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Open back gowns while the bane of hospitalized patients world-wide represent the most practical means of combining protection with accessibility when shirt and pant style clothing is not practical or possible discount innopran xl 40mg amex, as when casts or external appliances interfere buy discount innopran xl 40 mg online. Vanity issues aside it may be necessary to trim nails to address issues of hygiene (germs love to hide under nails) and prevent inadvertent self-injury by a patient who may flail about with pain or fever delirium generic innopran xl 40mg with mastercard. Having properly designed and sized clippers for the fingers and toes makes this task much easier for all concerned. Providing On-Going Care Having identified our goals we can move on the issue of how we are to address them. There are several areas that need to be addressed as part of the entire care “package” or plan. Databases: Vital Signs Having a database of vital signs is the key to recognizing abnormal vital signs later on. In an ideal situation you would have a record that details normal laying, sitting and standing blood pressures for your patient, as well as a resting pulse, and respirations, along with a temperature. Make sure to note whether the normal pulse is - 152 - Survival and Austere Medicine: An Introduction regular and strong in quality and rhythm, or irregular, weak, or bounding (very strong). Having a database of temperatures over time will allow you to gauge the effectiveness of antibiotics, for instance, or the onset of an infection. Similarly a person who is acutely dehydrated will see an increase in their temperature. Pulse Pulses may indicate a general state of health in the absence of illness or injury. A very rapid, thin pulse may indicate the presence of shock, whereas a slow pulse might signal that the patient is relaxed and relatively pain free. Since pulse rates vary widely amongst people the change in pulse rate and quality is more important than the rate itself. For example, for a person whose normal pulse rate at rest is 68 an increase of 20 per minute may indicate the presence of unaddressed pain. Blood Pressure Blood pressures are always obtained using a blood pressure cuff, either manually operated or electronic. Cuffs come in different sizes with a standard blood pressure cuff suitable for adolescents and adults. An upper arm larger than approximately 15 cm will require a larger cuff for an accurate reading or a false high will result. Conversely an arm smaller than approximately 8 cm will require a smaller diameter cuff or a false low reading will result. Breathing Normal breathing rates for an adult range between 14 and 20 per minute, or one breathe every 3 – 4 seconds. During times of illness this may increase, with more than 30 breaths a minute considered very significant. In addition to rate the apparent effort used to breath can also be indicative of distress or absence of same. Respiratory infections can cause labored breathing, evidenced by increased effort and rate. By tracking breathing rates and quality along with other vital signs it is possible to determine whether treatments are having a positive effect. Other Data to Collect and Record Bowel Movements As we age our bowel movements tend to become less frequent. Older - 153 - Survival and Austere Medicine: An Introduction adults may not have a proper bowel movement for several days without regular use of fiber in their diet and/or laxatives. As a rule a person should have one medium to large bowel movement at least every 3 days. Urination It is not necessary to record urine outputs for everyone but for some cases – especially burns - measuring output against fluids taken in (Intake and Output) is necessary to determine whether fluid balance is being maintained. The effects of disease, loss of fluids through other sources such as perspiration, vomiting, bowel movements, etc may affect this somewhat but as a general rule plan on a measured output of one and a half litres. Anything less than half this amount may be indicative of kidney malfunction and is cause for serious concern. For certain types of patients, such as burn cases or those with heart failure, matching Intake and Output (I & O) against daily weights can be critical to determine if an output deficit is the result of retained fluids. Weight Weight by itself may mean little other than as a general indication of nutritional status but changes in weight can be significant in terms of indicating changes in the patient’s condition. For instance fluid retention or loss can vary a person’s weight by several pounds (2 – 3 kilograms) per day. Sudden fluid gain can precipitate heart failure, and also may indicate failing kidney function if present along with decreasing urine output. Sudden weight loss normally indicates a loss of fluids from the body, a very important consideration with large-scale burns where we want to achieve balance in the body’s fluid load. Bed Mobility The ability to change positions in bed is often taken for granted by those not affected by illness or mobility problems. Pressure sores, which will be addressed later in this section, are one potential problem of immobility. Lifting Frames One device useful for caregiver and patient alike is the overhead lifting frame, or trapeze bar. The traditional model uses a triangular handle secured to the bar or frame positioned overhead by means of sturdy strap, rope, or chain. The bar or strap is used by the patient who has the upper body strength to lift themselves off the bed, allowing for self or assisted repositioning, or for the caregiver to change the bed linens without the patient exiting the bed. It saves both time and physical stress and offers the bedfast patient a sense of self-reliance. Besides preventing a weak or disoriented person from inadvertently rolling out of bed they can be used by the patient for repositioning by providing them with a handle to grab onto to pull or roll themselves. Modern hospital beds have fold-down rails but removable railings can be fashioned by fitting them with “legs” that attach to the bedside using screw clamps or other type of easily removable fastener. This will allow for a measure of safety while also allowing full access for bedding changes and transfers. Positioning Positioning can be defined as the art of arranging the patient properly to encourage maximum retention of function, comfort, and accessibility. As simple as it seems improper positioning can and does lead to breakdowns in skin integrity, loss of function of limbs, and prolonged recovery times. Elevation Elevating the head of the bed aids in breathing for some people, especially in instances of pneumonia, asthma, and emphysema, and can assist with keeping the airway clear. Simple techniques for achieving this in a bed not otherwise designed for the head to be elevated are to use blocks under the legs at the head end, or to place blocks, pillows or other items under the upper portion of the mattress. Positioning Pillows To reduce any tendency towards pressure sores and to increase patient comfort it is common practice to alternate the way patients lay by positioning them first on their left side, then their back, and finally on the right side before starting over, with changes every 2-3 hours. Pillows are used to prop the person who is otherwise unable to lay on one side unassisted.

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Sikkema (2014) generic innopran xl 40 mg amex, The Impact of methamphetamine (“tik”) on a peri-urban community in Cape Town cheap innopran xl 80mg with mastercard, South Africa purchase 80 mg innopran xl mastercard, International Journal of Drug Policy, Mar; 25(2): 219–225. Morojele and L Ramsoomar, (2016), Addressing adolescent alcohol use in South Africa, S Afr Med J 2016;106(6):551-553. Perceptions of sexual risk behaviours and substance abuse among adolescents in South Africa: a qualitative investigation. A qualitative study of home-brewed alcohol use among adolescents in Mankweng District, Limpopo Province, South Africa. Alcohol consumption and non-communicable diseases: Epidemiology and policy implications. A prospective study of metaphetamine use as a predictor of high school non-attendance in Cape Town, South Africa. Women’s discourses about secretive alcohol dependence and experiences of accessing treatment. Unpublished dissertation presented for the degree of Doctor of Philosophy in the Department of Psychology at the University of Stellenbosch; Pretorius, C. Umthente Uhlaba Usamila – The 2 nd South African Youth Risk Behaviour Survey 2008. Umthenthe uhlaba usamila – the 1st South African youth risk behaviour survey 2002. The comparative risk assessment for alcohol as part of the global burden of disease 2010 study: What changed from the last study? Alcohol consumption as a risk factor for pneumonia: A systematic review and meta-analysis. Setlalentoa M, Elma Ryke and Herman Strydom (2015) Intervention strategies used to address alcohol abuse in the North West province, South Africa Social work (Stellenbosch. Religious activity and risk behavior among African American adolescents: Concurrent and developmental effects. Evaluation of a Primary Prevention of Substance Abuse Programme Amongst Young people at Tembisa. Baseline study of the liquor industry including the impact of the national liquor act 59 of 2003. Conducting effective Substance abuse prevention work among the youth in South Africa. Identification and prediction of drinking trajectories in early and mid-adolescence. Violence as an impediment to a culture of teaching and learning in some South African schools. All rights reserved, worldwide The designations employed and the presentation of material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the United Nations concerning the legal status of any country, territory, city or area, or of its authorities, or concerning the delimitation of its frontiers or boundaries. Publishing production: English, Publishing and Library Section, United Nations Ofce at Vienna. Justice Tettey, wishes to express its appreciation and thanks to the following experts who participated in an expert group meeting and/or contributed to the development and review of this revision of Terminology and Information on Drugs: Dr. Eleuterio Umpiérrez Faculty of Chemistry, Universidad de la República, Uruguay Mr. The current revision of this publication is being prepared as a response to changes in drug markets and scheduling decisions of the Commission on Narcotic Drugs in recent years. The publication is neither exhaustive, nor meant to replace more comprehensive textbooks on drugs of abuse. It seeks to collate basic concepts and information on drugs of abuse, their corresponding abuse patterns, pharmacological efects and potential medical use, and act as an accessible and user-friendly resource. Comments and suggestions for improving content and/or format of this publication by readers are welcome. Lists of common substances, illicit forms and street names are not extensive listings, but selections. Street names can be ambiguous, and should not be relied upon to characterize a given drug. Sections on chemical constituents of cannabis plant, coca bush and opium poppy are not comprehensive listings, but focus on those substances which are of interest from a drug control point of view. The mechanism of action and resulting efects listed are a summary of the most widely recognized desired efects, undesired acute efects and efects due to chronic use of a given substance or group of substances. In order to make the publication more accessible, related information has been displayed in similar tabular forms across each chapter. In the Single Convention on Narcotic Drugs of 1961, as amended by the 1972 Protocol, narcotic drugs and their preparations are essentially listed in four schedules according to their dependence potential, abuse liability and therapeutic usefulness (fgure 1) [1]. The cannabis plant, however, exists in many diferent biological, chemical or morphological varieties. As a “dioecious” species, the plant can be staminate (male) or pistillate (female). However, there are individual cases of “monoecious” plants or hermaphrodites, where Cannabis herbal material both sexes coexist on one plant. The term “cannabis” is also generally used to describe diferent products obtained from the cannabis plant. Characteristically, cannabis resin is the dried brown or black resinous secretion of the flowering tops of the cannabis plant. For example, in South and South-West Asia, the following techniques are traditionally used: • The fruiting and flowering tops are rubbed between the palms of the hand, and resin is transferred to the palm. Cannabis resin • Another technique is to immerse the plant material in boiling water and remove resin from the surface. Common street names Charas Hashish Commonly Route of Chira Khif used forms administration H Pot Hash Shit Fine powder (also compressed into slabs) • Inhalation—either alone, or mixed with tobacco Loose or pressed sticky powder • Oral consumption (in the form of food and tea) Resin pressed or rolled into slabs, rods, balls or other shapes Cannabis oil Cannabis oil is obtained by extraction of the crude plant material, cannabis, or cannabis resin with an organic solvent. The extract is then fltered and evaporated to give an oil of required consistency. There are a variety of ongoing studies on other cannabinoid products for possible therapeutic uses. Activation of these receptors regulates the1 release of multiple neurotransmitters. Nonetheless, further research is needed to elucidate the full scope of the pharmacological efects and receptors involved. The comprehensive role of receptors in this context in producing pharmacological efects is not yet known. However, the activation of these receptors possibly results in a number of overlapping efects, as shown in the fgure below. Many of the substances in this structurally diverse group were initially designed for pharmacological research as potential pharmaceuticals to mimic the efects of cannabis.

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Identification and prediction of drinking trajectories in early and mid-adolescence discount innopran xl 40mg with visa. Violence as an impediment to a culture of teaching and learning in some South African schools purchase 40 mg innopran xl mastercard. All rights reserved cheap innopran xl 40 mg visa, worldwide The designations employed and the presentation of material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the United Nations concerning the legal status of any country, territory, city or area, or of its authorities, or concerning the delimitation of its frontiers or boundaries. Publishing production: English, Publishing and Library Section, United Nations Ofce at Vienna. Justice Tettey, wishes to express its appreciation and thanks to the following experts who participated in an expert group meeting and/or contributed to the development and review of this revision of Terminology and Information on Drugs: Dr. Eleuterio Umpiérrez Faculty of Chemistry, Universidad de la República, Uruguay Mr. The current revision of this publication is being prepared as a response to changes in drug markets and scheduling decisions of the Commission on Narcotic Drugs in recent years. The publication is neither exhaustive, nor meant to replace more comprehensive textbooks on drugs of abuse. It seeks to collate basic concepts and information on drugs of abuse, their corresponding abuse patterns, pharmacological efects and potential medical use, and act as an accessible and user-friendly resource. Comments and suggestions for improving content and/or format of this publication by readers are welcome. Lists of common substances, illicit forms and street names are not extensive listings, but selections. Street names can be ambiguous, and should not be relied upon to characterize a given drug. Sections on chemical constituents of cannabis plant, coca bush and opium poppy are not comprehensive listings, but focus on those substances which are of interest from a drug control point of view. The mechanism of action and resulting efects listed are a summary of the most widely recognized desired efects, undesired acute efects and efects due to chronic use of a given substance or group of substances. In order to make the publication more accessible, related information has been displayed in similar tabular forms across each chapter. In the Single Convention on Narcotic Drugs of 1961, as amended by the 1972 Protocol, narcotic drugs and their preparations are essentially listed in four schedules according to their dependence potential, abuse liability and therapeutic usefulness (fgure 1) [1]. The cannabis plant, however, exists in many diferent biological, chemical or morphological varieties. As a “dioecious” species, the plant can be staminate (male) or pistillate (female). However, there are individual cases of “monoecious” plants or hermaphrodites, where Cannabis herbal material both sexes coexist on one plant. The term “cannabis” is also generally used to describe diferent products obtained from the cannabis plant. Characteristically, cannabis resin is the dried brown or black resinous secretion of the flowering tops of the cannabis plant. For example, in South and South-West Asia, the following techniques are traditionally used: • The fruiting and flowering tops are rubbed between the palms of the hand, and resin is transferred to the palm. Cannabis resin • Another technique is to immerse the plant material in boiling water and remove resin from the surface. Common street names Charas Hashish Commonly Route of Chira Khif used forms administration H Pot Hash Shit Fine powder (also compressed into slabs) • Inhalation—either alone, or mixed with tobacco Loose or pressed sticky powder • Oral consumption (in the form of food and tea) Resin pressed or rolled into slabs, rods, balls or other shapes Cannabis oil Cannabis oil is obtained by extraction of the crude plant material, cannabis, or cannabis resin with an organic solvent. The extract is then fltered and evaporated to give an oil of required consistency. There are a variety of ongoing studies on other cannabinoid products for possible therapeutic uses. Activation of these receptors regulates the1 release of multiple neurotransmitters. Nonetheless, further research is needed to elucidate the full scope of the pharmacological efects and receptors involved. The comprehensive role of receptors in this context in producing pharmacological efects is not yet known. However, the activation of these receptors possibly results in a number of overlapping efects, as shown in the fgure below. Many of the substances in this structurally diverse group were initially designed for pharmacological research as potential pharmaceuticals to mimic the efects of cannabis. These products are O sold as smokable “herbal blends” and “legal highs” under a variety of brand names such as “Spice”, “K2”, “Kronic” and are labelled as “not for human consumption”. Also the content of products can vary both in terms of the actual substance or mixture of substances present and their concentration(s). Studies of potency in humans do not exist Monkees Go Bananas and users do not know what they are consuming, ofen leading to wrong doses Rockstar and severe side efects due to overdose. Opium and opiates “Opium” means the coagulated juice of the opium poppy, where “opium poppy” means the plant of the species Papaver somniferum L. It has white to red flowers and round to elongated capsules containing seeds which can range in colour from white to dark violet. Opium poppies 13 There are a number of psychoactive substances that can be extracted from opium, with morphine and codeine being the most predominant. It is Black Stuf O sticky, tar-like and dark brown when fresh, and becomes brittle and hard as it ages. Mud Commonly Route of used forms administration Sticky or hard, dark brown material in • Oral consumption (chewed) any form or shape • Inhalation Blocks wrapped in vegetable leaves Oral consumption (chewed) followed by plastic wrapping Production Raw opium is harvested from the seed capsule of the poppy, while the capsule is still in the green stage. The opium latex is obtained by making a series of shallow incisions into the capsule, which allows the latex to run onto its surface and be collected. Prepared opium Prepared opium is a sticky dark product obtained as a result of various treatments of raw opium, e. Commonly Route of used forms administration Sticky or hard, dark brown material in Inhalation any form or shape Sticks in the form of cigarettes Inhalation 15 Medicinal opium “Medicinal opium” means opium which has undergone the processes necessary to adapt it for medicinal use [2]. Common forms Light yellowish-brown powder consisting of yellowish or reddish-brown particles. Approved medical preparations of opium Tincture Fine brown powder Prepared opium Pastilles Syrup Common street names Chandu Poppy straw Sukhteh “Poppy straw” means all parts (except the seeds) of the opium poppy, afer mowing [2], which includes the dried upper part of the stem and the capsules of the poppy plant. Concentrate of poppy straw The material arising when poppy straw has entered into a process for the concentration of its alkaloids, when such material is made available in trade [2]. Commonly Route of used forms administration Brown or of-white powder [7] Oral consumption 16 3. However, opioids are synthetic compounds, which are derived from opiates O N but are not opiates themselves (see section 4). Opium, concentrate of poppy straw, O morphine and heroin are under Schedule I of the Single Convention on Narcotic Drugs of 1961. Heroin Morphine Morphine is the most prevalent alkaloid extracted from opium or poppy straw. Morphine can be found compressed into blocks with a variety of trademarks or names.

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People with metabolic syndrome would purchase innopran xl 40 mg otc, in any case 40mg innopran xl with mastercard, benefit from weight reduction innopran xl 80mg visa, higher levels of activity (65–71), lowering of blood pressure, avoidance of drugs that tend to cause hyperglycaemia (72–75), lowering of choles- terol with a statin (76–80), and reduction of hyperglycaemia with metformin. There is insufficient evidence from randomized trials to support more specific management of dyslipidaemias (81). In summary, the great strength of the risk scoring approach is that it provides a rational means of making decisions about intervening in a targeted way, thereby making best use of resources available to reduce cardiovascular risk. Alternative approaches focused on single risk factors, or concepts such as pre-hypertension or pre-diabetes, have been popular in the past, often because they represented the interests of specific groups in the medical profession and professional societ- ies. Such an approach, however, leads to a very large segment of the population being labelled as high risk, most of them incorrectly. If health care resources were allocated to such false-positive individuals, a large number of truly high-risk individuals would remain without medical attention. Risk scoring moves the focus of treatment from the management of individual risk factors to the best means of reducing an individual’s overall risk of disease. It enables the intensity of interven- tions to be matched to the degree of total risk (Figure 2). Further research is required to validate existing subregional risk prediction charts for individual populations at national and local levels, and to confirm that the use of risk stratification methods in low- and middle-income countries results in benefits for both patients and the health care system. These charts are intended to allow the introduction of the total risk stratification approach for management of cardiovascular disease, particularly where cohort data and resources are not readily available for development of population-specific charts. The charts have been generated from the best available data, using a modelling approach (Annex 5), with age, sex, smoking, blood pressure, blood cholesterol, and presence of diabetes as clinical entry points for overall manage- ment of cardiovascular risk. Some studies have suggested that diabetic patients have a high cardiovascular risk, similar to that of patients with established cardiovascular disease, and so do not need to be risk-assessed. In addition, in people with diabetes, there is no gender difference in the risk of coronary heart disease and stroke (82). Therefore, separate charts have been developed for assessment of cardiovascular risk in patients with type 2 diabetes. In many low-resource settings, there are no facilities for cholesterol assay, although it is often feasible to check urine sugar as a surrogate measure for diabetes. Annex 4 therefore contains risk prediction charts that do not use cholesterol, but only age, sex, smoking, systolic blood pressure, and presence or absence of diabetes to predict cardiovascular risk. Obesity, abdominal obesity (high waist–hip ratio), physical inactivity, low socioeconomic position, and a family history of premature cardiovascular disease (cardiovascular disease in a first-degree relative before the age of 55 years for men and 65 years for women) can all modify cardiovascular risk. These risk factors are not included in the charts, which may therefore underestimate actual risk in people with these characteristics. While including these risk factors in risk stratification would improve risk prediction in most populations, the increased gain would not usually be large, and does not warrant waiting to develop and validate further risk stratifica- tion tools. Nevertheless, these (and other) risk factors may be important for risk prediction, and some of them may be causal factors that should be managed. Clinicians should, as in any situa- tion, use their clinical acumen to examine the individual’s lifestyle, preferences and expectations, and use this information to tailor a management programme. The risk prediction charts and the accompanying recommendations can be used by health care professionals to match the intensity of risk factor management with the likelihood of cardio- vascular disease events. The charts can also be used to explain to patients the likely impact of interventions on their individual risk of developing cardiovascular disease. The use of charts will help health care professionals to focus their limited time on those who stand to benefit the most. It should be noted that the risk predictions are based on epidemiological data from groups of people, rather than on clinical practice. However, these objections do not detract from their potential to bring much-needed coher- ence to the clinical dilemmas of how to apply evidence from randomized trials in clinical practice, and of who to treat with a growing range of highly effective but costly interventions. Clinical assessment of cardiovascular risk Clinical assessment should be conducted with four aims: ● to search for all cardiovascular risk factors and clinical conditions that may influence prognosis and treatment; ● to determine the presence of target organ damage (heart, kidneys and retina); ● to identify those at high risk and in need of urgent intervention; ● to identify those who need special investigations or referral (e. Table 4 Causes, clinical features and laboratory tests for diagnosis of secondary hypertension Causes Clinical features and Investigations Renal parenchymal ◆ family history of renal disease (polycystic kidney), hypertension ◆ past history of renal disease, urinary tract infection, haematuria, analgesic abuse ◆ enlarged kidneys on physical examination ◆ abnormalities in urine analysis – protein, erythrocytes, leucocytes and casts ◆ raised serum creatinine Renovascular ◆ abdominal bruit hypertension ◆ abnormal renal function tests ◆ narrowing of renal arteries in renal arteriography Phaeochromocytoma ◆ episodic headache, sweating, anxiety, palpitations ◆ neurofibromatosis ◆ raised catecholamines, metanephrines in 24-hour urine samples Primary aldosteronism ◆ muscle weakness and tetany ◆ hypokalaemia ◆ decreased plasma renin activity and/or elevated plasma aldosterone level Cushing syndrome ◆ truncal obesity, rounded face, buffalo hump, thin skin, abdominal striae, etc. Physical examination A full physical examination is essential, and should include careful measurement of blood pres- sure, as described below. Measuring blood pressure Health care professionals need to be adequately trained to measure blood pressure. In addition, blood pressure measuring devices need to be validated, maintained and regularly calibrated to ensure that they are accurate (84). Two readings should be taken; if the average is 140/90 mmHg or more, an additional reading should be taken at the end of the consultation for confirmation. Blood pressure should be measured in both arms initially, and the arm with the higher reading used for future measurements. If the difference between the two arms is more than 20 mmHg for systolic pressure or 10 mmHg for diastolic pressure, the patient should be referred to the next level of care for examination for vascular stenosis. Patients with accelerated (malignant) hyperten- sion (blood pressure ≥ 180/110 mmHg with papilloedema or retinal haemorrhages) or suspected secondary hypertension should be referred to the next level immediately. Risk stratification is not necessary for making treatment decisions for these individuals as they belong to the high risk category; all of them need intensive lifestyle interventions and appropriate drug therapy (5). Each chart has been calculated from the mean of risk factors and the average ten-year event rates from countries of the specific subregion. They are useful as tools to help iden- tify those at high total cardiovascular risk, and to motivate patients, particularly to change behav- iour and, when appropriate, to take antihypertensive and lipid-lowering drugs and aspirin. An individual’s risk of experiencing a cardiovascular event in the next 10 years is estimated as follows: ● Select the appropriate chart (see Annex 3), depending on whether the person has diabetes or not. The mean of two non-fasting measurements of serum cholesterol by dry chemistry, or one non- fasting laboratory measurement, is sufficient for assessing risk. The strength of the various recommendations, and the level of evidence supporting them, are indicated as follows (13) in Table 5. High quality risk of confounding, bias or chance and a case control or cohort studies with a very significant risk that the relationship is not low risk of confounding or bias and a high causal probability that the relationship is causal 2+ Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal 2− Case control or cohort studies with a high risk of confounding or bias and a signifi- cant risk that the relationship is not causal 3 Non-analytical studies e. A body of evidence, including studies rated as 2++, is directly applicable to the target population and demonstrating overall consistency of results; or extrapolated evidence from studies rated as 1++ or 1+. A body of evidence, including studies rated as 2+, directly applicable to the target popu- lation and demonstrating overall consistency of results; or extrapolated evidence from studies rated as 2++. Low risk does nonfatal vascular nonfatal vascular fatal or nonfatal not mean “no” risk. Conservative Monitor risk profile Monitor risk profile Monitor risk profile management every 3–6 months every 3–6 months every 6–12 months focusing on lifestyle interventions is suggestedb. When resources are limited, individual counselling and provision of care may have to be prioritized according to cardiovascular risk. All smokers should be strongly encouraged to quit smoking by a health professional and supported in their efforts to do so. For individuals in low risk categories, they can have a health impact at lower cost, compared to individual counselling and therapeutic approaches.