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By: Q. Grok, M.B. B.CH. B.A.O., Ph.D.
Clinical Director, New York University Long Island School of Medicine
Write down a clinical question here 19 Notes 20 EBM step 1: Formulate an answerable Steps in EBM: question 1 symptoms 0f kidney stones order 5mg compazine mastercard. Track down the best First principle evidence of outcomes First medications migraine headaches purchase 5mg compazine visa, you must admit that you don’t know treatment synonym purchase genuine compazine on-line. Critically appraise the evidence (ie find out how method to find answers to questions without having any prior knowledge of good it is). Apply the evidence (integrate the results with clinical expertise and patient values). Dissecting the question into its component parts and restructuring it so that it is easy to find the answers is an essential first step in EBM. Te intervention or indicator What is the management strategy, diagnostic test or exposure that you are interested in (such as a drug, food, surgical procedure, diagnostic test or exposure to a chemical)? Te comparator or control What is the control or alternative management strategy, test or exposure that you will be comparing the one you are interested in with? Te outcome What are the patient-relevant consequences of the exposure in which we are interested? All clinical or research questions can be divided into these four components, which we call ‘P I C O’. Remember the PICO principle P Population/patientPopulation/patient II Intervention/indicatorIntervention/indicator C Comparator/control O Outcome 24 Different types of questions By far the most common type of clinical question is about how to treat a disease or condition. In EBM, treatments and therapies are called ‘interventions’ and such questions are questions of INTERVENTION. PROGNOSIS AND PREDICTION In each case the P I C O method can be used to formulate the question, as shown in the following examples. Te same approach can be used to research qualitative questions about health issues of a more general nature (PHENOMENA). Te studies that you will need to search for are different for the different types of questions and we will discuss this further in the next section (see ‘EBM step 2: Track down the best evidence’). Interventions can include individual patient care or population health activities (for example, screening for diseases such as cervical or prostate cancer). Example 1 A 28-year-old male presents with recurrent furunculosis for past 8 months; these episodes have been treated with drainage and several courses of antibiotics but keep recurring. To convert this to an answerable question, use the P I C O method as follows : P Population/patientPopulation/patient = patients with recurrent furunculosis II Intervention/indicatorIntervention/indicator = prophylactic antibiotics CC Comparator/control = no treatment O Outcome = reduction in recurrence rate of furunculosis Question: ‘In patients with recurrent furunculosis, do prophylactic antibiotics, compared to no treatment, reduce the recurrence rate? Other interventions you know about are nicotine replacement therapy and antidepressants. Develop a clinical research question using P I C O: P Population/patientPopulation/patient = II Intervention/indicatorIntervention/indicator = CC Comparator/control = O Outcome = Question: 27 Example 3 At a routine immunisation visit, Lisa, the mother of a -month-old, tells you that her baby suffered a nasty local reaction after her previous immunisation. Recently, a colleague told you that needle length can affect local reactions to immunisation in young children but can’t remember the precise details. Develop a clinical research question using P I C O to help you find the information you need: P Population/patientPopulation/patient = II Intervention/indicatorIntervention/indicator = CC Comparator/control = O Outcome = Question: 28 Example 4 In browsing one of the medical weeklies, you come across mention of imiquimod cream for treatment of basal cell carcinomas (BCC). Te idea of a cream for BCCs is surprising, so you wonder about the effectiveness and particularly the long-term cure rate of imiquimod cream. Develop a clinical research question using P I C O to help answer your query: P Population/patientPopulation/patient = II Intervention/indicatorIntervention/indicator = CC Comparator/control = O Outcome = Question: 29 Aetiology and risk factors Questions of aetiology and risk factors are about what causes a disease or health condition. Tey are the reverse of intervention questions because they deal with the harmful outcomes of an activity or exposure. Such questions commonly arise in relation to public health issues, such as whether eating certain foods increases the risk of heart disease, or being exposed to an environmental chemical increases the risk of cancer, and so on. Example 1 George has come in to your surgery to discuss the possibility of getting a vasectomy. He says he has heard something about vasectomy causing an increase in testicular cancer later in life.
Syndromes
Additional nance requirements would be 1 L water medicine song purchase compazine cheap online, 1000 kcal medicine quinine purchase cheap compazine on-line, 30 g doses of regular insulin should be administered to control protein medicine holder order compazine overnight delivery, 30 mmol sodium, and 20 mmol potassium. Fluid blood sugar levels; a 6-h interval between glucose meas- and electrolyte status must be closely monitored and urements is commonly used. In addition to meticulous adjusted according to the response of the patient and the attention to blood sugar levels, it is important to monitor development of other pathophysiologic conditions. Myocardial ischemia can be silent and Endocrine Disorders may be detected unexpectedly on postoperative electro- Diabetes mellitus, usually type II, is common among cardiograms. It has been estimated that of diabetic Thyroid disease is not as prevalent as diabetes but, if patients undergoing surgery, more than 75% are over the undetected, can result in major complications periopera- age of 50. The prevalence of hypothyroidism in hospitalized ment of surgical patients but also predisposes the patient older patients has been reported to be 9. With the stress and tissue injury of tain a high index of suspicion for thyroid illness in this surgery, there is an increase in many of the counterregu- population. The consequences of operating upon a latory hormones: cortisol, epinephrine, glucagon, and patient with unsuspected hypothyroidism can be signifi- growth hormone. These patients metabolize medications more slowly, esis, and the catecholamines can directly depress the and their increased sensitivity to central nervous system release of insulin from the pancreas and blunt insulin depressants can result in respiratory insufficiency. While the potential for these perioperative nutritional supplements: those who are complications should be suspected and preventive meas- severely malnourished before major surgery; and those ures instituted, hypothyroidism should not be considered who undergo operations resulting in prolonged periods an absolute contraindication to necessary operative of inadequate enteral intake. When to patients with a functioning gastrointestinal tract who hypothyroidism is severe, an intravenous dose of 300 to were malnourished preoperatively and who are unable to 500 mg l-thyroxine will significantly improve basal meta- consume adequate calories orally. Corticosteroids should also be given tion is indicated for malnourished patients who have a in the perioperative period because the acute rise in basal nonfunctioning gastrointestinal tract or for whom enteral metabolic rate can exhaust adrenal reserves. Older persons may be particu- Neuropsychiatric Disorders larly prone to iodine-induced hyperthyroidism from non- ionic contrast radiography. The prevalence of dementia ation is necessary, the patient can be treated with 1000 is about 5% among persons aged 65 years; it increases to mg propylthiouracil by mouth and a beta-blocker to about 25% in those 80 years of age and older. Sodium of older patients admitted for repair of hip fractures in iodide is often given to inhibit the release of thyroid Sweden reported a prevalence of dementia of 15%. Iodide Depression also is prevalent among older persons and can be given either by mouth or intravenously; adminis- can be exacerbated by any acute illness or hospitaliza- tration should be delayed until at least 1 h after the tion. Anesthesia and surgery can have profound effects propylthiouracil to allow time for the latter to block on mental functioning. Supplemental corticosteroids are also rec- with surgery along with the previously discussed effects ommended for hyperthyroid patients undergoing emer- on all the vital organ system can compromise cerebral gency operations. These supplements are given to protect function and exacerbate or precipitate neuropsychiatric against the possibility of adrenal insufficiency related to disorders. The physiologic and behavioral manifestations the chronic hyper-metabolic state and because corticos- of neuropsychiatric disorders can significantly complicate teroids may lower serum thyroxine and thyroid-stimulat- perioperative care and often lead to prolonged hospital ing hormone levels. The major manifestation of this condition is an alteration in consciousness, and it is, by Nutrition 99 definition, a transient disorder. One prospective study Surgery and wound healing cause increased energy reported delirium in 44% of older patients undergoing demands. In some malnourished or high- dure nor the type of anesthetic used (halothane versus risk patients, preoperative total parenteral nutrition has epidural) were predictors of an acute confusional state. Risk factors included age 70 years and parenteral nutrition should be reserved for those patients older; self-reported alcohol abuse; poor cognitive status; in whom the gastrointestinal tract cannot be used. A in commonly used nutritional indices are associated careful clinical assessment of the patient should focus with reduced perioperative morbidity; hence, the optimal on the possibility of infection, metabolic derangements, duration of nutritional support is unknown. Additional central nervous system events, myocardial ischemia, studies are needed in patients most likely to benefit from sensory deprivation, or drug intoxication. Pompei cimetidine, atropine, aminophylline preparations, antihy- Summary pertensives, steroids, and digoxin are medications com- monly associated with delirium, but all drugs should be Operative therapy is an important option for many of considered as possible causes.
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But medications 8 rights buy compazine discount, as the chapters illustrate treatment plan for anxiety safe 5 mg compazine, this is likely to be a different kind of marketing than that envisioned in the mid-1970s when the first mar- keting efforts were introduced into healthcare symptoms 16 weeks pregnant 5 mg compazine overnight delivery. Before the 1980s, marketing campaigns targeting healthcare con- sumers were relatively rare. In fact, the marketing activity that existed was primarily on the part of industry segments that were not involved in patient care (e. The industry was product driven and most "producers" of services oper- ated in semimonopolistic environments. There was an almost unlimited flow of customers (patients), and revenues were essentially guaranteed by third-party payers. Along with a num- ber of other significant changes in healthcare, competition was introduced for the first time. Healthcare organizations began to realize that to survive in this new world, they would have to adopt business practices long estab- lished in other industries. This involved, among other things, a shift from a product orientation to a service orientation. For the first time, then, the Introduction xiii market became a factor for the industry. These developments resulted in the introduction of marketing as a legitimate function in healthcare. By the mid-1980s, marketing departments had been established in most of the large healthcare organizations. Once introduced to each other, marketing and healthcare passed through a tentative getting-to-know-you period. By the mid-1980s, however, it was a romance in full bloom with the two being seen everywhere together. Healthcare organizations were spending feverishly on their newfound consort, and marketers rushed to take advantage of the sudden burst of interest. Those without formal depart- ments started developing marketing functions through other mechanisms. Hospitals were among the first to embrace marketing as a part of their operations. As new forces emerged in the industry, often led by entrepreneurs rather than clinicians, the use of marketing techniques proliferated. Innovative health- care programs, such as urgent care centers and freestanding diagnostic cen- ters, began using marketing as a means of attracting patients from the established sources of care. Unfortunately, in the early years healthcare executives did not see marketing for what it really was, and many expensive mistakes were made by the organizations pioneering healthcare marketing. Healthcare organi- zations failed to do their market research homework, rushed headlong into expensive media advertising, became obsessed with image rather than sub- stance, and failed to evaluate their hastily contrived marketing initiatives. As a result of these mistakes, by the late 1980s healthcare organiza- tions were slashing their marketing budgets, disbanding marketing staff, and generally scaling back this relationship. Healthcare did not want to break it off altogether, but it did not want to continue spending on ini- tiatives with uncertain benefits. Both parties—healthcare and marketing—could probably be blamed for the shaky initial relationship. The marketers that healthcare imported from other industries failed in their effort to convert existing marketing techniques to healthcare uses. The first rule of marketing, of course, is to know your market, and marketers did not. They were offering quick fixes and short-run answers in an industry that required long-term initiatives.
Diseases