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By: L. Cole, M.A.S., M.D.

Co-Director, New York Institute of Technology College of Osteopathic Medicine

There have been significant successes in clinical precision medicine in cancer care gastritis diet soda buy cheap lansoprazole 30mg online, such as using existing cancer treatments in new ways gastritis symptoms mayo clinic generic lansoprazole 15 mg mastercard, based on genotyping results gastritis symptoms in morning lansoprazole 30mg with visa. Many academic institutions have invested in precision medicine institutes gastritis green stool generic 15mg lansoprazole otc, and states have developed consortiums with the hope that genomic analysis can lead to interventions that will greatly improve health care outcomes. Our goal is to understand how precision medicine research projects are developing, as these will shape the future directions of clinical precision medicine that will use insights from multiple forms of data. Building on what we learned from the research community, we define precision medicine as the effort to collect, integrate, and analyze multiple sources of data in order to develop individualized insights about health and disease. Precision medicine captures what is traditionally recognized as medical data, such as lab results, as well as other kinds of nonmedical data, such as air and housing quality measures. Our view of precision medicine and our focus on research in this area is in line with what Rothstein calls "big data health research. This definition of precision medicine also allows us to identify how the challenges posed by big data in other fields may or may not play out in biomedical research and ultimately in medical practice. As boyd and Crawford argue, big data is important because "[i]ts value comes from the patterns that can be derived by making connections between pieces of data, about an individual, about individuals in relation to others, about groups of people, or simply about the structure of information itself. Therefore, this conception of health data as being analyzable to show relationships between different variables is key for understanding how precision medicine is developing in the research space. This is also why precision medicine can be understood as a new and emerging field, despite a long history of scientists and clinicians using biological and nonbiological information to tailor treatment and care. In the United States, there are a number of large-scale precision medicine research projects that are just beginning. Precision medicine, at its core, is a positive effort focused on improving health and well-being, rather than limiting or diminishing health. Because precision medicine is suffused with benevolence and good intentions, it is all the more important that researchers, technologists, government actors, and patient advocates be mindful of how this emerging field could unintentionally introduce bias into the process of delivering tailored medical care. There must be an understanding of ways in which gathering and analyzing health data could have discriminatory effects as well as an assessment of the likelihood of these potential risks becoming actual harms. As precision medicine has developed, mitigating risk, addressing bias, and achieving equity has been at the forefront of messaging around precision medicine research projects. Some of these projects have attempted to engage multidisciplinary researchers, practitioners, patient advocates, and patients in order to develop research that accounts for the complexity of tackling health problems and includes the voices of patients in the planning and implementation of these projects. For example, all of the large-scale precision medicine research projects noted above are attempting to recruit diverse participant pools in order to address the historical lack of representation in medical research. Though important, keeping data private and secure will not assure that these data will not be misused. Health data is subject to bias in multiple ways, and the increasing quantity and types of data that are available today can make it hard to identify where bias can emerge. They differ in that the former refers to bias in terms of the dataset and the latter refers to bias as a certain outcome. Because precision medicine brings together multiple data types, it also brings together medical research, social science, and computer science. These varying definitions of bias impact precision medicine, and these different types of bias interact in complicated ways. We define bias in precision medicine with these definitions in mind, acknowledging that bias can be introduced by human assumptions and then made invisible through automation or other technical processes. Therefore, we think about bias as the ways that certain errors and outcomes, particularly discriminatory ones, might be favored due to human assumptions, obfuscation due to automation, and data handling. Bias at any point in data handling for precision medicine can lead to the recapitulation of longstanding health disparities. Furthermore, precision medicine is intended to be an iterative process-findings are translated to be implemented in practice, producing more information from which future insights can be derived. Thus, discriminatory actions in the clinical practice could feed biased data back into the system. In an ecosystem in which research can lead to evidence that is used to inform clinical guidelines and treatments, biases can have potentially life-threatening impacts. The potential for bias and discrimination in precision medicine is a complex issue to tackle.

Everts chronic gastritis gallbladder order lansoprazole canada, personal communication gastritis kidney cheap 15mg lansoprazole, November 2006; Girls Educational & Mentoring Services gastritis symptoms australia order 30mg lansoprazole free shipping, 2006; Nixon et al gastritis diet purchase 30mg lansoprazole with amex. Given that girls may heal and develop through connections to others, and that trauma from prostitution is relational in nature, a gender-specific trauma recovery program should focus on the need for healing connections in the face of the complex relationships that girls bring into treatment. As explained in relation to traumatized girls in the juvenile justice system, "[Gender-specific trauma recovery programs] should help girls negotiate gender and family roles, determine appropriate boundaries in relationships, and avoid conflict and violence in [intimate] relationships" (Hennessey, Ford, Mahoney, Ko, & Siegfried, 2004). According to Harris and Fallot (2001), providers often need to make fundamental changes in their attitudes, beliefs, and practices related to understanding trauma and its impact in order to be more 24 U. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation successful in meeting the needs of their clients. Understanding the primary goals of services are empowerment and recovery (growth, mastery, and efficacy) which are prevention-driven, limited by survivor self-assessment and recovery needs, and requiring both the consumer and provider to assume shared risks, rather than the primary goals being stability and absence of symptoms, a crisis orientation, time-limited by economic and administrative needs, and oriented to minimizing provider liability. Understanding the service relationship is collaborative, with the survivor and provider having equally valuable knowledge, rather than viewing it as hierarchical with the provider having superior knowledge. This equal relationship ensures survivors are active planners and participants in ensuring their safety and developing services. This approach places a priority on choice and control and trust developed over time, rather than treating the survivor as a passive recipient where safety and trust are assumed from the outset. Characteristics of trauma-informed services also include universal screening and assessment for trauma; training all staff about trauma and its impact (especially the multiple and complex interactions of trauma and drug/alcohol use); hiring staff members who are knowledgeable about trauma dynamics; reviewing agency policies and procedures to identify any that are potentially harmful to trauma survivors (Carmen et al. Providing a context for bonding and a sense of safety through group processes is essential in a traumainformed approach. Other trauma-specific elements include helping clients develop new coping skills, find meaning in their lives, and see the correlation between their traumatic experiences and other symptoms they may have (Gatz et al. Integrating these elements into comprehensive services, along with the changes in beliefs, attitudes, and practices outlined above, is necessary for a traumainformed approach to services. Research conducted by Elliott, Bjelajac, Fallot, Markoff, and Reed (2005) suggests that service systems that do not follow a trauma-informed approach or do not have an understanding of the impact of trauma, can unintentionally create a destructive or negative environment. Many common practices in service settings can trigger trauma reactions, creating an unsafe place for survivors (Harris & Fallot, 2001). For example, a group home may send youth to their rooms as a punishment for misbehavior; imposing this punishment on victims of trafficking can result in the youth feeling a sense of confinement and trigger a traumatic reaction. Systems and providers that are unaware of these trauma-related issues may not serve their clients effectively (Elliott et al. Continuing research is needed to evaluate the traumainformed approach in order to better understand its effects on work with survivors of trauma, particularly victims of human trafficking. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation Involving Survivors of Trafficking in Developing and Providing Services Helping traumatized minor or adult females who have been trafficked develop trust with a provider is always challenging. Therefore, some advocates and service providers believe that the most successful programs serving young women exiting prostitution need to incorporate a peer-topeer counseling model and often hire survivors to provide either some or all of the services to clients (N. They operate under a harm reduction model and are offered a range of supports at a drop-in center. In an address to the United Nations, Hotaling (2000) remarked, "The personal knowledge and experience possessed by many of the staff enables [sic] us to effectively provide support and engender trust without re-traumatizing even the most fragile of clients. Clients have benefited from this model by being able to take charge of their lives, obtain and keep legal jobs, advance in education, and recover from substance abuse. More service providers who work with victims of international human trafficking are starting to engage survivors in programming. Interviews with survivors suggest that involving survivors, when they are ready, in the care of others can be beneficial to both the survivor and the victim (Caliber Associates, 2007). Some programs have formed communities of survivors to serve as peer groups, assisting other victims in rebuilding their sense of personal efficacy. Part of the success of these groups involves allowing victims to set the agenda for meetings and focus on what is most important to them. Activities have included computer training, language classes, ethnic celebrations, and even writing plays about their personal experiences. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation to work one-on-one with victims to help stabilize their life and offer opportunities for survivors to become involved in education and outreach activities (Bales & Lize, 2004).

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Outcomes were assessed at six to seven years based on reports of whether results were satisfactory gastritis diet menu purchase lansoprazole 15 mg with visa. At six month follow-up gastritis diet purchase lansoprazole online pills, there was statistically less recurrence of pain in the fusion group gastritis diet cheap generic lansoprazole uk. The main source of pain in the discectomy group was recurrent herniations and pseudoarthrosis in the fusion group gastritis diet purchase discount lansoprazole online. At final follow-up the results were slightly better in the fusion group, but the differences were not statistically significant. The authors concluded that fusion is recommended for young patients and discectomy for older patients. Matsunaga et al4 presented results from a retrospective study comparing results of percutaneous discectomy, discectomy and fusion for patients with simple disc herniations who were manual laborers and athletes. The study included 82 manual laborers and 28 athletes, of which 30 patients were treated with discectomy, 51 with percutaneous discectomy and 29 with discectomy and fusion. Duration of follow-up varied from two years and nine months to seven years and three months, with the percutanous group having the shortest follow-up and simple discectomy and fusion had similar follow-up profiles. For manual laborers there was a higher return to work with a fusion as opposed to discectomy. Lumbar fatigue was the main reason why people did not return to work and that was more commonly found in the simple discectomy patients. The authors concluded that manual laborers should undergo fusion for disc herniations to provide the best chance of return to work. Failed back surgery syndrome: the role of symptomatic segmental single-level instability after lumbar microdiscectomy. Endoscopic transforaminal lumbar decompression, interbody fusion and pedicle screw fixation - A report of 42 cases. Future Directions for Research Further research is required to identify subgroups of patients who may benefit from the addition of fusion to decompression as a primary procedure. Comparison of operative results of lumbar disc herniation in manual laborers and athletes. Clinical Results of Total Lumbar Disc Replacement Regarding Various Aetiologies of the Disc Degeneration A Study With a 2-Year Minimal Follow-up. Surgery for low back pain: A review of the evidence for an American pain society clinical practice guideline. Comparison of the results in patients operated upon for ruptured lumbar discs with and without spinal fusion. Is there a difference in outcome (clinical or radiographic) or complications between different surgical approaches in the treatment of a lumbar disc herniation with radiculopathy When surgery is indicated, performance of sequestrectomy or aggressive discectomy is recommended for decompression in patients with lumbar disc herniation with radiculopathy since there is no difference in rates of reherniation. Grade of Recommendation: B Barth et al1,2 reported results of a prospective study comparing microdiscectomy with sequestrectomy in patients with lumbar disc herniation and radiculopathy. Of the 84 patients included in the study, 42 were treated with microdiscectomy and 42 with sequestrectomy. Self-rated assessment de- this clinical guideline should not be construed as including all proper methods of care or excluding or other acceptable methods of care reasonably directed to obtaining the same results. The authors concluded that sequestrectomy was safe with no higher rate of recurrent symptoms. Schick et al3 described a prospective comparative study assessing clinical differences between sequestrectomy and microdiscectomy. Of the 200 patients included in the study, 100 were assigned to each treatment group. They recommended the technique especially in young people where preservation of disc height is important. Use of an operative microscope is suggested to obtain comparable outcomes to open discectomy for patients with lumbar disc herniation with radiculopathy whose symptoms warrant surgery. Grade of Recommendation: B Henrikson et al4 conducted a prospective randomized controlled trial evaluating whether microdiscectomy compared with standard discectomy would reduce the length of stay or postoperative morbidity in patients with lumbar disc herniation.

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A real-life costeffectiveness evaluation of budesonide/formoterol maintenance and reliever therapy in asthma alcoholic gastritis definition discount generic lansoprazole canada. Beta-agonist overuse and delay in obtaining medical review in high risk asthma: a secondary analysis of data from a randomised controlled trial gastritis losing weight buy lansoprazole 15mg line. The Expert Panel rated this outcome down twice for imprecision because the confidence interval was very wide and the boundaries of the confidence interval were consistent with both benefit and harm gastritis symptoms australia purchase lansoprazole 30 mg otc. The results were limited to 297 of 362 participants who completed the 6-month study the gastritis diet 15mg lansoprazole. The earlier report presented data on a more limited set of outcomes after 123 participants had completed a 90-day follow-up period. According to a 2019 Centers for Disease Control and Prevention report, Blacks have a twofold higher risk of asthma-related deaths than Whites; the rates are 2. However, the Expert Panel was particularly concerned about the findings in the real-world effectiveness trial, which could have more closely represented what might occur in clinical practice. Tiotropium is noninferior to salmeterol in maintaining improved lung function in B16-Arg/Arg patients with asthma. Tiotropium or salmeterol as add-on therapy to inhaled corticosteroids for patients with moderate symptomatic asthma: two replicate, double-blind, placebo-controlled, parallel-group, active-comparator, randomised trials. Importantly, the efficacy trials excluded participants with a history of glaucoma or urinary retention. The small effect on desirable outcomes was driven entirely by a reduction in the number of exacerbations, and the intervention had no effect on asthma control or asthma quality of life. The Expert Panel rated this outcome down for imprecision because the confidence intervals crossed the threshold for clinical significance and would have resulted in different conclusions based on the extremes of the confidence interval, which included both potential benefit and harm. Harms: the six studies4-8 in 3,065 participants that compared the efficacy of long-acting muscarinic antagonists with placebo added to inhaled corticosteroid therapy found a low rate of serious adverse events and no differences in serious adverse event rates between groups. Long-Term OnceDaily Tiotropium Respimat(R) Is Well Tolerated and Maintains Efficacy over 52 Weeks in Patients with Symptomatic Asthma in Japan: A Randomised, Placebo-Controlled Study. The Expert Panel rated this outcome down for risk of bias because of a lack of blinding of individuals with asthma, study personnel, and outcome assessors. The Expert Panel rated this outcome down for inconsistency because the confidence intervals were consistent with both benefit and harm. These results were limited to 297 of 362 participants who completed the 6-month study. The 2015 report appears to describe an extension of the findings reported in 2014. The 2014 report presented a more limited set of outcomes after 123 participants had completed a 90-day follow-up period. Harms: With respect to harms, the rate of undesirable effects appeared to be similar in the one study that directly compared montelukast vs. The study excluded individuals with significant illnesses or lung diseases, other than asthma. Although percentages of control days increased and symptom scores improved, these measures were not validated, and the magnitude of the difference was of uncertain significance. The Expert Panel rated this outcome down twice for imprecision because the confidence interval was very wide. The Expert Panel therefore did not consider the harms in this study when it addressed this key question. Because asthma disproportionately affects disadvantaged populations, the Expert Panel believes that this intervention is likely to increase health equity. The Expert Panel rated this outcome down for the inconsistencies among the three studies (one study had a narrow confidence interval suggesting no benefit, whereas the findings from the other two trials suggested a benefit). Certainty of evidence was not assessed for this outcome in the Agency for Healthcare Research and Quality systematic review report.

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