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After6months harms of initiating statin use for the primary prevention of cardio- to 6 years of follow-up 1000mg ciprofloxacin sale, statin use was associated with a decreased vascular events in adults 76 years and older discount ciprofloxacin 750 mg on-line. However discount ciprofloxacin 750 mg line, 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 Thetreatmentstrat- ment is no longer relevant and has been replaced by a preventive egy is treatment-to-target rather than by therapy dose (eg, 50% medication framework. Total cardiovascularrisk:areportoftheAmerican AspirinUsetoPreventCardiovascularDiseaseand cholesterol and risk of mortality in the oldest old. The tables and figures in this Pocket Guide follow the numbering of the 2017 Global Strategy Report for reference consistency. These include genetic abnormalities, abnormal lung development and accelerated aging. These comorbidities should be actively sought and treated appropriately when present as they can influence mortality and hospitalizations independently. Spirometry is the most reproducible and objective measurement of airflow limitation. Despite its good sensitivity, peak expiratory flow measurement alone cannot be reliably used as the only diagnostic test because of its weak specificity. Spirometry should be performed after the administration of an adequate dose of at least one short-acting inhaled bronchodilator in order to minimize variability. Spirometry in conjunction with patient symptoms and exacerbation history remains vital for the diagnosis, prognostication and consideration of other important therapeutic approaches. In the refined assessment scheme, patients should undergo spirometry to determine the severity of airflow limitation (i. Finally, their history of exacerbations (including prior hospitalizations) should be recorded. This classification scheme may facilitate consideration of individual therapies (exacerbation prevention versus symptom relief as outlined in the above example) and also help guide escalation and de-escalation therapeutic strategies for a specific patient. Pharmacotherapy and nicotine replacement reliably increase long-term smoking abstinence rates. However, individual patient factors must be considered when evaluating the patient’s need for supplemental oxygen. If effective resources and time are dedicated to smoking cessation, long-term quit success rates of up to 25% can be achieved. Counseling delivered by physicians and other health professionals significantly increases quit rates over self-initiated strategies. Stimulation of beta2-adrenergic receptors can produce resting sinus tachycardia and has the potential to precipitate cardiac rhythm disturbances in susceptible patients. Exaggerated somatic tremor is troublesome in some older patients treated with higher doses of beta2-agonists, regardless of route of administration. Antimuscarinic drugs  Antimuscarinic drugs block the bronchoconstrictor effects of acetylcholine on M3 muscarinic receptors expressed in airway smooth muscle. Inhaled anticholinergic drugs are poorly absorbed which limits the troublesome systemic effects observed with atropine. Toxicity is dose-related, which is a particular problem with xanthine derivatives because their therapeutic ratio is small and most of the benefit occurs only when near-toxic doses are given. Results from withdrawal studies provide equivocal results regarding consequences of withdrawal on lung function, symptoms and exacerbations. Reduction of total personal exposure to occupational dusts, fumes, and gases, and to indoor and outdoor air pollutants, should also be addressed. Key points for the use of other pharmacologic treatments are summarized in Table 4. Symptoms, exacerbations and objective measures of airflow limitation should be monitored to determine when to modify management and to identify any complications and/or comorbidities that may develop. These changes contribute to increased dyspnea that is the key symptom of an exacerbation. Other symptoms include increased sputum purulence and volume, together with increased cough and wheeze. More than 80% of exacerbations are managed on an outpatient basis with pharmacologic therapies including bronchodilators, corticosteroids, and antibiotics. Acute respiratory failure — non-life-threatening: Respiratory rate: > 30 breaths per minute; using accessory respiratory muscles; no change in mental status; hypoxemia improved with supplemental oxygen via Venturi mask 25-30% FiO2; hypercarbia i. Acute respiratory failure — life-threatening: Respiratory rate: > 30 breaths per minute; using accessory respiratory muscles; acute changes in mental status; hypoxemia not improved with supplemental oxygen via Venturi mask or requiring FiO2 > 40%; hypercarbia i. The management of severe, but not life threatening, exacerbations is outlined in Table 5. Respiratory Support Oxygen therapy  This is a key component of hospital treatment of an exacerbation. Supplemental oxygen should be titrated to improve the patient’s hypoxemia with a target saturation of 88- 92%. The indications for initiating invasive mechanical ventilation during an exacerbation are shown in Table 5. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Poor airway function in early infancy and lung function by age 22 years: a non-selective longitudinal cohort study. The lung health study: airway responsiveness to inhaled methacholine in smokers with mild to moderate airflow limitation. An official American Thoracic Society public policy statement: Novel risk factors and the global burden of chronic obstructive pulmonary disease. Occupational exposures are associated with worse morbidity in patients with chronic obstructive pulmonary disease. Lifetime risk of developing chronic obstructive pulmonary disease: a longitudinal population study. Risk factors for chronic obstructive pulmonary disease in a European cohort of young adults. Detecting chronic obstructive pulmonary disease using peak flow rate: cross sectional survey. The tobacco use and dependence clinical practice guideline panel s, and consortium representatives,.

Observational Evidence of a Link between Early Development and Later Disease The last three decades has seen the emergence of evidence demonstrating the importance of the environment during early life for the establishment of disease risk in later life and in future generations order 1000 mg ciprofloxacin otc. Observational Evidence of a Link between Early Development and Later Disease The last three decades has seen the emergence of evidence demonstrating the importance of the environment during early life for the establishment of disease risk in later life and in future generations ciprofloxacin 250 mg with mastercard. In Hertfordshire generic 250mg ciprofloxacin, sixteen thousand men and women born between 1911 and 1930 were traced. Death rates from coronary heart disease fell steadily across the birth weight distribution such that rates at the higher end of the distribution were roughly half those at the lower end [4]. Findings from the Swedish cohort study, which followed up 14,611 babies, also supported the inverse association between cardiovascular disease and birth weight [5]. The associations of birth weight with these diseases were independent of lifestyle risk factors, including smoking and alcohol intake, and of socio-economic status. The developmental origins model of disease pathogenesis is supported by biological evidence from animal experiments. These have shown that alteration of maternal diet during pregnancy can modify offspring physiological processes, and that these modifications are lasting rather than transient [6]. Such a phenomenon is an example of phenotypic plasticity where a genotype can give rise to different physiological or morphological states depending on the prevailing environmental conditions during development. Studies in experimental animals have made it clear that the long-term effects of early life nutrition act through developmental changes to organs and tissues such as the pancreas, liver, kidneys, skeletal muscle and adipose tissue. Newborn size (equivalent to birth weight in human studies) is frequently used as an indicator of the intra-uterine experience, because it is easy to measure, but can only be a crude proxy of these changes at tissue level. Animal experiments have shown that overfeeding mothers with high fat or high energy diets, leading to maternal diabetes and obesity, will increase insulin resistance, diabetes and cardiovascular changes in their offspring [7,8]. Recently, there has been accumulating evidence that paternal diet, body composition and health can also affect the health of the offspring [9]. Low birth weight, an indicator of poor nutrition in utero, is associated with higher infant mortality, poorer educational outcomes in childhood and poorer long term health [11]. Social, psychological and occupational exposures during infancy, childhood and adult life will modify risk of ill health and disease. Maternal Nutrition Observational evidence of a link between early life and later disease has led to an interest in maternal influences on the development of the fetus. A girl or woman’s nutritional status before and during pregnancy influences outcomes both for her pregnancy and for the developing fetus [12]. It also has a strong influence on risk of pre-term delivery and impaired growth and development in utero and after birth. Recent studies have shown that prenatal exposure to gestational diabetes could lead to epigenetic alterations that increase the risk of type 2 diabetes later in life. In India, for example, findings of the Pune maternal nutrition study suggest that micronutrient deficiencies (such as vitamin B12) can also lead to low birth weight and an increased risk of later diabetes [13]. Healthcare 2017, 5, 14 4 of 12 Maternal undernutrition is usually caused by food shortage or economic hardship which leads to food insecurity and result in inadequate intake of nutrients. Exposure to undernutrition in utero is associated with low birth weight and stunting in childhood, which are in turn associated with shorter adult height and reduced economic productivity [14,15]. Undernutrition in utero also has adverse effects on cognitive development and so is also associated with lower levels of educational attainment. Overnutrition occurs when the energy consumed outstrips energy expended and usually leads to overweight and obesity. For women during pregnancy, overnutrition leads to greater risk of gestational diabetes and hypertensive disorders of pregnancy. For the fetus, maternal gestational diabetes leads to an increased risk of macrosomia, high blood glucose and insulin and these are associated with neonatal hypoglycemia, congenital anomalies, preterm birth, stillbirth and neonatal death. There is also evidence that obese women accumulate more metabolites in their ovarian follicles and this has been associated with increased risk of cardiovascular disease and obesity in later life in their offspring [18]. Deficiencies of specific vitamin and minerals can be caused by insufficient intake due to poor or inadequate diet, or by an increased demand for nutrients, for example because of rapid growth or menstrual bleeding. Micronutrient deficiencies can occur even when there is overnutrition, and lifestyle factors such as alcohol intake and smoking can affect their absorption. Deficiencies of vitamins and minerals in mothers will affect their offspring as many micronutrients pass across the placenta from mother to fetus. Similar results have emerged from the Southampton Women’s Survey (at birth and six years) [20], with recent findings from the Australian Raine cohort demonstrating relationships persisting to 20 years old [21], around the age of peak bone mass [21]. Many interventions to improve maternal nutrition begin only once a women knows she is pregnant and seeks ante-natal care, thus missing the majority of the first trimester, when placentation and organogenesis occur. Studies in Southampton have shown that women of childbearing age, who are disadvantaged by having low levels of educational attainment, have diets of poor quality [23]. Maternal diets of poor quality have been associated with less optimal patterns of skeletal development, adiposity and cognitive development in their children [24]. Evidence shows that many women (especially young women) do not plan or prepare for pregnancy and unplanned pregnancies are still common [22]. The health behaviors of women during pregnancy are strongly influenced by their social circumstances and studies have shown that only a small proportion of women planning a pregnancy follow the recommendations for a healthy pregnancy such as increased fruit and vegetable consumption, folic acid intake, smoking and alcohol cessation [25]. Genetic polymorphisms could potentially explain both poor fetal development and later risk of disease. A study by the Wellcome Trust Care Control Consortium identified several new genetic loci and genes that influence an individual’s susceptibility to a range of conditions including coronary heart disease and type 1 and 2 diabetes [26]. More importantly, Healthcare 2017, 5, 14 5 of 12 even combining the effects of known genetic loci associated with particular diseases does not account for a substantial levels of risk at the population level [27]. Epigenetic Mechanisms The emergence of epigenetics is allowing exploration of the molecular mechanisms that link early exposures to later disease. Epigenetic mechanisms underlie the developmental plasticity, that is fundamental to the link between fetal development and risk of later disease [3]. There is evidence that maternal factors can modulate gene expression in their offspring thus influencing [8,28]. For example maternal malnutrition had led to altered gene methylation and increased risk of offspring metabolic syndrome in adult life [29]. In addition, recent studies have shown that prenatal exposure to gestational diabetes could lead to epigenetic alterations that increase the risk of type 2 diabetes later in life [30]. Influences of early development on satiety and food preferences suggest that, once set points are established in early life, it may be difficult or even impossible to reverse them. This might explain why lifestyle interventions in adult can have limited effects and are difficult to sustain [22]. Behavioural Mechanisms The health behaviors that people adopt will modify their risk of disease across the lifecourse. Childhood and adolescence are stages of the lifecourse when health behaviors become established [32,33]. These risk factors are responsible for considerable burden of disease on a global level [34]. They can have direct effects on health or can act by influencing the development of high blood pressure and elevated blood glucose and cholesterol levels, which will then raise the risk of chronic diseases such as cardiovascular disease and diabetes. There is also evidence that infants who are breastfed have reduced risk of obesity and diabetes in adulthood. Poor diet is common during childhood including iron and vitamin deficiencies during infancy and consumption of inappropriate energy-dense foods that increase the risk of obesity during childhood [36,37].

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Beyond these considerations cheap 500mg ciprofloxacin otc, the development of a culture of transparency ciprofloxacin 750 mg cheap, dedication discount ciprofloxacin 250mg with amex, collaboration and partnership certainly represents the way forward for the development of patient and public information. Optimization of exposures requires that operators understand the equipment they use and that the image quality is consistent with the clinical need. Educating operators on optimization is a responsibility of professional bodies and manufacturers alike, and this should be updated throughout the lifetime of the equipment. The enhanced capabilities of equipment in the last 10 years, since the Malaga conference, are astounding. Multidetector technology has revolutionized the role of this modality within the clinical setting, with single breath-hold chest scans providing previously unavailable information regarding the lungs, and the possibility of single beat cardiac scans being achievable. The increased availability of medical equipment and its use in new clinical settings means that the number of examinations an individual may experience in a lifetime has increased dramatically. Even in the United Kingdom, the use of cross-sectional imaging has risen in excess of 10% per annum over the past 10 years and shows little sign of reaching a plateau. Well publicized data from the United States of America have shown that the population dose from medical exposures is now around half of that from all exposures. However, there is some evidence that users are not always fully aware of all the dose saving technology available and how it works. The range of doses delivered at different clinics for the same examination demonstrates this. Without a thorough knowledge of how modern equipment works, it is possible to increase rather than decrease the dose delivered to the patient. In the past few years, justification has been the major focus within medical radiation protection circles and there is no doubt that there is scope for considerable dose saving when only justified procedures are undertaken. Nevertheless, optimization also has a role and there is a need for more attention to be paid regarding the impact of image quality on dose. The view that the image quality needed is that to adequately demonstrate the clinical problem and no more, is often unseen within conferences, the scientific literature and in manufacturers’ training and publicity material. The community as a whole has a responsibility to address both image quality and dose when considering optimization and to aim for a satisfactory diagnosis rather than the best possible image quality. Finally, regulators have a role to play, by providing platforms and frameworks, for and with users and manufacturers. Again, better understanding and cooperation will help, but ultimately, the regulator relies on the professionals in the field to work with the manufacturers in order to optimize exposures. Physicians all over the world can discuss any disease process without physical contact with the patient. The essence of radiological imaging in health care is to accrue maximum benefits against the radiation risk. The advance in technology has resulted in improved imaging information acquisition and a great desire for good quality diagnostic images. Radiologists play a crucial role as gate-keepers for radiological protection of patients, personnel and the public. The gate-keeper role is between justification and optimization of radiation protection of patients. Radiological imaging does not obey the socioeconomic status of the patient, nor the economic dynamics of the times. Once you are declared as a patient or you need an investigation due to altered body physiology, then you become a subject of different types of imaging. A radiological survey in Kenya has revealed that the majority of patients undergo a general radiography examination. The statistics indicate that per million people, there are 26 sets of X ray equipment, 5 radiographers, 3 radiologists and 0. Thus, each radiographer and each radiologist would perform 189 300 and 325 000 examinations per year. These figures send an alarming message about the percentage of the population exposed to radiation risk and calls for an urgent international response to protect the patient, imaging personnel and the general public. There are other factors that enhance the upsurge in radiation risk: the inadequacy or non-existence of quality assurance programmes, unskilled or inadequately trained personnel, a poorly funded health sector with no funds allocated for dosimetry studies, and the high cost of imaging, leading to the mushrooming of imaging facilities that acquire refurbished or cheap equipment that is not assessed for compliance. This will enable imaging professionals, biomedical/ maintenance engineers and technologists to be involved in patient dose research, tracking and monitoring. Proper training and a good understanding of patient dose monitoring by imaging professionals will enhance the optimization of radiation protection in medicine. Lack of preventive care, diagnosis and access to adequate health services are among the major factors responsible for this. In recent years, the world has observed major growth in the number and in the applications of medical imaging and radiotherapy technologies. This growth has had an impact on reducing disease mortality and increasing prevention in high income countries. Low income countries have difficulties in obtaining the benefits of such technological developments. Multiple factors, such as infrastructure, health technology assessment and management, human resources, quality of care and safety, economic constraints and cultural aspects, contribute to the challenge. In particular, the lack of an appropriate regulatory infrastructure, well maintained equipment, trained staff and physical infrastructures, threatens the safety of patients and health workers. A more widespread use of medical imaging and radiotherapy technologies and improvement in treatment approaches will lead to a reduction in mortality and help to combat many diseases and conditions of public health concern, as well as to improved quality of life for people in developing countries. The services of radiation medicine encompass a wide spectrum of clinical applications. Modalities such as ultrasound and X ray examinations alone can solve around 80% of diagnostic problems in developing countries. Radiotherapy is used today for the treatment of many kinds of tumours, and is frequently administered in combination with surgery, chemotherapy or both. Demand for radiation medicine services has increased worldwide due to the global increase of diseases, new clinical applications, the increase in world population, an ageing population, lifestyle changes and worldwide health care programmes and reforms. The lack of appropriate infrastructure and technologies, well maintained equipment, trained staff, and governmental regulations, among other factors, threatens the safety of patients and health workers in low income countries. Even where the technology is available, both the quality and safety of the procedures may be questionable or even dangerous for the patient and health workers. Most of the mortality causes are conditions for which timely ultrasound imaging could increase survival rates [3]. Acute lower respiratory infection, mostly pneumonia, is the leading cause of childhood mortality, accounting for about 4 million deaths per year in low income countries. Appropriate case management, focusing on early detection and treatment of the disease, has been challenging to implement, especially in low income countries that often face poor access to basic health care. Radiography would appear to be the best available method for diagnosing pneumonia if relevant health professionals knew how to interpret the images, and these met the necessary quality standards [4].

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For this growing group of tizens as well as patients will be signifcantly confronted patients buy ciprofloxacin 500 mg low price, ways must be identifed to evaluate benefts and with it in ‘digital health’ (by information and training) generic 250mg ciprofloxacin with mastercard, in risks of medication which are usually tested in younger and the ‘internet of things’ (by devices) and in social networks healthier populations and where the evidence base is weak buy ciprofloxacin 1000 mg low cost. Mo- plicit examination of what is necessary in order to allow reover, approaches for individualisation of drug therapy in the promise of the innovation to be realised. For example, the light of several comorbidities and patients’ preferences well-defned patient pathways are needed for the appro- should be tested and validated. Participation of patients and their commendations empowerment must play a crucial role in improving adhe- rence; otherwise the best drugs will not be efective. A combination of beneft–risk evaluation with real-time data and the use of observational, epidemiological or in Research on regulatory and legal issues should be sup- silico studies to demonstrate efectiveness even on indi- ported in order to update and adapt current regulations. These evaluations le regulatory procedure across all regulators, taking into will also enable post-marketing surveillance to spot rare account ethical, legal and social aspects. This would lead adverse events and include spontaneous reporting and to reduced costs and fewer administrative hurdles and analysis of electronic health records. Those approaches often include a combina- without considering the global perspective. These new models are based on a con- der collaboration in research and development tinuous adaption of the use of new technologies to the using an ‘Open Innovation’ approach. European bi-directional fow of ideas and interchange between harmonisation in these areas would also facilitate interna- companies. Innovation in lic, private and user partnerships, seems to be particular- the area of rare diseases has recently benefted from such ly interesting for enabling the introduction of promising international coordination through the International Rare innovation, where the added value is of high plausibility. The rare di- tems accompanied by research that reduces the inherent sease feld ofers many ‘lessons learned’ and can help to uncertainties under real-world conditions. Peer reviewed ensure that similar international structures can be esta- collaborative research using open data is a model that blished. Encourage a systematic early dialogue between innovators, patients and decision-makers th- In this context translational projects closer to the pati- roughout all regulatory steps to provide guidan- ent/market should be driven by the end-users’ needs. Companies are This recommendation is closely allied to the revision of the hesitant to access the market due to the limited under- regulatory and legal framework to produce a clearer and standing of certifcation, validation and regulations: for harmonised approach with interconnected components. Innovators and companies should be research, even at an early stage, considers the regulatory encouraged to seek guidance early in relation to options and reimbursement evaluation needs, e. This will importance to involve patients in this dialogue, especially facilitate access to resources and competences, both of in terms of defning endpoints, patient-relevant outcomes which are lacking among the diferent actors involved in and intended comparative value. Eu- tial approval in a well-defned patient subgroup with comed) and biotechnology industries (e. It is open to industry, acade- including the prevention of an illness before its onset. It ofers a safe harbour and open posed to death), but their patients might even experien- dialogue with expert regulators who ofer their perso- ce absolute recovery. Market entry pathways have to be ad- vative development methods or trial designs), ofer an apted in order to assure a safe, efective and competitive ofcial response to very specifc scientifc questions environment for patients and industry. In total, ten early dialogues is to carry out basic and translational research as well are planned with the aim to conduct seven on drugs as the instruction and distribution of new genomics and three on medical devices. In this sense, some major drivers Healthcare should be considered: a) the technology itself; b) the sys- tem and its organisation (including its workforce); and c) Introduction the interaction between the system and the client. There are today several policy tools to manage the difusi- on of innovations in healthcare, one of which is payment The technology or group of technologies, if we consider tre- mechanisms. The challenges faced by payment autho- atments and companion diagnostics, by itself ofers bene- rities are manifold. How can promising innovations be fts that are linked to its inherent characteristics: the capaci- driven forward while avoiding the difusion of undesirab- ty of creating tailored solutions that increase the safety and le ones? How can the execution of studies required for efcacy of treatments and the generation of further data sound reimbursement decision-making be encouraged? And how can appropriate utilisation and difusion of the- However, there are still some challenges that have not been se innovations be ensured in terms of patient population solved and health systems have not yet produced a harmo- and provider setting? Afordability is a central element nised and common defnition of what represents added for reimbursement, and thus an additional challenge of value (Henshall et al. Inevitably competing from the perspective of healthcare systems is very much policy goals have to be balanced: maximising health be- linked to the expression ‘clinical utility’ as well as ‚personal nefts for the population as a whole and ensuring that in- utility‘ and when diagnostics and treatments go hand-in- novation is fnancially rewarded, while at the same time hand, there is a need to consider how the existence and containing costs. That is, if we can efectively and correctly categori- spective of healthcare systems. The possibility of providing se patients, will other therapeutic or preventive measures diagnostics and care that are tailored to the characteristics be taken and will that improve the health of the afected of the individual has been one of the main goals of he- patients? There is the promise of better tem, its organisation and its workforce to assume and en- outcomes; each patient will be given only what he or she sure the adequate implementation of this technology and needs, avoiding the at times trial-and-error based ‘classi- paradigm. There is also the prospect of a interoperability of existing clinical record databases for this reduction in costs related to this trial-and-error paradigm, new purpose (see Challenge 2); the ability of health profes- together with a reduction in resources required to address sionals to build the capacity required for them to assume risks such as adverse events and incomplete benefts that their new role (see Challenge 1); and appropriate systems might arise from not applying the best available option. Initially, there will be a need for invest- ethical practices, there is a need for a trustworthy and trans- ment in quality assurance, organisational aspects and ca- parent interaction between healthcare systems and clients, pacity building. For this purpose, the should provide services with sufcient guarantees of safe- analysis of the target population and its characteristics, the ty and quality and, in principle, on the basis of supporting development of adapted materials and improved health the paradigm of the general assembly of United Nations literacy are crucial. While there are no one-size-fts-all solu- on Universal Health Coverage that includes a system for tions, good practice can be shared (see also Challenge 1). European Best New models for pricing and reimbursement have to be Practice Guidelines for Quality Assurance, Provision and discussed. Where patients provide their personal health Use of Genome-based Information and Technologies: data and Member States invest in infrastructure, the pri- 2012 Declaration of Rome. Reimbursement has to ensure campaigns, support patient groups and recognise the fair rewards for the research investment and risks taken by patient’s right to seek information. This should be done the producer, but also afordability for the entire health by initiating and supporting constructive and informati- system as well as equity for each patient. At the same time, health systems have need sound economic and medical evidence to support to shift focus from acute disease treatment to preventive their decision-making process. Funding organisations health management in parallel with treatment of disea- should collaborate with healthcare providers to identify se. Develop prospective surveillance systems for is crucial to promote inter-, trans- and multi-disciplinarity personal health data that facilitate accurate and in healthcare providers (e. Encourage a citizen-driven framework for the adoption of electronic health records. In this case, major challenges can be identifed: accuracy of data, interoperability of databases, which includes the ca- As has been pointed out earlier, the interaction between pacity to trace individuals while securing anonymity, and health system and client is one of the major points to ana- appropriate storage capacities. Another limiting factor is lyse, especially considering that the owners of the data are the capacity to analyse and integrate big data (see Challen- the patients. There are initiatives paving the way by establishing tronic data storage and data-sharing; this is relevant when supercomputing centres in order to solve this problem of there is a need to combine clinical data with other data storage, integration and analysis (Merelli, 2014). Promote engagement and close collaboration platforms, coordination at the semantic level and, fnally, between patients, stakeholders and healthcare education mechanisms and awareness raising.

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