Infection prevention depends upon a system of practices in which all blood and bodily fluids, including cerebrospinal fluid, sputum and semen, are considered to be infectious. All such fluids from all people are treated with the same degree of caution, so no judgement is required about the potential infectivity of a particular specimen. Hand washing, the use of barrier protection such as gloves and aprons, the safe handling and disposal of ‘sharps’ and medical waste and proper disinfection, cleaning and sterilisation are all part of creating a safe hospital.

They must also have a willingness to monitor their blood glucose frequently and record blood glucose readings, carbohydrate intake, insulin boluses, and exercise. Besides assessing the patient’s physical and mental status, review and record pump-specific information, such as the pump’s make and model.Also assess the type of insulin being delivered and the date when the infusion site was changed last. Assess the patient’s level of consciousness and cognitive status. If the patient doesn’t seem competent to operate the device, notify the healthcare provider and document your findings.

During worldwide marketing experience, rare cases of various congenital anomalies, including cleft palate and limb defects, have been reported in the offspring of patients being treated with salbutamol. Some of the mothers were taking multiple medications during their pregnancies. Because no consistent pattern of defects can be discerned, a relationship with salbutamol use cannot be established.

One modifiable behaviour with major therapeutic implications for CVD is inactivity. Inactive or sedentary behaviour has been associated with numerous health conditions and a review of several studies has confirmed that prolonged total sedentary time (measured objectively via an accelerometer) has a particularly adverse relationship with cardiovascular risk factors, disease, and mortality outcomes. The cardiovascular effects of leisure time physical activity are compelling and well documented. Adequate physical leisure activities like walking, swimming, cycling, or stair climbing done regularly have been shown to reduce type 2 diabetes, some cancers, falls, fractures, and depression. Improvements in physical function and weight management have also been shown, along with increases in cognitive function, quality of life, and life expectancy.

Several occupational studies have shown adequate physical activity in the workplace also provides benefits. Seat-bound bus drivers in London experienced more coronary heart disease than mobile conductors working on the same buses, as do office-based postal workers compared to their colleagues delivering mail on foot. The AHA recommends that all Americans invest in at least 30 minutes a day of physical activity on most days of the week. In the face of such unambiguous evidence, however, most healthy adults, apparently by choice it must be assumed, remain sedentary.

The cardiovascular beneficial effects of regular exercise for patients with a high risk of coronary disease have also been well documented. Leisure time exercise reduced cardiovascular mortality during a 16-year follow-up study of men in the high risk category. In the Honolulu Heart Study, elderly men walking more than 1.5 miles per day similarly reduced their risk of coronary disease. Such people engaging in regular exercise have also demonstrated other CVD benefits including decreased rate of strokes and improvement in erectile dysfunction. There is also evidence of an up to 3-year increase in lifespan in these groups.

Among patients with experience of heart failure, regular physical activity has also been found to help improve angina-free activity, prevent heart attacks, and result in decreased death rates. It also improves physical endurance in patients with peripheral artery disease. Exercise programs carried out under supervision such as cardiac rehabilitation in patients who have undergone percutaneous coronary interventions or heart valve surgery, who are transplantation candidates or recipients, or who have peripheral arterial disease result in significant short- and long-term CVD benefits.

Since data indicate that cardiovascular disease begins early in life, physical interventions such as regular exercise should be started early for optimum effect. The US Department of Health and Human Services for Young People wisely recommends that high school students achieve a minimum target of 60 minutes of daily exercise. This may be best achieved via a mandated curriculum. Subsequent transition from high school to college is associated with a steep decline in physical activity. Provision of convenient and adequate exercise time as well as free or inexpensive college credits for documented workout periods could potentially enhance participation. Time spent on leisure time physical activity decreases further with entry into the workforce. Free health club memberships and paid supervised exercise time could help promote a continuing exercise regimen. Government sponsored subsidies to employers incorporating such exercise programs can help decrease the anticipated future cardiovascular disease burden in this population.

General physicians can play an important role in counselling patients and promoting exercise. Although barriers such as lack of time and patient non-compliance exist, medical reviews support the effectiveness of physician counselling, both in the short term and long term. The good news is that the percentage of adults engaging in exercise regimes on the advice of US physicians has increased from 22.6% to 32.4% in the last decade. The empowerment of physicians, with training sessions and adequate reimbursement for their services, will further increase this percentage and ensure long-term adherence to such programmes. Given that risk factors for CVD are consistent throughout the world, reducing its burden will not only improve the quality of life, but will increase the lifespan for millions of humans worldwide, not to mention saving billions of health-related dollars.

Text 2: Power of Placebo

Ted Kaptchuk is a Professor of Medicine at Harvard Medical School. For the last 15 years, he and fellow researchers have been studying the placebo effect – something that, before the 1990s, was seen simply as a thorn in medicine’s side. To prove a medicine is effective, pharmaceutical companies must show not only that their drug has the desired effects, but that the effects are significantly greater than those of a placebo control group. However, both groups often show healing results. Kaptchuk’s innovative studies were among the first to study the placebo effect in clinical trials and tease apart its separate components. He identified such variables as patients’ reporting bias (a conscious or unconscious desire to please researchers), patients simply responding to doctors’ attention, the different methods of placebo delivery and symptoms subsiding without treatment – the inevitable trajectory of most chronic ailments.

Kaptchuk’s first randomised clinical drug trial involved 270 participants who were hoping to alleviate severe arm pain such as carpal tunnel syndrome or tendonitis. Half the subjects were instructed to take pain-reducing pills while the other half were told they’d be receiving acupuncture treatment. But just two weeks into the trial, about a third of participants – regardless of whether they’d had pills or acupuncture – started to complain of terrible side effects. They reported things like extreme fatigue and nightmarish levels of pain. Curiously though, these side effects were exactly what the researchers had warned patients about before they started treatment. But more astounding was that the majority of participants – in other words the remaining two-thirds – reported real relief, particularly those in the acupuncture group. This seemed amazing, as no-one had ever proved the superior effect of acupuncture over standard painkillers. But Kaptchuk’s team hadn’t proved it either. The ‘acupuncture’ needles were in fact retractable shams that never pierced the skin and the painkillers were actually pills made of corn starch. This study wasn’t aimed at comparing two treatments. It was deliberately designed to compare two fakes.

Kaptchuk’s needle/pill experiment shows that the methods of placebo administration are as important as the administration itself. It’s a valuable insight for any health professional: patients’ feelings and beliefs matter, and the ways physicians present treatments to patients can significantly affect their health. This is the one finding from placebo research that doctors can apply to their practice immediately. Others such as sham acupuncture, pills or other fake interventions are nowhere near ready for clinical application. Using placebo in this way requires deceit, which falls foul of several major pillars of medical ethics, including patient autonomy and informed consent.

Years of considering this problem led Kaptchuk to his next clinical experiment: what if he simply told people they were taking placebos? This time his team compared two groups of IBS sufferers. One group received no treatment. The other patients were told they’d be taking fake, inert drugs (from bottles labelled ‘placebo pills’) and told also, at some length, that placebos often have healing effects. The study’s results shocked the investigators themselves: even patients who knew they were taking placebos described real improvement, reporting twice as much symptom relief as the no-treatment group. It hints at
a possible future in which clinicians cajole the mind into healing itself and the body – without the drugs that can be more of a problem than those they purport to solve.

But to really change minds in mainstream medicine, researchers have to show biological evidence – a feat achieved only in the last decade through imaging technology such as positron emission tomography (PET) scans and functional magnetic resonance imaging (MRI). Kaptchuk’s team has shown with these technologies that placebo treatments affect the areas of the brain that modulate pain reception. ‘It’s those advances in “hard science”’, said one of Kaptchuk’s researchers, ‘that have given placebo research a legitimacy it never enjoyed before’. This new visibility has encouraged not only research funds but also interest from healthcare organisations and pharmaceutical companies. As private hospitals in the US run by healthcare companies increasingly reward doctors for maintaining patients’ health (rather than for the number of procedures they perform), research like Kaptchuk’s becomes increasingly attractive and the funding follows.

Another biological study showed that patients with a certain variation of a gene linked to the release of dopamine were more likely to respond to sham acupuncture than patients with a different variation – findings that could change the way pharmaceutical companies conduct drug trials. Companies spend millions of dollars and often decades testing drugs; every drug must outperform placebos if it is to be marketed. If drug companies could preselect people who have a low predisposition for placebo response, this could seriously reduce the size, cost and duration of clinical trials, bringing cheaper drugs to the
market years earlier than before.