Sample Answer for NURS 6630 Assessing and Treating Patients With Psychosis and Schizophrenia Included After Question
Psychosis and schizophrenia greatly impact the brain’s normal processes, which interfere with the ability to think clearly. When symptoms of these disorders are uncontrolled, patients may struggle to function in daily life. However, patients often thrive when properly diagnosed and treated under the close supervision of a psychiatric mental health practitioner. For this Assignment, as you examine the patient case study in this week’s Learning Resources, consider how you might assess and treat patients presenting with psychosis and schizophrenia.
To prepare for this Assignment:
- Review this week’s Learning Resources, including the Medication Resources indicated for this week.
- Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of patients with schizophrenia-related psychoses.
The Assignment: 5 pages
Examine Case Study: Pakistani Woman With Delusional Thought Processes. You will be asked to make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.
At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.
Introduction to the case (1 page)
- Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.
NURS 6630 Assessing and Treating Patients With Psychosis and Schizophrenia
Decision #1 (1 page)
- Which decision did you select?
- Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
- Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #2 (1 page)
- Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
- Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
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Decision #3 (1 page)
- Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
- Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Conclusion (1 page)
- Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.
Note: Support your rationale with a minimum of five academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. You should be utilizing the primary and secondary literature.
Learning Resources
Required Readings (click to expand/reduce)
Freudenreich, O., Goff, D. C., & Henderson, D. C. (2016). Antipsychotic drugs. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 72–85). Elsevier.
Medication Resources (click to expand/reduce)
Note: To access the following medications, use the Drugs@FDA resource. Type the name of each medication in the keyword search bar. Select the hyperlink related to the medication name you searched. Review the supplements provided and select the package label resource file associated with the medication you searched. If a label is not available, you may need to conduct a general search outside of this resource provided. Be sure to review the label information for each medication as this information will be helpful for your review in preparation for your Assignments.
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Required Media (click to expand/reduce)
Optional Resources (click to expand/reduce)
Lopes Write Policy
For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.
Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.
Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?
Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.
Late Policy
The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.
Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.
If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.
I do not accept assignments that are two or more weeks late unless we have worked out an extension.
As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.
Communication
Communication is so very important. There are multiple ways to communicate with me:
Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.
Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.
Important information for writing discussion questions and participation
Welcome to class
Hello class and welcome to the class and I will be your instructor for this course. This is a -week course and requires a lot of time commitment, organization, and a high level of dedication. Please use the class syllabus to guide you through all the assignments required for the course. I have also attached the classroom policies to this announcement to know your expectations for this course. Please review this document carefully and ask me any questions if you do. You could email me at any time or send me a message via the “message” icon in halo if you need to contact me. I check my email regularly, so you should get a response within 24 hours. If you have not heard from me within 24 hours and need to contact me urgently, please send a follow up text to
I strongly encourage that you do not wait until the very last minute to complete your assignments. Your assignments in weeks 4 and 5 require early planning as you would need to present a teaching plan and interview a community health provider. I advise you look at the requirements for these assignments at the beginning of the course and plan accordingly. I have posted the YouTube link that explains all the class assignments in detail. It is required that you watch this 32-minute video as the assignments from week 3 through 5 require that you follow the instructions to the letter to succeed. Failure to complete these assignments according to instructions might lead to a zero. After watching the video, please schedule a one-on-one with me to discuss your topic for your project by the second week of class. Use this link to schedule a 15-minute session. Please, call me at the time of your appointment on my number. Please note that I will NOT call you.
Please, be advised I do NOT accept any assignments by email. If you are having technical issues with uploading an assignment, contact the technical department and inform me of the issue. If you have any issues that would prevent you from getting your assignments to me by the deadline, please inform me to request a possible extension. Note that working fulltime or overtime is no excuse for late assignments. There is a 5%-point deduction for every day your assignment is late. This only applies to approved extensions. Late assignments will not be accepted.
If you think you would be needing accommodations due to any reasons, please contact the appropriate department to request accommodations.
Plagiarism is highly prohibited. Please ensure you are citing your sources correctly using APA 7th edition. All assignments including discussion posts should be formatted in APA with the appropriate spacing, font, margin, and indents. Any papers not well formatted would be returned back to you, hence, I advise you review APA formatting style. I have attached a sample paper in APA format and will also post sample discussion responses in subsequent announcements.
Your initial discussion post should be a minimum of 200 words and response posts should be a minimum of 150 words. Be advised that I grade based on quality and not necessarily the number of words you post. A minimum of TWO references should be used for your initial post. For your response post, you do not need references as personal experiences would count as response posts. If you however cite anything from the literature for your response post, it is required that you cite your reference. You should include a minimum of THREE references for papers in this course. Please note that references should be no more than 5 years old except recommended as a resource for the class. Furthermore, for each discussion board question, you need ONE initial substantive response and TWO substantive responses to either your classmates or your instructor for a total of THREE responses. There are TWO discussion questions each week, hence, you need a total minimum of SIX discussion posts for each week. I usually post a discussion question each week. You could also respond to these as it would count towards your required SIX discussion posts for the week.
I understand this is a lot of information to cover in 5 weeks, however, the Bible says in Philippians 4:13 that we can do all things through Christ that strengthens us. Even in times like this, we are encouraged by God’s word that we have that ability in us to succeed with His strength. I pray that each and every one of you receives strength for this course and life generally as we navigate through this pandemic that is shaking our world today. Relax and enjoy the course!
Hi Class,
Please read through the following information on writing a Discussion question response and participation posts.
Contact me if you have any questions.
Important information on Writing a Discussion Question
- Your response needs to be a minimum of 150 words (not including your list of references)
- There needs to be at least TWO references with ONE being a peer reviewed professional journal article.
- Include in-text citations in your response
- Do not include quotes—instead summarize and paraphrase the information
- Follow APA-7th edition
- Points will be deducted if the above is not followed
Participation –replies to your classmates or instructor
- A minimum of 6 responses per week, on at least 3 days of the week.
- Each response needs at least ONE reference with citations—best if it is a peer reviewed journal article
- Each response needs to be at least 75 words in length (does not include your list of references)
- Responses need to be substantive by bringing information to the discussion or further enhance the discussion. Responses of “I agree” or “great post” does not count for the word count.
- Follow APA 7th edition
- Points will be deducted if the above is not followed
- Remember to use and follow APA-7th edition for all weekly assignments, discussion questions, and participation points.
- Here are some helpful links
- Student paper example
- Citing Sources
- The Writing Center is a great resource
As we begin this session, I would like to take this opportunity to clarify my expectations for this course:
Please note that GCU Online weeks run from Thursday (Day 1) through Wednesday (Day 7).
Course Room Etiquette:
- It is my expectation that all learners will respect the thoughts and ideas presented in the discussions.
- All postings should be presented in a respectful, professional manner. Remember – different points of view add richness and depth to the course!
Office Hours:
- My office hours vary so feel free to shoot me an email at [email protected] or my office phone is 602.639.6517 and I will get back to you within one business day or as soon as possible.
- Phone appointments can be scheduled as well. Send me an email and the best time to call you, along with your phone number to make an appointment.
- I welcome all inquiries and questions as we spend this term together. My preference is that everyone utilizes the Questions to Instructor forum. In the event your question is of a personal nature, please feel free to post in the Individual Questions for Instructor forumI will respond to all posts or emails within 24 or sooner.
Late Policy and Grading Policy
Discussion questions:
- I do not mark off for late DQ’s.
- I would rather you take the time to read the materials and respond to the DQ’s in a scholarly way, demonstrating your understanding of the materials.
- I will not accept any DQ submissions after day 7, 11:59 PM (AZ Time) of the week.
- Individual written assignments – due by 11:59 PM AZ Time Zone on the due dates indicated for each class deliverable.
Assignments:
- Assignments turned in after their specified due dates are subject to a late penalty of -10%, each day late, of the available credit. Please refer to the student academic handbook and GCU policy.
- Any activity or assignment submitted after the due date will be subject to GCU’s late policy
- Extenuating circumstances may justify exceptions, which are at my sole discretion. If an extenuating circumstance should arise, please contact me privately as soon as possible.
- No assignments can be accepted for grading after midnight on the final day of class.
- All assignments will be graded in accordance with the Assignment Grading Rubrics
Participation
- Participation in each week’s Discussion Board forum accounts for a large percentage of your final grade in this course.
- Please review the Course Syllabus for a comprehensive overview of course deliverables and the value associated with each.
- It is my expectation that each of you will substantially contribute to the course discussion forums and respond to the posts of at least three other learners.
- A substantive post should be at least 200 words. Responses such as “great posts” or “I agree” do notmeet the active engagement expectation.
- Please feel free to draw on personal examples as you develop your responses to the Discussion Questions but you do need to demonstrate your understanding of the materials.
- I do expect outside sources as well as class materials to formulate your post.
- APA format is not necessary for DQ responses, but I do expect a proper citation for references.
- Please use peer-related journals found through the GCU library and/or class materials to formulate your answers. Do not try to “Google” DQ’s as I am looking for class materials and examples from the weekly materials.
- I will not accept responses that are from Wikipedia, Business com, or other popular business websites. You will not receive credit for generic web searches – this does not demonstrate graduate-level research.
- Stay away from the use of personal pronouns when writing.As a graduate student, you are expected to write based on research and gathering of facts. Demonstrating your understanding of the materials is what you will be graded on. You will be marked down for lack of evidence to support your ideas.
Plagiarism
- Plagiarism is the act of claiming credit for another’s work, accomplishments, or ideas without appropriate acknowledgment of the source of the information by including in-text citations and references.
- This course requires the utilization of APA format for all course deliverables as noted in the course syllabus.
- Whether this happens deliberately or inadvertently, whenever plagiarism has occurred, you have committed a Code of Conduct violation.
- Please review your LopesWrite report prior to final submission.
- Every act of plagiarism, no matter the severity, must be reported to the GCU administration (this includes your DQ’s, posts to your peers, and your papers).
Plagiarism includes:
- Representing the ideas, expressions, or materials of another without due credit.
- Paraphrasing or condensing ideas from another person’s work without proper citation and referencing.
- Failing to document direct quotations without proper citation and referencing.
- Depending upon the amount, severity, and frequency of the plagiarism that is committed, students may receive in-class penalties that range from coaching (for a minor omission), -20% grade penalties for resubmission, or zero credit for a specific assignment. University-level penalties may also occur, including suspension or even expulsion from the University.
- If you are at all uncertain about what constitutes plagiarism, you should review the resources available in the Student Success Center. Also, please review the University’s policies about plagiarism which are covered in more detail in the GCU Catalog and the Student Handbook.
- We will be utilizing the GCU APA Style Guide 7th edition located in the Student Success Center > The Writing Center for all course deliverables.
LopesWrite
- All course assignments must be uploaded to the specific Module Assignment Drop Box, and also submitted to LopesWrite every week.
- Please ensure that your assignment is uploaded to both locations under the Assignments DropBox. Detailed instructions for using LopesWrite are located in the Student Success Center.
Assignment Submissions
- Please note that Microsoft Office is the software requirement at GCU.
- I can open Word files or any file that is saved with a .rtf (Rich Text Format) extension. I am unable to open .wps files.
- If you are using a “.wps” word processor, please save your files using the .rtf extension that is available from the drop-down box before uploading your files to the Assignment Drop Box.
Grade of Incomplete
- The final grade of Incomplete is granted at the discretion of the instructor; however, students must meet certain specific criteria before this grade accommodation is even possible to consider.
- The grade of Incomplete is reserved for times when students experience a serious extenuating circumstance or a crisis during the last week of class which prevents the completion of course requirements before the close of the grading period. Students also must pass the course at the time the request is made.
- Please contact me personally if you are having difficulties in meeting course requirements or class deadlines during our time together. In addition, if you are experiencing personal challenges or difficulties, it is best to contact the Academic Counselor so that you can discuss the options that might be available to you, as well as each option’s academic and financial repercussions.
Grade Disputes
- If you have any questions about a grade you have earned on an individual assignment or activity, please get in touch with mepersonally for further clarification.
- While I have made every attempt to grade you fairly, on occasion a misunderstanding may occur, so please allow me the opportunity to learn your perspective if you believe this has occurred. Together, we should be able to resolve grading issues on individual assignments.
- However, after we have discussed individual assignments’ point scores, if you still believe that the final grade you have earned at the end of the course is not commensurate with the quality of work you produced for this class, there is a formal Grade Grievance procedurewhich is outlined in the GCU Catalog and Student Handbook.
A Sample Answer For the Assignment: NURS 6630 Assessing and Treating Patients With Psychosis and Schizophrenia
Title: NURS 6630 Assessing and Treating Patients With Psychosis and Schizophrenia
Psychopharmacology for Schizophrenia
The schizophrenia spectrum and other psychotic disorders are among devastating mental illnesses. These conditions are characterized by hallucinations, delusions, abnormal motor behavior, disorganized thought, and speech which collectively impair the social, occupational, and personal functioning of an individual. Consequently, they necessitate treatment. Interventions for schizophrenia spectrum and psychotic disorders are principally by antipsychotics. However, psychoeducation as an adjunct is central to preventing relapses. Antipsychotics are broadly categorized as typical and atypical antipsychotics. Atypical antipsychotics are the newer agents known for their less extrapyramidal side effects. All antipsychotics except clozapine have similar clinical effectiveness. Therefore, the choice of a particular antipsychotic will largely depend on the adverse effect profile and the patient’s clinical status. This piece of paper will extensively explore clozapine including its mechanism of action, pharmacokinetics, pharmacodynamics, dosing, and side effects among other aspects.
Clozapine
- Clozapine is a second-generation antipsychotic. It is a dibenzodiazepine derivative. Clozaril, FazaClo ODT, and Versacloz are the chief brand names for this medication (Khokhar et al., 2018).
- It is FDA approved for the treatment of treatment-resistant schizophrenia (Khokhar et al., 2018). Schizophrenia is considered treatment-resistant if an adequate trial of 2 antipsychotic agents (at least one-second generation) offers suboptimal resistance.
- Clozapine is deployed in the reduction of suicidal risk particularly in patients with schizoaffective disorder or schizophrenia.
- Off-label uses of clozapine include management of dopaminomimetic psychosis and adolescents with bipolar disorder although its adverse effects have limited these clinical benefits (Rachamallu et al., 2019).
Pharmacokinetics
- Pharmacokinetics refers to what the body does to the drug. It includes aspects such as absorption, distribution, metabolism, and excretion.
- Clozapine is rapidly and well absorbed after oral administration. Peak plasma concentrations are achieved after approximately 1.5 to 2.5 hours (Khokhar et al., 2018). Following oral administration, sedation is apparent within 15 minutes but optimal after 1 to 6 hours. The antipsychotic effect is delayed for 1 to numerous weeks after commencement.
- The duration of action of clozapine spans from 4 to 12 hours (Khokhar et al., 2018). However, food appears not to have any effect on clozapine. The drug is rapidly and extensively distributed. It crosses the blood-brain barrier and the placenta. An estimated 97% of the drug is ordinarily plasma protein bonded.
- The drug undergoes the first pass effect. It is metabolized by the liver (CYP1A2, CYP2D6, and CYP3A4 isoenzymes (Khokhar et al., 2018). Finally, 50% of the metabolized drug is excreted in the urine while 30% is via feces.
Pharmacodynamics
- The precise antipsychotic mechanism is not fully known. However, a combination of adrenergic, cholinergic, and serotonergic neurotransmitter systems plays a crucial role alongside the more dominant dopaminergic system.
- The principal mechanism of action of clozapine is antagonism at D2 receptors and 5-HT2A receptors leading to diminished schizophrenic and suicidal behavior.
- Clozapine also binds to H1 receptors, alpha 1 and alpha 2 adrenergic receptors, and muscarinic M1 receptors. Antagonism at these receptor sites considerably contributes to therapeutic and adverse effects including constipation, somnolence, and orthostatic hypotension.
Dosing, Administration Route, and Considerations
- Clozapine is administered orally. In adults, it is usually started at 25 mg given once or two times daily. This dosage is then increased by 25 to 50 mg/day over 2 weeks up to a target dose of 300 to 450 mg/day (Wells & McCormack, 2020). A further increase by 100 mg/day may be required once or twice daily although the total daily dosage should not exceed 900 mg/day (Wells & McCormack, 2020).
- A treatment period of at least 2 years is recommended. Safety of clozapine has not been established in children less than 16 years while elderly patients are at increased risk of mortality in the presence of dementia-related psychosis.
- Should never be used in pregnancy unless the benefits outweigh the risks. Finally, the drug should be discontinued during lactation or the mother may bottle-feed
Half-Life
- Refers to the duration it takes for the amount of its active substance in the body to diminish by half.
- Directly proportional to the rate of metabolism and elimination of the drug. The half-life varies considerably across various pharmacological agents. It is used to determine the dosing frequency.
- The half-life of clozapine is approximately 8 to 12 hours.
Side Effects and Contraindications
- Clozapine is contraindicated in patients with bone marrow suppression, uncontrolled epilepsy, severe CNS depression, and hypersensitivity (de Leon et al., 2020).
- The side effects of this drug include neuroleptic malignant syndrome, sedation, dizziness, QT interval prolongation, ventricular arrhythmias, agranulocytosis, leukopenia, hypotension, tachycardia, dry mouth, increased salivation, rash, sweating, visual disturbances, and extrapyramidal reactions (de Leon et al., 2020).
Overdose Considerations, Diagnostics, and Lab Monitoring
- Clozapine overdose is devastating due to the risk of delayed effects. Patients should thus be monitored for a couple of days. The principal management of clozapine overdose is supportive therapy and activated charcoal.
- Prior to initiation of therapy, a complete blood count including absolute neutrophil count (ANC) should be obtained. During therapy, WBC and ANC should be monitored weekly for the first 6 months, then every 2 weeks, and finally, weekly for 4 weeks after discontinuation (Wells & McCormack, 2020).
- Similarly, blood glucose levels and lipid levels should be obtained initially and monitored throughout therapy.
Comorbidities Considerations
- Clozapine is principally metabolized by the liver hence patients with hepatic impairment necessitate a dosage reduction due to increased concentrations. Similarly, the elimination of clozapine may be impaired in renal disease.
- Individuals with significant renal impairment also require dosage reduction (Dragoi et al., 2020). Geriatric patients have diminished renal, hepatic, and cardiac function as well as concomitant drug therapy. Consequently, necessary dosage adjustments should be made.
- Finally, the CYP2D6 isoenzyme metabolizes clozapine. Individuals with poor CYP2D6 metabolizer phenotype should also have their clozapine dosage adjusted accordingly (Dragoi et al., 2020).
Legal, ethical Considerations
- Informed consent must be obtained before initiation of this drug as well as proper documentation (Carpenter & Buchanan, 2020).
- Additionally, all rights of safe drug administration must be strictly adhered to including the right dose, right patient, right drug, and right route among others (Carpenter & Buchanan, 2020).
- Finally, given the adverse effect profile of clozapine, it should only be reserved for FDA-approved indications. A cost-benefit analysis must always be conducted before initiating this drug.
Patient Education
- The patient should be encouraged to take medication as directed. Those on prolonged therapy require gradual discontinuation over 1 to 2 weeks.
- Enlighten the patient on extrapyramidal symptoms and the need to promptly report their occurrence.
- Furthermore, the patient should be taken through the procedures and impetus of the Clozaril patient management system (Wells & McCormack, 2020).
- The patient should be educated on the best way of changing the position to avoid orthostatic hypotension.
- Similarly, patients should be advised to stop cigarette smoking which diminishes clozapine levels.
- Female patients should be enlightened on the need to notify healthcare providers if planning a pregnancy or breastfeeding (Wells & McCormack, 2020).
- Likewise, the patient should be instructed to continue medical follow up including laboratory tests and eye exams.
- Finally, the patient should be enlightened on the possible adverse effects and the need to frequently rinse the mouth.
Conclusion
Clozapine is a second-generation antipsychotic with a generally poor adverse effect profile. It is therefore reserved for treatment-resistant schizophrenia. The use of clozapine in pediatric patients has not been established. It is important to understand the pharmacokinetics, pharmacodynamics, side effects, indications, and contraindications of a drug to offer the desired patient education.
References
Carpenter, W. T., & Buchanan, R. W. (2020). Antipsychotic medications: Flawed concepts and ethics. Schizophrenia Bulletin, 46(5), 1030. https://doi.org/10.1093/schbul/sbaa076
de Leon, J., Ruan, C.-J., Schoretsanitis, G., & De Las Cuevas, C. (2020). A rational use of clozapine based on adverse drug reactions, pharmacokinetics, and clinical pharmacopsychology. Psychotherapy and Psychosomatics, 89(4), 200–214. https://doi.org/10.1159/000507638
Dragoi, A. M., Radulescu, I., Năsui, B. A., Pop, A. L., Varlas, V. N., & Trifu, S. (2020). Clozapine: An updated overview of pharmacogenetic biomarkers, risks, and safety-particularities in the context of COVID-19. Brain Sciences, 10(11), 840. https://doi.org/10.3390/brainsci10110840
Khokhar, J. Y., Henricks, A. M., Sullivan, E. D. K., & Green, A. I. (2018). Unique effects of clozapine: A pharmacological perspective. Advances in Pharmacology (San Diego, Calif.), 82, 137–162. https://doi.org/10.1016/bs.apha.2017.09.009
Rachamallu, V., Elberson, B. W., Vutam, E., & Aligeti, M. (2019). Off-label use of clozapine in children and adolescents-A literature review. American Journal of Therapeutics, 26(3), e406–e416. https://doi.org/10.1097/MJT.0000000000000894
Wells, C., & McCormack, S. (2020). Clozapine initiation for schizophrenia: A review of clinical effectiveness and guidelines. https://www.ncbi.nlm.nih.gov/books/NBK562945/