
applies? baseline risk estimate
Interaction? May be related if from same
evidence base applies?
Risk group correct (same
features)?
Influenced by the confidence in the estimate of the
baseline risk estimate that was assumed when
modeling?
Risk of bias, imprecision, publication bias,
inconsistency, upgrading criteria apply
26. 1. How important are multiple comorbidities for
guidelines? K
ey questions
2. How have other organizations involved in the
development of guidelines for single chronic
disease approached the problem of multiple
comorbidities?
3. What are the implications of multiple
comorbidities for pharmacological treatment?
4. What are the potential changes induced by
multiple comorbidities in guidelines?
5. What are the implications of considering a
population of older patients with multiple
comorbidities in designing clinical trials?
27. Potential changes induced by multiple
comorbidities in guidelines
• Underlying Question: How should
physicians make treatment recommendations
for people with multiple comorbidities,
particularly if they are elderly?
– Clinical decision-making in such patients requires
estimation of the often subtle balance of benefits
and harms, i.e. the net benefits or net harms
– This frequently involves considerable uncertainty,
and requires estimation of a baseline risk over a
given time period
– Values and preferences patients place on
treatment options and outcomes
• Patient-oriented guidance must incorporate
these judgments
28. Potential changes induced by multiple
comorbidities in guidelines
To address these issues, comorbidities could be considered in all
disease guidelines in several aspects:
1. Explicitly discussing whether patients with the most
common comorbidities were included in the disease-
specific trials
– Is the patient, to whom the study results are being applied,
sufficiently like, or exchangeable to, the average patient in the
trial?
– When high-quality randomized studies are available, the
evidence will frequently be indirect for the multi-morbid
population, and the quality of evidence may be downgraded
– Review of the evidence in layers considering both people with
and without multiple comorbidities, as well as people of different
ages
2. Considering the absolute risk reduction from therapy for
a patient with multiple comorbidities
– Recognize that a person with multiple comorbidities may be at
either higher or lower absolute risk than the ‘average’ person
– Is it known whether the relative benefit of therapy increases or
decreases in people with each combination of the multiple
29. 1. How important are multiple comorbidities for
guidelines? K
ey questions
2. How have other organizations involved in the
development of guidelines for single chronic
disease approached the problem of multiple
comorbidities?
3. What are the implications of multiple
comorbidities for pharmacological treatment?
4. What are the potential changes induced by
multiple comorbidities in guidelines?
5. What are the implications of considering a
population of older patients with multiple
comorbidities in designing clinical trials?
30. Implications of considering a population with
multiple comorbidities in designing clinical trials
• Patients in clinical trials do not adequately
reflect the true population of people with any
chronic disease in terms of the burden of
multiple comorbidities
– Older patients and patients with multiple
comorbidities are specifically excluded from most
clinical trials
– The number of trials with explicit age exclusions
for older patients has decreased, but exclusions
for comorbidities have increased
• Exclusion and inclusion criteria are less
important than who is the ‘average’ patient in a
trial. Few exclusion criteria may still not prevent
few people with comorbidities being enrolled
and results will be of questionable relevance.
31. Implications of considering a population with
multiple comorbidities in designing clinical trials
• Key Message: Developing recommendations for patients with
multiple comorbidities requires careful consideration of the
directness of evidence
Fails to reflect diversity
of the population
Broadly representative of
the population in terms of
risk, responsiveness, and
vulnerability
Individuals who benefit
much more from treatment
than average members of
the population
From: Kravitz RL, Duan N, Braslow J. Evidence‐based medicine, heterogeneity
of treatment effects, and the trouble with averages. Milbank Q 2004;82:661–687.
32. Summary
Framework for Development of Multiple Comorbidity
Clinical Practice Guidelines and Patient Involvement
Step How Example for COPD
1. Define all problems for a Ask patients or review the literature Primary concern: Dyspnea,
given patient depression, swelling of legs?
2. Which outcome is of Use tools to elicit values and preferences Ranking techniques, e.g.
greatest importance (e.g. ranking exercises, visual analog comparing dyspnea with
to a patient with multiple tools) fatigue and hospitalizations
co‐morbidity (described in detail)
3. Define possible options Literature search (focus on SR), expert LABA, diuretics, beta‐blockers,
to intervene input on what might work antidepressants
4. Evaluate whether ‐ Evaluate subgroup effects/ ‐ LABAs may be worse in
benefits or downsides heterogeneity patients with dyspnea
differ across ‐ Did trials include subgroups and are from COPD and CHF
populations (in particular subgroup effects credible? ‐ Treatment of dyspnea
those with different ‐ Evidence that biology differs? leads to improvement in
comorbidity) ‐ Judgement about directness of evidence depression
5. Evaluate greatest net ‐ Systematically judge expected benefits ‐ Beta‐blockers with greatest
benefit across populations against potential downsides after net benefit in pop. of interest
based on evidence profiles considering various interventions ‐ Treatment of depression
and present to panel ‐ Explain to patients second largest net benefit
making recommendations ‐ LABA and diuretic net benefit
and to patients smaller than beta‐blockers