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People who were previously infested are sensitized and may develop symptoms in 1 Yes buy ditropan 2.5 mg visa gastritis chronic cure, until after treatment to 4 days ditropan 5mg cheap gastritis symptoms and chest pain. Spread - By having repeated direct contact with the skin of a person with scabies buy ditropan with amex gastritis bananas. Contagious Period From when a child gets the mites until 24 hours after treatment begins discount ditropan 5mg free shipping gastritis diet vegetarian. Prevention  At time of treatment, wash items used in the past 48 hours in hot water and put them in a hot dryer. These bacteria can easily spread from person to person, especially from children in diapers. Outbreaks have been linked to ground beef, exposure to animals in public settings including petting zoos, unpasteurized dairy products or fruit juices, raw fruits and vegetables, salami, yogurt, drinking water, and recreational water. Specimens should not be obtained earlier than 48 hours after discontinuation of antibiotics. The child care should be closed to new admissions during the outbreaks, and no transfer of exposed children to other centers should be allowed. Outbreaks: Screenings should be conducted by the Missouri State Public Health Lab. Other restrictions may apply; call your local/state health department for guidance. Wash hands thoroughly with soap and warm running water after using the toilet and changing diapers and before preparing or eating food. Staff should closely monitor/assist handwashing of all children, as appropriate, after they have used the bathroom or have been diapered. In the classroom, children should not serve themselves food items that are not individually wrapped. Wash hands thoroughly with soap and warm running water after touching any animals. Use a thermometer o to ensure that the internal temperature of the meat is at least 155 F. Childcare: Spread Yes, until diarrhea has - By eating or drinking contaminated food or beverages. Prevention  Wash hands after using the toilet and changing diapers and before preparing food or eating. Spread can occur when people do not properly wash their hands after using the toilet or changing diapers. If not removed by good handwashing, the Shigella bacteria may contaminate food or objects (such as toys) and infect another person when the food or object is placed in that person’s mouth. For some children, the bacteria can be found in the feces up to 4 weeks after illness. The child care should be closed to new admissions during the outbreaks, and no transfer of exposed children to other centers should be allowed. Shigellosis is transmitted easily and can be severe, so all symptomatic persons (employees and children) should be excluded from childcare setting in which Shigella infection has been identified, until diarrhea has ceased for 24 hours, and one (1) stool culture is free of Shigella spp. Specimens should not be obtained earlier than 48 hours after discontinuation of antibiotics. Antimicrobial therapy is effective in shortening the duration of diarrhea and eradicating organisms from feces. No one with Shigella should use swimming beaches, pools, spas, water parks, or hot tubs until 1 week after diarrhea has stopped. Food service employees infected with Shigella bacteria should be excluded from working in food service. Other restrictions may apply; call your local/state health department for guidance. Shigella bacteria can be resistant to one or more antibiotics, so physicians should test to see which antibiotics are effective. Wash hands thoroughly with soap and warm running water after using the toilet or changing diapers and before preparing or eating food. Staff should closely monitor or assist all children, as appropriate, with handwashing after children have used the bathroom or been diapered. In the classroom, children should not serve themselves food items that are not individually wrapped. If you think your child Symptoms has Shigellosis: Your child may have diarrhea (may be watery and/or  Tell your childcare contain blood or mucus), stomach cramps, nausea, provider or call the vomiting, or fever. Childcare: Spread Yes, until the child has - By eating or drinking contaminated food or beverages. No, unless the child is not feeling well and/or Call your Healthcare Provider has diarrhea. Prevention  Wash hands after using the toilet or changing diapers and before preparing food or eating. This usually occurs when the immune system is weakened for various reasons, including certain illnesses or conditions, or treatments, or aging. Although shingles usually occurs in adulthood, children who were infected with varicella in utero or during infancy may develop shingles during childhood. Clusters of blisters appear soon after, usually on one side of the body and closer together than in chickenpox. Shingles is a milder illness in children than in adults, but it can be a serious illness in those who have weakened immune systems. When people who have not had chickenpox have contact with the fluid from the shingles blisters, they can develop chickenpox. Persons with severe, disseminated shingles should be excluded regardless of whether the sores can be covered. Wash hands thoroughly with soap and warm running water after contact with fluid from blisters or sores. Getting varicella vaccine within 3 days, and possibly up to 5 days, of exposure may prevent chickenpox in these people. If you think your child Symptoms has Shingles: At first, your child may have a lot of pain and itching. Childcare and School: Spread No, if blisters can be covered with clothing or Shingles does not spread from person-to-person as bandage. If someone who has not had chickenpox in the past touches the fluid from the shingles blisters they may Yes, if blisters cannot be get chickenpox. When staph is present on or in the body without causing illness, it is called colonization. Because staph is so often present on skin, it is the leading cause of skin and soft tissue infections.

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During operations order ditropan in india gastritis spanish, surgeons can see through anatomical structures such as blood vessels in the liver based on the patient’s radiology images therefore they can perform more precise excisions cheap 5 mg ditropan gastritis symptoms on dogs. Recreational Cyborgs Cyborgs will be everywhere around us including a new generation of hipsters who implant devices and technologies in their bodies just to look better or have new functionalities buy cheap ditropan 5mg online gastritis diet . Advances in medical technology will not just repair physical disadvantages such as impaired eye sight but will create superhuman powers from having an eyesight of an eagle to having a hearing of a bat generic 5 mg ditropan with mastercard gastritis diet . While a patient wearing implanted defibrillators or pacemakers can also be added to the group of cyborgs, more cases when patients ask for the implantation of a certain digital device without having medical problems or only for augmenting human capabilities can be expected creating a biological imbalance due to financial differences. Redesigned Hospital Experience Improving diagnostics and treatments is not enough any more, but we need to massively improve the healthcare experience whether the process takes place in a hospital or at home. The delivery of healthcare must acquire features regarding the customer experience from other industries. Transparent decision trees should also be available for patients after getting a diagnosis therefore informed decisions can be made with their doctors who would serve as partners in the care. And companies such as the recently launched Calico from Google will make attempts at reaching these goals. Remote Touch While the human touch is the key in the practice of medicine, after some time we will have to use remote touch due to the shortage of doctors and increasing number of patients. The force feedback technique used by the video game industry has the potential to be used in medicine as well. It has been demonstrated that biopsy sampling can be simulated in a 3D environment using a force- feedback controlled device. Surgeons could be trained with the technique to get better at a procedure even before operating on real patients. Robotic Interventions The number of studies examining the use of robots in the operating room has been increasing rapidly in the past couple of years. Robots can be used in remote surgery, surgical rehearsal in pre-operative planning, intra-operative navigation, simulation and training, among others. It is clear robotic interventions can add a lot to the success of operations and different procedures. One of the best examples is still the Da Vinci system, but other robots in the fields of emergency response or radiosurgery are also available. Surgical instruments will be so precise in a few years’ time that it will be impossible to control them manually, therefore robotic or mechatronic tools will be needed in order to reach the required accuracy. Robotic Nurse Assistant With the growing number of elderly patients, introducing robot assistants to care homes and hospitals is inevitable. It could be a fair solution for moving patients and performing basic medical procedures such as drawing blood. In the next step, it might also perform analysis on the blood from detecting biomarkers to obtaining genetic data. Semantic Health Records The only way to constantly improve a system is to generate and analyze data to find solutions for improving it. The basic requirement of improving healthcare is everyone accessing their own medical/health data stored in semantic databases facilitating public health research as well. Semantic datasets could generate alerts about upcoming medical issues and potential complications. Smartwatch Smartphones have not been able to replace pagers due to practical reasons, but an easily accessible wearable device might have the potential to make this step. A smartwatch could be used for consultations, making calls, sending messages, scheduling visits, as a pager or even for displaying fresh lab test results. We are not far from destroying all obstacles in exchanging medical information, drug, medical equipment or life itself through the so called biological teleportation and the advances of 3D printing. Virtual trials In the era of open access and crowdsourced scientific information, we will have to find a solution for conducting clinical trials without experimenting on people gathering the same amount of information in the same quality as before but in a much faster, non-invasive, humane and reliable way. Every country needs an E-patient Dave, a Jack Andraka and a Regina Holliday to fulfill these goals. Virtual Dissection Medical students will study anatomy on virtual dissection tables and not on human cadavers. What we studied in small textbooks will be transformed into virtual 3D solutions and models using augmented reality. We can observe, change and create anatomical models as fast as we want, as well as analyze structures in every detail. Patients could go through an upcoming operation step by step or choose a hospital based on its „virtual experience” package. Moreover, as the first bi-directional brain- machine interface became available, monkeys in an experiment could use a brain implant not only to control a virtual hand, but also to get feedback that tricks their brains into "feeling" the texture of virtual objects. Virtual-Digital Brains Ian Pearson, in his book, You Tomorrow, wrote about the possibility that one day we would be able to create digital selves based on neurological information. As Google hired Ray Kurzweil to create the ultimate artificial intelligence controlled brain, this opportunity should not be so far away. We might have been searching for the clues of living forever in the wrong places so far. Wearable e-skins Measuring easily quantifiable data is the key to a better health, therefore the future belongs to digestible, embedded and wearable sensors; the latter working like a thin e-skin. These sensors will measure all important health parameters and vital signs from temperature, and blood biomarkers to neurological symptoms 24 hours a day transmitting data to the cloud and sending alerts to medical systems when a stroke is happening real time. Examples include hydration sensors for athletes and intelligent textiles that change color indicating diseases. Whether you are a patient or a medical professional, follow the 1 main trends and try to be up-to-date by using digital methods. Constantly look for solutions to improve your practice as a 2 medical professional or your health as a patient. Embrace digital in a comfortable way and use techniques that 3 make your life easier and your work more efficient. No matter how important role digital will play in our lives, human 8 touch is and will always be the key in the doctor-patient relationship. You Tomorrow This work is licensed under the Creative Commons Attribution-NonCommercial- NoDerivs 3. The formation of the Ghana Psychic and Traditional Healers Association in 1961 and the establishment of the Centre for Scientific Research into Plant Medicine in 1975 attest to this fact. Also in 1991 the government established a unit for the coordination of Traditional Medicine (which is now Traditional and Alternative Medicine Directorate) which was followed by the setting up of the Food and Drugs Board in 1992, which among others, is to certify the sale of Traditional Medicine products to the public. Although all these documents provide a legal policy framework for the development of Traditional Medicine, there is no single document that coordinates the general policy direction of government in the area of traditional medicine. It cuts across sectoral boundaries and provides a national position for which all sectors have to buy into. Almost all the relevant traditional medicine institutions and organizations were involved in the process of developing the document. Others included were Sociology and Biochemistry Departments of the University of Ghana and the Faculty of Pharmacy of the Kwame Nkrumah University of Science and Technology. It is hoped that the document will be relevant to all government institutions working towards the development of Traditional Medicine.

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In the suggests that many strategies used in diagnostic decision great majority of cases cheap 2.5mg ditropan with amex gastritis y dolor de espalda, this approach leads to the correct making are adaptive and work well most of the time order 2.5 mg ditropan with mastercard gastritis vs ulcer. The patient’s diagnosis is instance order ditropan line gastritis symptoms heartburn, physicians are likely to use data on patients’ health made quickly and correctly order generic ditropan pills gastritis diet , treatment is initiated, and both outcome as a basis for judging their own diagnostic acumen. This explains why this That is, the physician is unconsciously evaluating the num- approach is used, and why it is so difficult to change. In ber of clinical encounters in which patients improve com- addition, in many of the cases where the diagnosis is incor- pared with the overall number of visits in a given period of rect, the physician never knows it. If the diagnostic process Berner and Graber Overconfidence as a Cause of Diagnostic Error in Medicine S11 routinely led to errors that the physician recognized, they In the discussion about individually focused solutions, could get corrected. Additionally, the physician might be we review the effectiveness of clinical education and prac- humbled by the frequent oversights and become inclined to tice, development of metacognitive skills, and training in adopt a more deliberate, contemplative approach or develop reflective practice. In the section on systems-focused solu- strategies to better identify and prevent the misdiagnoses. A fas- We believe that strategies to reduce misdiagnoses should cinating (albeit frightening) observation is the general ten- 84,108,132 focus on physician calibration, i. Exactly the between the physician’s self-assessment of errors and actual same tendency is seen in testing of medical trainees in 128 147 errors. Klein has shown that experts use their intuition on regard to skills such as communicating with patients. In a routine basis, but rethink their strategies when that does a typical experiment a cohort with varying degrees of ex- not work. Physicians also rethink their diagnoses when it is pertise are asked to undertake a skilled task. In fact, it is in these situations of the task, the test subjects are asked to grade their own that diagnostic decision-support tools are most likely to be performance. In fact, it could be Data from a study conducted by Friedman and col- 108 argued that their awareness needs to be increased for a leagues showed similar results: residents in training per- select type of case: that in which the healthcare provider formed worse than faculty physicians, but were more con- thinks he/she is correct and does not receive any timely fident in the correctness of their diagnoses. A systematic feedback to the contrary, but where he/she is, in fact, mis- review of studies assessing the accuracy of physicians’ taken. Typically, most of the clinician’s cases are diagnosed self-assessment of knowledge compared with an external correctly; these do not pose a problem. For the few cases measure of competence showed very little correlation be- 148 where the clinician is consciously puzzled about the diag- tween self-assessment and objective data. The authors nosis, it is likely that an extended workup, consultation, and also found that those physicians who were least expert research into possible diagnoses occurs. In ad- categories of solutions: strategies that focus on the individ- dition to their enhanced ability to make this distinction, ual and system approaches directed at the healthcare envi- experts are likely to make the correct diagnosis more ronment in which diagnosis takes place. Another approach is to the healthcare environment so that the data on the patients, advocate the development of expertise in a narrow domain. At the level of the individual clini- mutually exclusive and the major aim of both is to improve cian, the mandate to become a true expert would drive more the physician’s calibration between his/her perception of the trainees into subspecialty training and emphasize develop- case and the actual case. Both Bordage and Norman champion this the rate of diagnostic errors is not yet available, although 156 approach, arguing that “practice is the best predictor of preliminary results are encouraging. Extensive practice with simulated cases may rates the principles of metacognition and 4 additional at- supplement, although not supplant, experience with real tributes: (1) the tendency to search for alternative hypothe- ones. The key requirements in regard to clinical practice are ses when considering a complex, unfamiliar problem; extensive, i. Experi- tion to strategies that aim to increase the overall level of mental studies show that reflective practice enhances diag- clinicians’ knowledge, other educational approaches focus 161 nostic accuracy in complex situations. However, even on increasing physicians’ self-awareness so that they can advocates of this approach recognize that it is an untested recognize when additional information is needed or the assumption in terms of whether lessons learned in educa- wrong diagnostic path is taken. Singh and colleagues advocate this strategy; their definition of types of situational awareness is similar to what One could argue that effectively incorporating the education 115,155 and training described above would require system-level others have called metacognitive skills. For instance, at the level of healthcare systems, in Hall champion the idea that metacognitive training can reduce diagnostic errors, especially those involving subcon- addition to the development of required training and edu- scious processing. The logic behind this approach is appeal- cation, a concerted effort to increase the level of expertise of ing: Because much of intuitive medical decision making the individual would require changes in staffing policies and involves the use of cognitive dispositions to respond, the access to specialists. These would orient clinicians to the general allow the less expert clinician to function like a more expert concepts of metacognition (a universal forcing strategy), clinician. Computer- or web-based information sources also familiarize them with the various heuristics they use intu- may serve this function. These resources may not be very itively and their associated biases (generic forcing strate- different from traditional knowledge resources (e. Once the initial diagnosis is made, the clinician figuratively gazes into a These approaches focus on providing better and more ac- crystal ball to see the future, sees that the initial diagnosis is curate information to the clinician primarily to improve not correct, and is thus forced to consider what else it could calibration. A related technique, which is taught in every medical for reducing medical errors have formed the background of school, is to construct a comprehensive differential diagno- the patient safety movement, although they have not been 163 164 sis on each case before planning an appropriate workup. Nolan advo- Although students and residents excel at this exercise, they cates 3 main strategies based on a systems approach: pre- rarely use it outside the classroom or teaching rounds. As vention, making error visible, and mitigating the effects of we discussed earlier, with more experience, clinicians begin error. Most of the cognitive strategies described above fall to use a pattern-recognition approach rather than an exhaus- into the category of prevention. Other examples of cognitive The systems approaches described below fall chiefly into forcing strategies include advice to always “consider the the latter two of Nolan’s strategies. One approach is to opposite,” or ask “what diagnosis can I not afford to provide expert consultation to the physician. Usually a diagnostic decision-sup- only in artificial situations and many of them have been per- port system is used once the error is visible (e. The history of these systems is reflective of the overall Using the system may prevent an initial misdiagnosis and problem we have demonstrated in other domains: despite may also mitigate possible sequelae. A variety they do use them, many physicians are simply reluctant to of diagnostic decision-support systems were developed out 181 use decision-support tools in practice. Miller’s overall conclusions were that while data on how often they are used compared with how often the niche systems for well-defined specific areas were they could/should have been used. The title, “A Report Card on data into the programs, it is likely that their usage would be Computer-Assisted Diagnosis—The Grade Is C,” of Kas- even lower or that the data entry may be incomplete. In a subsequent study, Berner tering, because what is usually displayed is a (sometimes 167 and colleagues found that less experienced physicians lengthy) list of diagnostic considerations. Also, as Teich and colleagues noted with of the Iliad system in educational settings. More disturbing was potentially useful, but the limited interest in them has made that use of the system actually increased costs, perhaps by several commercial ventures unsustainable. Because such puzzles occur rarely, which was initially begun as a pediatric system and now is there is not enough use of the systems in real practice 174–178 also available for use in adults. A second general category of a 179 180 Miller and Berner have reviewed the challenges in systems approach is to design systems to provide feedback evaluating medical diagnostic programs.

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The 2006 California heat wave: impacts on hospitalizations and emergency department visits buy 5 mg ditropan otc gastritis red wine. Sugar-sweetened beverages and risk of metabolic syndrome and type 2 diabetes a meta-analysis purchase ditropan 5 mg without prescription gastritis olive oil. Evidence for impaired insulin production and higher sensitivity in stunted children living in slums order ditropan master card gastritis diet in dogs. A survey of macro damages from Non-communicable chronic diseases: another challenge for global governance generic ditropan 2.5mg without prescription gastritis diarrhea. Socioeconomic status and obesity in adult populations of developing countries: a review. The World Health Report 2001: Mental Health: New Understanding, New Hope: World Health Organization. Human Thermal Environments: The Effects of Hot, Moderate, and Cold Environments on Human Health, Comfort and Performance (2nd ed. Effect of socioeconomic deprivation on waiting time for cardiac surgery: retrospective cohort study. The link between childhood undernutrition and risk of chronic diseases in adulthood: a case study of Brazil. Forum Leaders’ Statement on Non-Communicable Diseases: Pacific in an Crisis, Leaders Declare: Secretariat of the Pacific Islands Community. Prevention and Control of Noncommunicable Diseases Regional Committee 51st Session, Manila, Philippinesn 18-22 September (Vol. A summary of the findings of the Commission on Macroeconomics and Health: investing in health for economic development Report of the Commission on Macroeconomics and Health. Noncommunicable Disease and Poverty: The Need for Pro-poor Strategies in the Western Pacific Region - A Review Regional Office for the Western Pacific World Health Organization,. Pacific Islanders pay heavy price for abandoning traditional diet Bulletin of the World Health Organization (Vol. Noncommunicable Disease and Poverty: The Need for Pro-poor Strategies in the Western Pacific Region - A Review. Noncommunicable Disease and Poverty: The Need for Pro-poor Strategies in the Western Pacific Region - A Review. Leaving No One Behind Public health—the practice of preventing disease and promoting health—effectively targets environmental factors and health behaviors that contribute to chronic conditions. The health risk factors of physical inactivity, tobacco use and exposure and poor nutrition are the leading causes of chronic disease. With even a small reduction in the prevalence of chronic disease, the combined health and productivity cost savings of prevention lead to a positive return on investment within a short time. Nearly 70% of frst heart attacks and 77% of frst strokes occur in people with hypertension. Cardiovascular disease is the estimation tool, which uses the leading cause of morbidity and mortality in the United States, Pooled Cohort Equations from accounting for 1 of every 3 deaths among adults. There is high certainty that the net benefit is moderate, or Offer or provide this service. There is at least moderate certainty patients depending on individual that the net benefit is small. There is moderate or high certainty that the service Discourage the use of this service. If the service is offered, I statement patients should understand the uncertainty about the balance of benefits and harms. This conclusion is therefore unlikely to be strongly affected by the results of future studies. The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estimate is constrained by such factors as the number, size, or quality of individual studies. As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion. The calculator Risk Assessment derived from these equations takes into account age, sex, race, cholesterol levels, systolic blood pressure level, antihypertension treatment, presence of diabetes, and smoking status as risk factors. Statins are a class of lipid-lowering medications that function by inhibiting the enzyme 3-hydroxy-3-methyl-glutaryl coenzyme A Preventive reductase. For a summary of the evidence systematically reviewed in making this recommendation, the full recommendation statement, and supporting documents, please go to https://www. Aseparaterecommendationstatementalso bloodpressurelevel,antihypertensiontreatment,presenceofdia- found insufficient evidence to assess the balance of benefits and betes,andsmokingstatusasriskfactorsinthepredictionmodeland harms of screening for dyslipidemia in children and adolescents. Specific recommendations from other organiza- ofbenefitthataninterventionwithdemonstratedefficacycanhave tions for such individuals are discussed in the “Recommendations in a specific population directly depends on the incidence of dis- of Others” section. This is one of optimal intervals for cardiovascular risk assessment are uncertain. StatinRegimensUsedinAvailableTrials Dose, mga Statin Low Moderate High Atorvastatin 10-20 40-80 Fluvastatin 20–40 40 twice daily Fluvastatin extended release 80 Lovastatin 20 40 aDosecategoriesarefromthe AmericanCollegeof Pitavastatin 1 2-4 Cardiology/AmericanHeart Pravastatin 10-20 40-80 Association2013guidelinesonthe Rosuvastatin 5-10 20-40 treatmentofbloodcholesterolto reduceatherosclerotic Simvastatin 10 20-40 24 cardiovascularriskinadults. Thedegreeofcholesterolreductionmaybeattributable, shared decision making that weighs the potential benefits and in part, to interindividual variability in response to statins, not just harms, the uncertainty about risk prediction, and individual statin dosage. There Suggestions for Practice Regarding the I Statement may be individual clinical circumstances that warrant consider- for Initiating Statin Therapy for Primary Prevention ation of use of high-dose statins; decisions about dose should be based on shared decision making between patients and clinicians. Anotherstudyusing Burden of Disease datafromtheMedicalExpenditurePanelSurvey,whichdidallowfor In 2011, an estimated 375 000 adults died of coronary heart dis- thedifferentiationofindividualswithandwithoutvasculardisease easeand130 000diedofcerebrovasculardisease. Themediandurationoffollow-upwas3years, Other Considerations and 3 trials were stopped early because of observed benefits in the Research Needs and Gaps interventiongroup. Research is needed to Scandinavian Cardiac Outcomes Trial—Lipid Lowering Arm) evaluate the optimal frequency of cardiovascular risk assessment, trials10,40 because of their large sample sizes, the estimate was including serum lipid screening. After6months harms of initiating statin use for the primary prevention of cardio- to 6 years of follow-up, statin use was associated with a decreased vascular events in adults 76 years and older. However, in the available estimates when trials were stratified according to dose. Nostudieswere tent across different clinical and demographic subgroups (even identifiedthatdirectlycomparedtreatmentwithstatinstitratedto among adults without marked dyslipidemia). Becausetheab- Harms of Statin Use soluteunderlyingriskislower,feweradultswhosmokeorhavedys- In randomized trials of statin use for the primary prevention of lipidemia,diabetes,orhypertensionanda7. As such, any decision to ini- withdrawal because of adverse events compared with placebo, tiateuseofalow-tomoderate-dosestatininthispopulationshould and there were no statistically significant differences in the risk of involve shared decision making that weighs the potential benefits experiencing any serious adverse event. It should also take into consideration the personal prefer- levels with statin use. Some comments requested clarification regarding the op- foundnoassociationwithstatinuse,41butananalysisfromtheWo- timal dose of statins. Thesepersonsshouldbescreenedandtreatedinaccordancetoclini- Recommendations of Others cal judgment for the treatment of dyslipidemia. Thetreatmentstrat- ment is no longer relevant and has been replaced by a preventive egy is treatment-to-target rather than by therapy dose (eg, 50% medication framework.

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