By F. Ilja. University of Science and Arts of Oklahoma.

Additional references were identified from the reference lists of retrieved articles generic 200 mg prometrium fast delivery 6mp medications. All relevant articles prometrium 200 mg with visa 7 medications that cause incontinence, including prospective and retrospective studies, reviews and meta-analysis, published in English or French that examined the association between gestational exposure to metronidazole and the risk of adverse pregnancy outcomes (having data on preterm birth or birth defects) were reviewed. Only etiologic studies with clinical relevant definition of exposure were considered (exposure during the last two trimesters of pregnancy for studies evaluating preterm birth and exposure during the first trimester for birth defects). The initial selection criteria were broad enough to ensure that as many studies as possible were assessed for review. Case series and studies that reported exposure to other routes of administration (topical or intravenous) without data on oral exposure were excluded. We also calculated the prevalence of preterm birth and birth defects, for papers where these data 206 were not reported. Studies on gestational exposure to metronidazole and the risk of preterm birth Our search strategy retrieved a total of 908 references, from which 225 were initially considered for inclusion. After an exhaustive assessment of their titles and abstracts, 187 documents were rejected, leaving 38 for full text evaluation. Delivery before 37 weeks of gestation was the primary outcome for the majority of these studies. Exposure to metronidazole alone was the main exposure definition in 10 studies, whereas the rest of the articles assessed exposure to metronidazole in association with other antibiotics. Studies on gestational exposure to metronidazole and the risk of birth defects Our search strategy retrieved a total of 131 references, from which 98 were initially considered for inclusion. After an exhaustive assessment of their titles and abstracts, 52 documents were rejected, leaving 46 for full text evaluation. Finally, we retrieved 13 studies that investigated the association between exposure to metronidazole during pregnancy and the risk of birth defects. Ten 207 were cohort studies; one was a case-control study and two were meta- analysis. Any birth defect was the primary outcome for the majority of these studies, whereas some articles assessed only major defects. Exposure to metronidazole (alone or in combination) during the first trimester of pregnancy was the main exposure in all the studies. Gestational exposure to metronidazole alone and the risk of preterm birth In 1994, Morales et al. Nevertheless, at that time it was not clear whether pregnant women in their first gestation would benefit with treatment. Intention-to-treat analysis showed no difference between metronidazole and placebo groups in overall preterm birth rates [(31/429 - 7. In a subgroup of women with previous history of preterm birth, the authors were able to verify the same 208 protective effect reported earlier by Morales et al. However, results from a population-based observational study conducted by Sorensen et al. However, information on previous preterm births and indication for use were lacking in their dataset (12). However, despite findings suggesting a protective effect, authors stated that it is unknown whether any antibiotic regimen reduced preterm birth associated with an intrauterine infection. At that point of the evidence, metronidazole treatment of infections that predispose to preterm birth only showed to be effective for pregnant women with a previous inflammatory process caused by a chronic infection and hence, treatment of asymptomatic women would not be useful. In 209 these studies, the subjects with a history of preterm birth suffered from a chronic bacterial processes, and this could be responsible for their findings of lower rates of preterm birth after exposure to metronidazole. Based on the results of their meta-analyis, Morency and Bujold concluded that the use of metronidazole should be avoided during the second trimester of pregnancy (17). It is not clear why metronidazole used alone may increase the risk of early delivery but it is possible that the eradication of normal bacterial vaginal flora caused by this agent allows growth of harmful organisms, leading to ascending infection, stimulation of the inflammatory process and early delivery. Gestational exposure to metronidazole in association with other antibiotics and the risk of preterm birth In spite of the controversy regarding the use of metronidazole alone for the treatment of infections that predispose to preterm birth, the benefits of the association of this agent with other antibiotics was demonstrated during the decade of 1990. Despite these findings, which seemed to indicate a clear benefit of treating bacterial vaginosis with metronidazole in association with other antibiotics, a large systematic review conducted by Okun et al. The authors however, did not assess the benefits of metronidazole in association with other antibiotics. However, this trial was designed to evaluate the potential benefit of administering an antibiotic intervention to non-pregnant women before conception in an effort to reduce preterm delivery in the subsequent pregnancy; hence exposure did not take place during pregnancy. The lack of efficacy of treatment with metronidazole associated with other agents showed by some studies raised the question if there is an adverse interaction between the antibiotics and the physiological process inducing preterm birth, which could be responsible for the increase in the risk.

It can severely irritate the area to which it has been applied; the irritation can cause vomiting buy prometrium 200 mg cheap symptoms uti in women. In higher dosages cheap prometrium 200 mg on line medicine ball core exercises, the drug is said to be nauseant, Power, Bilberry Leaf and to have the effect of promoting labor and menstruation. Mode of Administration: The ground drug and liquid extract They are 4 to 7 mm long, short-pedicled, greenish and tinged are used for infusions and poultices. The corolla is globular-jug-shaped and Daily Dosage: The usual dose is 2 to 4 gm dissolved in has 5 tips. Hegnauer R, Chemotaxonomie der Pflanzen, Bde 1-11: Birkhauser Verlag Basel, Boston, Berlin 1962-1997. Madaus G, Lehrbuch der Biologischen Arzneimittel, Bde 1-3, Habitat: The plant is common to central and northern Nachdruck, Georg Olms Verlag Hildesheim 1979. Not to be Confused With: Myrtilli folium should not be confused with the fruits of Vaccinium uliginosum. Other Names: Whortleberry, Blueberry, Burren myrtle, Wolters B, Zierpflanzen aus Nordamerika. Anthocyanides have been shown to cyandins slow the synthesis of polymeric collagen in diabetic patients (Boniface, 1996. The authors of the gentisic acid study concluded that Bilberry provides protection against hemorrhage of the retina (Sevin, 1996. External uses include inflammation of the oral animal experiments, lipid-lowering. It is thought that the chromium content of the drug is responsible for a possible antidiabetic effect. Externally the berry is used for mild inflammation of the mucous membranes of meric procyanidins mouth and throat. There is moderate Flavonoids: including among others, hyperoside, isoquercit- support in animal model trials that support the vasoprotective rin, quercitrin, astragaline and anti-edema properties of Bilberry. The literature also Iridoids: including asperuloside, onotropein (only in the demonstrates efficacy in animal models for the treatment of unripe fruits) diabetes, hyperlipidemia and gastric ulcers. Folk medicine uses include internal use for vomiting, bleeding and hemor- Caffeic acid derivatives: chlorogenic acid roids and external use for poorly healing skin ulcers and Pectins wound healing. Drug Interactions: Bilberry has a platelet aggregation Several animal studies have demonstrated that anthocyano- inhibiting effect. There is a possiblility that the herb can sides have a collagen stabilizing effect, and provide protec- interact with other platelet aggregation inhibitors such as tion againts ischemia reperfusion injury (Bertuglia, 1995. No health hazards or side effects are known in conjunction extracts prevent photo-induced oxidation of low density with the proper administration of designated therapeutic lipoproteins. Dombrowicz E, Zadernowski R, Swiatek L Phenolic acids in leaves of Arctostaphylos uva ursi L. Further information in: Daily Dosage: The daily dosage of tea is 1 cup 2 to 3 times daily. Madaus G, Lehrbuch der Biologischen Arzneimittel, Bde 1-3, Nachdruck, Georg Olms Verlag Hildesheim 1979. How Supplied: Roth L, Daunderer M, Kormann K, Giftpflanzen, Pflanzengifte, Most commercially available capsules and tablets are stand- 4. Effect of Vacciniu myrtillus anthocyanosides drug in cold water, bring to a simmer for 10 minutes, then on ischaema reperfusion injury in hamster cheek pouch strain (1 teaspoonful = 4 g drug). Cignarella A, Bertozzi D, Pinna C, Puglisi L, Hypolipidemic activity of Vaccinium myrtillus leaves on an model of Bettini V et al. Ophthalmologica: 152:109- cm long by 2 to 5 cm wide, rhomboid-triangular, acuminate, 117. They are dark green and glabrous above and Further information in: a lighter green below; they are initially downy and later pubescent in the vein axils. Madaus G, Lehrbuch der Biologischen Arzneimittel, Bde 1-3, Nachdruck, Georg Olms Verlag Hildesheim 1979.

The numerous No health hazards or side effects are known in conjunction stamens are long and fused at the base purchase 100 mg prometrium amex schedule 8 medications list. The pods are about with the proper administration of designated therapeutic 10 cm long and contain 5 to 6 shiny brown seeds order prometrium 200mg fast delivery treatment trends. The sapwood is white and the aid and is also administered internally in combination heartwood is black. Food Hydrocolloids acetate, camphene, camphor, myrcene, alpha- and beta- 3:65-75, 1989. Unproven Uses: Gumweed is also used for infections in the Flower and Fruit: Gumweed has a number of individual mucous membranes of the upper respiratory tract. Health risks following the proper administration of designat- If present, the ligules are 7 to 15 mm long and yellow to ed therapeutic dosages are not recorded. The achaenes older scientific literature (Lewin) include gastric irritation are 2 to 3 mm, oblong and brown. Large dosages, however, are said to have a are 3 to 5 mm long and usually finely serrulate. The alternate leaves are 3 to 7 cm long, other galenic preparations for internal use. Daily Dosage: The recommended dosage is 4 to 6 g of drug Habitat: The plant grows in the Southwestern U. Hagers Handbuch der 10) are cylindrical and have black glandular hairs and a Pharmazeutischen Praxis, 4. It has opposite, elliptical-oval leaves, which Madaus G, Lehrbuch der Biologischen Arzneimittel, Bde 1-3, are rounded to cordate at the base and dotted black. Habitat: The plant originated in Madagascar and east Africa; it grows in many areas throughout tropical Africa. Phytopharmaka und Production: Haronga is a collective term for extracts from pflanzliche Homoopathika. The leaves are collected and then air-dried whole; the bark is peeled and also air-dried. In animal experiments, it has demonstrated a choleretic, cholecystokinetic and antihepatoxic effect. Flower and Fruit: The inflorescences are richly blossomed, terminal and umbel-like, with a diameter of about 20 cm. The severe liver function disorders, gallstone illnesses, obstruc- fruit is a roundish, reddish drupe. Leaves, Stem and Root: The evergreen plant is a fern with long, wide, simple, short-petioled dark green fronds. They How Supplied: Forms of commercial pharmaceutical repara- are arranged in clusters and are broad linear-lanceolate, 2- tions include drops, tablets and compound preparations. Habitat: The plant is indigenous to almost all of Europe, North America, northern Africa, and eastern Asia. Mucilages Gehrmann B, Analytische Studie an Harungana Flavonoids: including among others, kaempferol-7-rhamno- madagascariensis Lam. Thiaminase (probably present only in the fresh plant) Hansel R, Keller K, Rimpler H, Schneider G (Hrsg. It has 5 lanceolate, acute and uneven may be explained by the saponin content, as can its use for sepals with an appendage and 5 uneven petals, the largest of catarrh of the upper respiratory tract. The 5 stamens also have an appendage at hemolytic and increases chloride elimination in the urine. Approved hy Commission E: • Inflammation of the skin Leaves, Stem and Root: Heartsease is annual to perennial and grows about 30 cm high. The shoots are usually yellowish Unproven Uses: External uses include mild seborrheic skin green, glabrous or covered in scattered hairs. The stem is diseases, cradle cap in children and various skin disorders, erect, angular, unbranched or branched, glabrous or short- including wet and dry exanthema, eczema, Crusta lactea, haired. The lower internally as a mild laxative for constipation and as an leaves are cordate; the upper ones are oblong-elliptical.

This is a term used to emphasise the mutilating nature of the practice 100 mg prometrium with mastercard medications you should not take before surgery, as part of a world- wide campaign to eliminate the procedure prometrium 200mg line symptoms stomach cancer. However, the word mutilation may cause offence to some who practice or have experien- ced the procedure. Most women from affected communities would understand that the intent of their mothers and female relatives would have not been to mutilate, but to en- hance their daughter’s opportunities for marriage and economic security, and success in the world. Its use in consultation may have the potential to be counterproductive to for- ming an effective professional relationship with the patient and hence detrimental to the provision of her ongoing care for what is a sensitive issue. Terms that women may use include circumcision, cut- ting, traditional female cutting or surgery, or sunna. This latter procedure is known as infibulation and is sometimes Area Healed referred to as pharaonic circumcision. Excision of the prepuce, with or without excision of part or the entire clitoris (figure 1). Excision of the clitoris with part or total excision of the labia minora (fi- gure 2). Excision of part or all of the external genitalia and stitching/na- rrowing of the vaginal opening (infundi- bulation) (figure 3). Labour assisted at Hospital Clínico Universitario and/or labia, stretching of the clitoris Lozano Blesa of Zaragoza, Spain. Labour and intra- assisted at Hospital Clínico Universitario Lozano Blesa partum defibulation performed at Hospital Clínico of Zaragoza, Spain. This extrapolates to approximately 2 million girls per year at risk of being circumcised. It is practiced mainly in 28 African countries, where prevalence rates range from 5% to 98% (figure 4). It predates both Christianity and Islam and does not pertain to any specific religion. Countries in Africa with Egypt Communities practicing female circumcision Mauritania Mali Senegal Niger Chad Sudan Eritrea Burquina Djbouti Gambia Guinea- Faso Nigeria Bissau C. Ethiopia Sierra Leone Cameroon Liberia Somalia Ghana Benin Democratic Uganda Cote Togo Republic Kenya d’Ivoire of Congo (Ivory Coast) (Zaire) Tanzania Figure 4. The presence of this scar tissue, which is less elastic than the perineal and vaginal tissue would normally be, might cause differing degrees of obstruction and tears or episiotomy. In the opposite, Abdulrahim3 work shows that, with proper management, there is no sta- tistically significant difference in outcome of labour between women who deliver vagina- lly, with and without defibulation. It is sufficient to reassure the patient that she and her baby are under no special risk. Under no circumstance should a woman be subjected to caesarean section solely to avoid defibulation, regardless of whether she requests it or the provider suggests it6. For some authors the optimum time for a defibulation is the second trimester under local or spinal anaesthesia. This is thought to prevent acute problems at the time of delivery related to the risk of un- familiarity of the staff on duty with defibulation. Other professionals and a number of women prefer de-infibulation during labour as part of the birth process as they then only have to experience a painful procedure once. Care must be taken not to injure intact parts of the clitoris that may be buried under the anterior part of the hood. The edges of the skin are stitched apart with a running absorbable, non reactive suture. Any extension of the an- terior incision above the urethra may be repaired at this time. A routine repair of the episiotomy or perineal tear is also frequently required post labour. Careful cut of the scar between two fingers to avoid injuring urethra or intact parts of the clitoris.

Diagnostically sensitive findings in a patient with suspected or proven infection include fever or hypothermia trusted 100mg prometrium medicine tablets, tachypnea discount prometrium 100mg otc medicine universities, tachycardia, and leukocytosis or Coagulopathy leukopenia (Table 29-1); acutely altered mental status, Although thrombocytopenia occurs in 10–30% of patients, thrombocytopenia, an elevated blood lactate level, or the underlying mechanisms are not understood. The septic counts are usually very low (<50,000/μL) in patients response can be quite variable, however. Moreover, the systemic responses of uninfected Neurologic Complications patients with other conditions may be similar to those When the septic illness lasts for weeks or months,“criti- characteristic of sepsis. Guillain-Barré ruptured aortic aneurysm, myocardial infarction, occult hemorrhage, cardiac tamponade, post–cardiopulmonary 285 Available information about patterns of antimicrobial bypass syndrome, anaphylaxis, and drug overdose. When culture results become available, the least two blood samples (10 mL each) should be regimen can often be simplified because a single obtained (from different venipuncture sites) for culture. Meta-analyses have (<10 organisms/mL of blood), prolonged incubation of concluded that, with one exception, combination cultures may be necessary; S. In many cases, blood cultures are negative; this that aminoglycoside monotherapy for P. Most patients require antimicrobial therapy for at these cases, Gram’s staining and culture of material from least 1 week; the duration of treatment is typically influ- the primary site of infection or of infected cutaneous enced by factors such as the site of tissue infection, the lesions may help establish the microbial etiology. The skin adequacy of surgical drainage, the patient’s underlying and mucosae should be examined carefully and repeat- disease, and the antimicrobial susceptibility of the bac- edly for lesions that might yield diagnostic information. Successful management requires urgent mea- neutropenic patients, cutaneous sites of tenderness and sures to treat the infection, provide hemodynamic and erythema, particularly in the perianal region, must be respiratory support, and eliminate the offending microor- carefully sought. Rapid assessment and diag- severe sepsis arising from the urinary tract, sonography nosis are therefore essential. Adequate organ perfu- chemotherapy was the major determinant of outcome; a sion is thus essential. If the patient is allergic to β-lactam agents, use ciprofloxacin (400 mg q12h) or levofloxacin (500–750 mg q12h) plus clindamycin (600 mg q8h). If the local prevalence of cephalosporin-resistant pneumococci is high, add vancomycin. If the patient is allergic to β-lactam drugs, vancomycin (15 mg/kg q12h) plus ciprofloxacin (400 mg q12h) or levofloxacin (750 mg q12h) or aztreonam (2 g q8h) should be used. If the patient is allergic to β-lactam drugs, ciprofloxacin (400 mg q12h) or levofloxacin (750 mg q12h) plus vancomycin (15 mg/kg q12h) plus tobramycin should be used. An ade- of the SvO2 at >70% was associated with significantly quately powered and randomized trial of vasopressin improved survival of patients who were admitted to infusion has not been performed. The potent vasoconstrictor that may be most useful in treatment algorithm included rapid administration of patients who have vasodilatory shock and relative resis- fluids, antibiotics, and vasopressor support; erythro- tance to other pressor hormones. If clinical same group then studied intensive glucose control in improvement occurs over 24–48 h, most experts would critically ill medical patients and found a survival benefit continue hydrocortisone therapy, tapering and discon- only for patients who remained in the intensive care unit tinuing it after 5–7 days. Hypoglycemia was much more com- regarding hydrocortisone therapy may come from the mon in the intensive-insulin group. Frequent monitoring of blood glu- impending respiratory collapse; mechanical ventilation cose levels is indicated to avoid hypoglycemia during is often initiated to ensure adequate oxygenation, divert intensive insulin therapy. The results of recent studies favor the use of ment, many patients with severe sepsis or septic shock low tidal volumes (6 mL/kg of ideal body weight or as die. Numerous interventions have been tested for their low as 4 mL/kg if the plateau pressure >30 cmH2O). Patients undergoing mechanical ventilation require The list includes endotoxin-neutralizing proteins; careful sedation with daily interruptions; elevation of inhibitors of cyclooxygenase or nitric oxide synthase; the head of the bed helps to prevent nosocomial anticoagulants; polyclonal immunoglobulins; glucocor- pneumonia. H2-receptor antagonist may decrease the risk of gas- Unfortunately, none of these agents has improved rates trointestinal hemorrhage in ventilated patients. This lack of reproducibility has were given to raise the hematocrit to 30% if the had many contributing factors, including (1) hetero- patient’s SvO2 was <70%. A dramatic example of this problem was seen Bicarbonate is sometimes administered for severe in a trial of tissue factor pathway inhibitor (Fig. Patients who are hypercatabolic and in more than one placebo-controlled clinical trial before have acute renal failure may benefit greatly from it is accepted as part of routine clinical practice. In a single randomized controlled nutritional supplementation may reduce the impact of trial in which drug or placebo was given within 24 h of protein hypercatabolism; the available evidence, which is the patient’s first sepsis-related organ dysfunction, not strong, favors the enteral delivery route.

While this patient is wet order prometrium 100 mg with mastercard medications names, she has none of the other signs of a cholinergic toxicity buy prometrium 100 mg with amex medications not to take before surgery. Fever from an overdose is a poor prognostic indicator and should usually be addressed with large doses of benzodiazepines and intravenous fluids. Symptomatic patients require observation or admission until they are asymptomatic. In the undifferentiated altered mental status patient, blood sugar level should immediately be checked. The nearest poison control center should be contacted (1-800-222-1222) for overdoses, accidental ingestions, and adverse drug effects. American Academy of Clinical Toxicology, European Association of Poisons Centres, Clinical Toxicologists. National academy of clinical biochemistry laboratory medicine practice guidelines: recommendations for the use of laboratory tests to support poisoned patients who present to the emergency department. Past history includes numerous skin abscesses, hepatitis C and injection drug use. There is a low-grade fever, the heart rate is 115 bpm and blood pressure is 120/60 mm Hg. Establish a definitive diagnosis as quickly as possible, beginning with a careful search for a pus pocket. Recognize the risk factors associated with necrotizing infections and with unusual pathogens. Appreciate that uncomplicated abscesses often require only incision and drainage, and no antibiotics, for cure. There has been a recent rise in the incidence of these infections linked to the emergence of community-associated methicillin resistant Staphylococcus aureus. Red flags can alert the astute clinician to a necrotizing infection as well as to unusual pathogens that require special antibiotics. Circular infections (as opposed to circumferential) on the buttock, groin and lower extremity almost always harbor pus near the center. Fluctuance may be absent if the abscess is deep, as often occurs in the pannus of the buttock or thigh, or if the abscess is early in its course. Bedside ultrasound, using a high frequency linear transducer, can identify deep abscesses that are not appreci- ated on physical examination. Spontaneous, superficial skin abscesses are called furuncles and patients often assume these are spider bites. Abscesses associ- ated with injection drug use, and those occurring near the perineum may contain gram negative and anaerobic bacteria. Abscesses are typically surrounded by a vari- able amount of cellulitis (so-called purulent cellulitis), and large abscesses may cause fever. Nonpurulent cellulitis tends to occur on the lower extremities in a circumferential pattern, often in an area of preexisting edema. Erysipelas is a superficial, sharply demarcated cellulitis caused by S pyogenes that often occurs in elderly patients on the face or lower extremities, and causes fever and leukocytosis. Cellulitis in certain settings is always considered high risk, either because it is caused by esoteric or resistant pathogens, or because of the likelihood of severe disease requiring admission or an operation. Infected puncture wounds of any kind are high risk and likely to involve deep structures like bone, joint or tendon, and to respond poorly to conventional antibiotics alone. Tenosynovitis, an orthopedic emergency, can complicate puncture wounds on the palmar hand and fingers. These infections typi- cally spread rapidly along subcutaneous and muscular facial planes and produce toxins and trigger an intense cytokine response that lead to septic shock. An important risk factor for community onset necrotizing fasciitis is injec- tion drug use, particularly subcutaneous and intramuscular injection (“skin popping”) of black tar heroin. Other infection patterns that should raise a red flag are neglected diabetic foot ulcers and infections of the perineum, particularly in men. The Clostridial infections associated with injection drug use may produce dra- matic tissue edema and extreme leukocytosis. The diagnosis is made when subcutaneous devitalized tissue, muscle necrosis and “dishwater pus” are found. In most cases drainage is best accomplished by incision with a scalpel and exploration of the cavity with a clamp, although needle aspiration is a good option for small abscesses on the face.

Within cohort studies with a follow-up purchase 100 mg prometrium otc treatment 20 initiative, this can either be achieved by comparing the incidence of events of interest between patients using comparative drugs cheap prometrium 100mg mastercard medications 1800, or to compare incidence rates within a single group of patients between the time when they used the drug and the time when they did not use the drug of interest 177,178. In order to limit confounding by indication in the case-control study, presented in chapter 3. By including these patients only, we have ensured that prognostic factors such as cardiovascular risk factors (e. Regrettably, this strategy is not applicable in studies where the effects of statin use on the risk of developing autoimmune disorders will be evaluated. Since statins are the frst choice agents in the treatment for patients with hyperlipidaemia, other lipid-lowering agents are less frequently prescribed. Due to the small sample size, it was not feasible to use other lipid-lowering medication users as an appropriate control group. Another approach for limiting confounding by indication in observational studies is to match by characteristics (e. Additionally, we conducted subgroup analyses in patients with the same indication (with or without cardiovascular diseases and cardiovascular related risk factors) as described in chapters 3. Another method to minimise confounding by indication is to estimate propensity scores and analyse the data within homogenous levels of propensity scores. By using stratifcation or matching, for instance, by the propensity score a balance of covariates between the statin users and non-users may be achieved 179. Finally, adjustment for confounding factors or inclusion of a single propensity score value (as a covariate) in the analyses by using multivariable regression analysis may minimise confounding by indication. The propensity score technique usually does not result in substantially different treatment effect estimates compared with the conventional regression methods 184,185. The conventional regression and propensity score techniques, however, are similar in that they can only adjust for known and measured potential confounders 186. We used multiple imputation methods (chapter 4) or a missing indicator method (missing data in the variables were treated as a separate category in the analysis) (chapter 3. Another approach that is used to reduce unmeasured confounding is by data linkage. By using a trusted third party, medical and research data can be separated from the name, address and postal code (encrypted). Another possibility of linking data can involve encrypting patients’ identifcation into a unique personal identifcation number, as in Denmark. In Denmark, each person is issued with a unique personal identifcation number upon birth or immigration. This unique personal identifcation number encodes, among other information, date of birth and sex, and by that means, information on a given subject can be linked to multiple data sources 191,192. We urge physicians, pharmacists and other healthcare providers, and above all, patients to report potential side effects to pharmacovigilance centres. Inform physicians and pharmacists of statin-associated autoimmune disorders In general, statins are considered to be safe although the market withdrawal of cerivastatin has demonstrated that some serious adverse effects are not always detected in clinical trials. The most commonly reported side effects of statins are marked elevation of liver enzymes and muscular abnormalities 200. Physicians and pharmacists should be informed about these possible statin-associated autoimmune disorders. Prescribing statins in low cardiovascular risk patients According to several guidelines, patients with a high risk of cardiovascular disease should be treated with statins 182,183,201–205. However, the fndings in this thesis shed new light on the beneft-risk ratio of statins. However, others have not corroborated these fndings 66–70, and therefore; more defnitive studies in healthy (low-risk) subjects are needed. Until this question is resolved, one should be conservative in prescribing statins to individuals with a low cardiovascular risk. Drug labels inform healthcare professionals on the safe and effective use of a specifc drug.