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Empirical studies have suggested it yields more precise estimates of the intervention effects in comparison with a single direct or indirect estimate (Cooper et al 2011 impotence at 30 years old buy extra super viagra 200mg, Caldwell et al 2015) l-arginine erectile dysfunction treatment extra super viagra 200mg without prescription. In addition erectile dysfunction pills for heart patients order extra super viagra 200 mg line, network meta-analysis can provide information for comparisons between pairs of interventions that have never been evaluated within individual randomized trials erectile dysfunction medication nhs generic extra super viagra 200mg otc. The simultaneous comparison of all interventions of interest in the same analysis enables the estimation of their relative ranking for a given outcome (see Section 11. It then introduces the notion of transitivity (and its statistical analogue, coherence) as the core assumption underlying the validity of an indirect comparison. Note that the chapter only introduces the statistical aspects of network meta-analysis; authors will need a knowledgeable statistician to plan and execute these methods. Indirect comparisons are necessary to estimate the relative effect of two interventions when no studies have compared them directly. For example, suppose there are randomized trials directly comparing provision of dietary advice by a dietitian (which we refer to as intervention A) with advice given by a doctor (intervention B). Suppose there are also randomized trials comparing dietary advice given by a dietitian (intervention A) with advice given by a nurse (intervention C). We wish to learn about the relative effect of advice by a doctor versus a nurse (B versus C); the dashed line depicts this comparison, for which there is no direct evidence. All else being equal, the benefit of B over C is equivalent to the benefit of B over A plus the benefit of A over C. For this simple case where we have two direct comparisons (three interventions) the analysis can be conducted by performing subgroup analyses using standard metaanalysis routines (including RevMan): studies addressing the two direct comparisons. The difference between the summary effects from the two subgroups gives an estimate for the indirect comparison. When four or more competing interventions are available, indirect estimates can be derived via multiple routes. This relationship can be written mathematically as effect of B versus C = effect of A versus C effect of A versus B In words, this means that we can compare interventions B and C via intervention A (Figure 11. The validity of an indirect comparison requires that the different sets of randomized trials are similar, on average, in all important factors other than the intervention comparison being made (Song et al 2003, Glenny et al 2005, Donegan et al 2010, Salanti 2012). Studies that compare different interventions may differ in a wide range of characteristics. Sometimes these characteristics are associated with the effect of an intervention. We refer to such characteristics as effect modifiers; they are the aspects of diversity that induce heterogeneity in pairwise meta-analyses. If the A versus B and A versus C randomized trials differ with respect to their effect modifiers, then it would not be appropriate to make an indirect comparison. Transitivity requires that intervention A is similar when it appears in A versus B studies and A versus C studies with respect to characteristics (effect modifiers) that may affect the two relative effects (Salanti et al 2009). Transitivity requires all competing interventions of a systematic review to be jointly randomizable. That is, we can imagine all interventions being compared simultaneously in a single multi-arm randomized trial. Researchers undertaking indirect comparisons should assess whether such differences are sufficiently large to induce intransitivity. In principle, transitivity can be evaluated by comparing the distribution of effect modifiers across the different comparisons (Salanti 2012, Cipriani et al 2013, Jansen and Naci 2013). Imbalanced distributions would threaten the plausibility of the transitivity assumption and thus the validity of indirect comparison. In practice, however, this requires that the effect modifiers are known and have been measured. There are also some statistical options for assessing whether the transitive relationship holds in some circumstances, which we discuss in Section 11. Extended guidance on considerations of potential effect modifiers is provided in discussions of heterogeneity in Chapter 10 (Section 10. For example, we may believe that age is a potential effect modifier so that the effect of an intervention differs between younger and older populations. If the average age in A versus B randomized trials is substantially older or younger than in A versus C randomized trials, transitivity may be implausible, and an indirect comparison B versus C may be invalid. The top row depicts a situation in which all patients in all trials have moderate severity. The second row depicts a similar situation in a second population of patients who all have severe disease.
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Brownstein recommends a combination of vitamin C erectile dysfunction treatment cost in india 200mg extra super viagra visa, unrefined salt and magnesium erectile dysfunction young male causes buy 200 mg extra super viagra overnight delivery, including baths of Epsom salts and sea salt erectile dysfunction 50 order extra super viagra 200mg on line. The patient is advised to avoid all sources of bromine impotence juice recipe order extra super viagra 200 mg on line, including fire retardant in carpet, clothing and mattresses, and bromide-treated breads, baked goods and grains. Bromine and chlorine are used extensively in materials in automobiles of recent vintage-in the seats, armrests, door trim, shift knobs-so avoidance of riding in cars with the windows closed is important. Brownstein reports numerous benefits from the protocol including reduced need for thyroid medications, reduced allergies, increased energy, reduced fibromyalgia, weight loss, clearing of ovarian cysts and reduction of hypothyroid symptoms such as brain fog. In his experience, side effects including metallic taste in mouth, sneezing, excess saliva and frontal sinus pressure occur in less than 5 percent of patients. For ongoing thyroid protection, it is important to avoid sources of bromide, fluoride and chloride (including environmental perchlorates, often found in drinking water). That means drinking purified or filtered water instead of tap water, consuming organic food (conventional produce and grains are treated with bromide-, chloride- or fluoride-containing pesticides and fumigants), avoiding bromated breads and consuming plenty of unrefined sea salt along with an iodine-rich diet. Those amounts of iodine would have resulted in serum inorganic iodine levels 100 times higher than the serum inorganic iodide levels of 10-6M claimed by Wolff and Chaikoff to result in the W-C effect. According to Abraham, "Medical iodophobia resulted in the thyroid hormone thyroxine simple goiter and hypothyroidism. So, the manufacturers of thyroxine also resulted in the destruction of the thyroid gland by means of radioiodide this condition had previously been treated successfully with Lugol solution. The radioablation of the thyroid gland with radioiodide resulted in 90 eventually joining the ever-increasing thyroxine-consuming population. An even greater negative effect is realized if iodine deprivation is combined with goitrogen saturation, using the potent "Iodine is involved in many vital mental and physical functions, and Medical textbooks discuss inorganic, non-radioactive iodine only in relahypothyroidism and endemic goiter. Based on an iodine/iodide loading test needed to control cretinism, hypothyroidism and endemic goiter. The German government claims that the earth has no iodine and that natural foods do not contain enough iodine. Doctors tell us about studies showing that these patients should not eat iodized food as it makes their disease worse. In Germany iodized salt in packaged food has to be declared but iodine in salt in restaurants or in bread is not labeled. We had it during the Third Reich and it took quite a lot of government campaigning to bring back mass iodization, a public relations campaign to convince people that iodine is healthy and has no dangers at all. Government officials say that people can choose iodized or noniodized salt but no one mentions the hidden salt. In Germany they sell salt with iodine and fluorine-both affect the metabolism and can damage the thyroid gland. Natural salt has the advantage of giving us minerals we need and in a way that our body can handle instead of the low quality chemistry added to food or water. A natural diet can offer more benefit for our heatlh and fewer dangers and side effects. In India, Himalayan salt was banned and iodized sald then sold five times as much as natural salt. Abraham believes that the vast majority of people, 98 to 99 percent, can take iodine in doses ranging from 10 to 200 mg a day without any clinically adverse effects on thyroid function. Alan Gaby in an editorial published in the Townsend Letter for Doctors and Patients "Recently, a growing number of doctors have been using iodine supplements in fairly large doses in their practices," wrote Gaby. First is the notion that the optimal dietary iodine intake for humans is around 13. Second is the claim that a newly developed iodine-load test can be used as Gaby takes issue with the argument that the optimal human requirement is 13. Case reports suggest that iodine therapy can improve energy levels, overall well-being, sleep, digestive problems and headaches. Five individuals within our office took the test and, by the criteria outlined, we were all iodine-deficient. After about six weeks of continuous treatment, I experienced dysphagia [difficulty swallowing], resulting in lower chest pain on swallowing both food and fluids. I told the Laboratory Director that I was going to discontinue taking the Iodoral since I had concluded that it was the potential cause. To my surprise, she told me that she had experienced exactly the same symptom and had also discontinued the treatment.
Conclusion: In a limited setting of social and economic cost of providing frivolous care in an expensive hospital for chronic or terminal conditions that would be better managed through treatment or palliative care at home (or less acute setting) home based care effort can better meet the needs of Rwandans at the community level and has started to show the efficiency in providing quality care to people in need of palliative care erectile dysfunction causes smoking 200mg extra super viagra visa. Aik1 1 University of Malaya/Faculty of Medicine erectile dysfunction in diabetes medscape trusted 200 mg extra super viagra, Unit of Silent Mentor Program erectile dysfunction protocol review article discount extra super viagra 200 mg overnight delivery, Kuala Lumpur natural erectile dysfunction treatment remedies buy discount extra super viagra 200 mg line, Malaysia; 2University of Malaya/Faculty of Medicine, Department of Obstetrics & Gynaecology, Kuala Lumpur, Malaysia Background: Birth, aging, illness and eventually death are the natural events in the life. As our body is not permanent, we can do something meaningful even after death, such as donating body as a Silent Mentor. This concept was initiated by Dharma Master Cheng Yen from Taiwan at Tzu Chi University in 2002. University of Malaya started this program in 2012 with intention to provide surgical skill training and cultivate humanistic values. In each workshop, 4 to 6 Silent Mentors are initiated and ten medical students are assigned to one mentor. The program includes receiving the Silent Mentor within six hours of death and placing into deep freezer, performing home visits to the relatives to know the life story, medical illness, verbal or written final wish of the donors and their expectation on medical students, preparing their own mentors before, during, and after each workshop, presentation about their mentors before workshop and at gratitude ceremony and sending off their beloved mentors by medical students and relatives after gratitude ceremony. The students have the opportunity to learn anatomy and basic surgical skill on their mentors over three evenings, and also opportunity to take care of their mentors with utmost respect during the program. Over 800 medical students from local and oversea universities have been trained by volunteer trainers. Within six years, many pledgers with great love have signed up to donate their bodies for medical education and research in this holistic approach. Methods: Retrospective analysis of the demographics, social characteristics and final wishes of donors who had contributed to the Silent Mentors Program of University Malaya, based on information derived from their registration data and home visits. Results: From March 23, 2012 until March 28, 2018, 1174 individuals have signed up for this program, and 84 had already served as Silent Mentors. Sixty were Buddhists, 13 Christian, 4 Catholic, 2 Hindu, 3 Taoism and 2 from other religion. Their final wishes expressed that medical students and doctors are able to learn procedures from their donated body to become skillful doctors to help suffering patients in future. They also wished that students may become caring doctors and will contribute to the medical field regardless of monetary benefits. Conclusion: Silent Mentor program offers a different approach in medical education and research. Most of selfless Silent Mentors wished that they can help to train students to become not only competent, but also empathic and compassionate doctors. Nowak Makarere University, Pharmacology, Kampala, Uganda Background: the rise in breast cancer prevalence rate across the globe and in Africa is a public health issue. Accessibility to the effective and affordable therapeutic options for the management of breast cancer in sub-Saharan Africa is challenging due to high costs, questionable effectiveness and toxicity of treatments available. Studies have documented the use of complimentary and alternative medicine in contemporary cancer treatment in form of standardized phytomedicines. However, the scientific evidence on their efficacies, synergy, safety and adequacy is still lacking. Furthermore, Carica papaya Linn (leaf extract), artemisinin and molecular iodine have been previously reported to have activity against breast cancer but their synergistic effect has not been validated. Aim: this study seeks to evaluate synergistic effects of Carica papaya Linn (leaf extract), Vernonia amygdalina Delile (leaf extract), artemisinin and molecular iodine against breast cancer cell lines in vitro and safety profile in selected animal models in vivo. Bioactive compounds in combination(s) will be identified using chromatographic and spectroscopic methods. Conclusion: this study will provide a significant contribution into aspects of herbal medicine in breast cancer research, as there is limited research and development efforts in respect to new products to treat breast cancer in the African context. The development of natural, efficacious, cost effective, safer, easier accessible breast cancer management alternative is anticipated as a result of the study. Some of the compounds found in the chosen plants may be used as templates for development of new anticancer product. Finally, 15 low effort, high impact priority research ideas for various health outcomes across research disciplines were identified based on discussion with the larger group to reach consensus. The second Web-based survey resulted in identification of 5 key priority research ideas by all stakeholders as being the most important. Outcomes: Taking into account the vital role of nonhealth sectors, key performance indicators were assigned for each sectors and a regular in-house reporting system has been institutionalized to allow effective progress, which was monitored by a committee lead by Prime Minister office. Developing national targets and indicators with accountability scheme is essential to monitor progress.
Difficult decisions should be documented in the review erectile dysfunction review extra super viagra 200 mg fast delivery, checked with the advisory group (if available erectile dysfunction urethral medication discount 200 mg extra super viagra free shipping, see Chapter 1) depression and erectile dysfunction causes buy generic extra super viagra 200 mg line, and Box 3 erectile dysfunction treatment portland oregon extra super viagra 200mg amex. What are the most important characteristics that describe these people (participants)? Are there other types of people who should be excluded from the review (because they are likely to react to the intervention in a different way)? In particular, post-hoc decisions about inclusion or exclusion of studies should keep faith with the objectives of the review rather than with arbitrary rules. Following pre-specified eligibility criteria is a fundamental attribute of a systematic review. Review authors should make sensible post-hoc decisions about exclusion of studies, and these should be documented in the review, possibly accompanied by sensitivity analyses. Changes to the protocol must not be made on the basis of the findings of the studies or the synthesis, as this can introduce bias. Third, there should be consideration of whether there are population characteristics that might be expected to modify the size of the intervention effects. Identifying subpopulations may be important for implementation of the intervention. If relevant subpopulations are identified, two courses of action are possible: limiting the scope of the review to exclude certain subpopulations; or maintaining the breadth of the review and addressing subpopulations in the analysis. Restricting the review with respect to specific population characteristics or settings should be based on a sound rationale. It is important that Cochrane Reviews are globally relevant, so the rationale for the exclusion of studies based on population characteristics should be justified. For example, focusing a review of the effectiveness of mammographic screening on women between 40 and 50 years old may be justified based on biological plausibility, previously published systematic reviews and existing controversy. On the other hand, focusing a review on a particular subgroup of people on the basis of their age, sex or ethnicity simply because of personal interests, when there is no underlying biologic or sociological justification for doing so, should be avoided, as these reviews will be less useful to decision makers and readers of the review. Maintaining the breadth of the review may be best when it is uncertain whether there are important differences in effects among various subgroups of people, since this allows investigation of these differences (see Chapter 10, Section 10. Review authors may combine the results from different subpopulations in the same synthesis, examining whether a given subdivision explains variation (heterogeneity) among the intervention effects. Alternatively, the results may be synthesized in separate comparisons representing different subpopulations. Splitting by subpopulation risks there being too few studies to yield a useful synthesis (see Table 3. Consideration needs to be given to the subgroup analysis method, 37 3 Defining criteria for including studies Table 3. The authors hypothesized that e-learning programmes for doctors would be more effective than for other health professionals, but did not provide a rationale (Vaona et al 2018). In a review of platelet-rich therapies for musculoskeletal soft tissue injuries, a subgroup analysis was undertaken to examine if the effects of platelet-rich therapies were modified by the type of condition. In planning a review of beta-blockers for heart failure, subgroup analyses were specified to examine if the effects of beta-blockers are modified by the underlying cause of heart failure. The rationale was based on the findings of another review that suggested that children and adolescents may respond differently to antidepressants. In a review of hip protectors for preventing hip fractures in older people, separate comparisons were specified based on setting (institutional care or communitydwelling) for the critical outcome of hip fracture (Santesso et al 2014). Setting Setting of care (primary care, hospital, community) Rurality (urban, rural, remote) Socio-economic setting (low and middleincome countries, high-income countries) Hospital ward. All subgroup analyses should ideally be planned a priori and stated as a secondary objective in the protocol, and not driven by the availability of data. In practice, it may be difficult to assign included studies to defined subpopulations because of missing information about the population characteristic, variability in how the population characteristic is measured across studies. The latter issue mainly applies for participant characteristics but can also arise for settings or geographic locations where these vary within studies. Review authors should consider planning for these scenarios (see example reviews Hetrick et al 2012, Safi et al 2017; Table 3. For example, in a review of the effect of a given anticoagulant on deep vein thrombosis, the intervention can be defined precisely. A more complicated definition might be required for a multi-component intervention composed of dietary advice, training and support groups to reduce rates of obesity in a given population.