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Finally discount 75 mg plavix with visa, the new reliance on electronic searching methods has increased the role of the health sciences librarian who can provide guidance and assis- tance in the searching process and should be consulted early in the process cheap plavix 75mg on line. Databases and websites are updated frequently and it is the librarian’s role to maintain a competency in expert searching techniques to help with the most difficult searching challenge. Pierre Pachet, Professor of Physiology, Toulouse University, 1872 Learning objectives In this chapter you will learn: r the unique characteristics, strengths, and weaknesses of common clinical research study designs r descriptive – cross-sectional, case reports, case series r timed – prospective, retrospective r longitudinal – observational (case–control, cohort, non-concurrent cohort), interventional (clinical trial) r the levels of evidence and how study design affects the strength of evidence. Since various research study designs can accomplish different goals, not all studies will be able to show the same thing. Therefore, the first step in assessing the validity of a research study is to determine the study design. The ability to prove causation and expected potential biases will largely be determined by the design of the study. Identify the study design When critically appraising a research study, you must first understand what dif- ferent research study designs are able to accomplish. Characterizations in this manner, or so-called timed studies, have traditionally been divided into prospec- tive and retrospective study designs. Prospective studies begin at a time in the past and subjects are followed to the present time. Retrospective studies begin at the present time and look back on the behavior or other characteristics of those subjects in the past. These are terms which can easily be used incorrectly and misapplied, and because of this, they should not be referred to except as gener- alizations. As we will see later in this chapter, “retrospective” studies can be of several types and should be identified by the specific type of study rather than the general term. Descriptive studies Descriptive studies are records of events which include studies that look at a series of cases or a cross-section of a population to look for particular charac- teristics. These are often used after several cases are reported in which a novel treatment of several patients yields promising results, and the authors publishing the data want other physicians to know about the therapy. Case reports describe individual patients and case series describe accounts of an illness or treatment in a small group of patients. In cross-sectional studies the interesting aspects of a group of patients, including potential causes and effects, are all observed at the same time. Case reports and case series Case reports or small numbers of cases are often the first description of a new disease, clinical sign, symptom, treatment, or diagnostic test. They can also be a description of a curriculum, operation, patient-care strategy, or other health- care process. Some case reports can alert physicians to a new disease that is about to become very important. One series con- sisted of two groups of previously healthy homosexual men with Pneumocystis carinii pneumonia, a rare type of pneumonia. These diseases had previously only been reported in people who were known to be immunocompromised. It quickly became evident as more clinicians noticed cases of these rare diseases. Since most case reports are descriptions of rare diseases or rare presenta- tions of common diseases, they are unlikely to occur again very soon, if ever. To date, physicians have not been deluged with a rash of young methamphetamine users with strokes. Therefore, case reports are a useful venue to report unusual symptoms of a common illness, but have limited value. New treatments or tests described in a study without any control group also fall under this category of case reports and case series. At best, these descriptive studies can suggest future directions for research on the treatment or test being reported. They are cheap, relatively easy to do with existing medical records, and potential clini- cal material is plentiful. If you see new presentations of disease or interesting cases, you can easily write a case report. These studies do not provide explanations and cannot show asso- ciation between cause and effect. Since no comparison is made to any control group, contributory cause cannot be proven. A good general rule for case studies is to “take them seriously and then ignore them. Called the “all-or- none case series,” this occurs when there is a very dramatic change in the out- come of patients reported in a case series.

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There is general agreement that the amount of nitrogen accreted due to a pregnancy involving 12 buy plavix 75mg line. There is also evidence from both nitrogen balance studies and whole body potassium counting that there are additional maternal protein-containing tissues that accumu- late during pregnancy and are presumed to be in skeletal muscle (Kalhan generic plavix 75mg online, 2000; King, 1975; King et al. Evidence Considered in Estimating the Average Requirement Nitrogen and Potassium Balance. King and coworkers (1973) studied 10 adolescent women aged 15 to 19 years during the last trimester of preg- nancy. Since all but one of the individuals were more than 4 years beyond menarche, the authors excluded consideration of maternal height growth. Nitrogen retention was linearly related to protein intake when five different nitrogen levels (9. The average nitrogen retention (corrected for skin and miscellaneous nitrogen losses) was 2. Nitrogen balance studies in pregnant women that account for skin and miscellaneous losses have shown that nitrogen retention during all periods of pregnancy is double the theoretical factorial gain (Calloway, 1974; King, 1975; King et al. The average potassium deposition, measured by total body 40potassium counts, was 3. The results of measurements of total body potassium during pregnancy from the study of King’s group (1973) and five other reports are shown in Table 10-15, and yield a weighted mean value of 2. To calculate nitrogen deposition, King and coworkers (1973) used the potassium/nitrogen ratio of 2. This was reported as being about 30 percent in a group of adolescent women in the third trimester of pregnancy (King et al. Closer review of the data indi- cates that for those six adolescents who demonstrated a positive efficiency at multiple levels of protein intake, the mean of the slope of the positive nitrogen balances was 0. While other physiological changes occurring in pregnancy appear to enhance nutrient utilization during periods of increased need (e. As calculated in Table 10-16, the average protein deposition was converted to the amount of intake needed to provide this level: 7. The protein needed to maintain the new tissue accreted during preg- nancy must also be added. The increase of body weight during a full-term pregnancy averages approximately 16 kg, which is the median weight gain of 4,218 women who had good pregnancy outcomes (Carmichael et al. Weight gain during pregnancy is made up of both additional fat and new lean tissue (including fetus, amniotic fluid, increased plasma volume, etc. The incremental weight gain at the 50th percen- tile for normal weight individuals with good pregnancy outcomes at the end of the first trimester is 2. The amount of protein to support additional tissue is calculated in Table 10-16 using a factor of 0. While it is recognized that pregnancy lean tissue contains a greater amount of water, correction for assumed differences in body com- position have not been made given the lack of actual data delineating protein maintenance needs in pregnant women. This results in an average total additional need for protein during the last two trimesters of preg- nancy of about 21 g/d over prepregnancy requirements. Burke and coworkers (1943) conducted an observational study of 216 mothers giving birth to single infants in Boston and found a significant correlation between average daily protein intake and birth length and birth weight. They concluded that for practical purposes, a protein intake less than 75 g/d was associated with an infant who would be short and light in weight. Studies from the Montreal Diet Dispensary have also shown a relationship between maternal protein- energy intake and birth weight (Higgins, 1976). This study involved 1,736 low-income pregnant women, 20 years of age or more, whose average maternal protein and energy intakes at various stages of pregnancy were 68 g and 2,249 kcal/d during pregnancy, and were increased to an average of 101 g of protein and 2,778 kcal/d by supplementing the mothers with whole milk and eggs during a subsequent pregnancy. Birth weights were significantly higher for siblings with supplemented mothers compared with their older siblings born to the same mothers when they did not receive the supplementary milk and eggs. These data support the value increased intake of foods high in protein and energy during pregnancy and the additional requirements outlined above. The problem of adolescent pregnancy is that the mother may still be completing her growth (Frisancho et al. In those pregnancies in which the mother’s growth is not yet completed, it appears that there is competition between maternal and fetal growth needs (Hediger et al. The Montreal Diet Dispensary studied the effect of supplementing 1,203 low-income pregnant adolescents with whole milk and eggs and compared them with 1,203 pregnant adolescents who did not receive the additional milk and eggs in their diets (Dubois et al. The adoles- cents in the intervention group increased their protein intake from 73 g/d to approximately 125 g/d in addition to significantly increasing their energy intake. Participation in the intervention resulted in significantly increased mean birth weights and reduced the rate of low birth weights by 39 percent (p < 0. It is composed of two components: the amount needed to maintain the new pregnant tissue and the amount needed for initial depo- sition. The amount of protein deposition is corrected for the efficiency of protein deposition (using the estimate from the slope of 0. Since little weight gain occurs during the first trimester, it is assumed that roughly one-third of the total increase in protein deposition during the 40 weeks of pregnancy (~ 925 g) occurs during the second trimester, with two-thirds occurring during the third trimester.

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In many institutions buy plavix 75mg overnight delivery, physician mistrust of hospital motivations and strategies is a dominant theme 75mg plavix sale. Mistrust Although competitive tensions between physician-sponsored enter- prises and hospitals have contributed to this problem, many physi- cians view the hospital as a battleship whose wake is sufficient to swamp the small boats it operates. The fact that hospitals and physi- cians have completely separate information domains complicates the ability to implement new clinical information systems. The Hospital as Potential Information Source Hospitals are presently committing major capital resources to com- puterize both operations and clinical services. As argued above, physician practices, even many large groups, are capital poor and thus lag in automating their processes and services. It is entirely possible given the present course that hospitals will complete this Physicians 85 process a decade or more ahead of physicians, leaving what physi- cians “know” about their patients locked up in paper records and their memories. When physicians do automate, if no compatibility standards are set in advance, they will use incompatible software and be unable to move clinical information between their systems and those of the hospital. Optimal patient care would require that the clinical team be able to access important clinical information about a patient at any place and at any time. Because hospitals have capital, and physicians, generally speaking, do not, hospitals could be a potential source for modern digital clinical information systems, as well as patient care support tools like disease management, for their physicians. If hospitals could help bring about a shared record format across their medical staffs, it would be easier for physicians to send patient information to one another for consultative purposes. Historically, physicians have been extremely reluctant to permit hospitals access to their private practices. Many experiments by hos- pitals during the 1990s with salaried employment of physicians and with practice management support ended in costly failure. Physi- cians resisted installing inexpensive software that enabled them to perform remote order entry or retrieval of test results from hospi- tals because they thought it opened a portal that enabled hospital executives to understand their practice’s economics. Legal and Regulatory Barriers Besides the mistrust discussed above, legal and regulatory barriers make linking hospitals and physicians difficult. Federal Medicare regulations forbid hospitals from offering physicians anything of value (including software and services) if it would influence their patterns of hospital utilization. These statutes were intended to pre- vent hospitals from, in effect, bribing physicians to bring their pa- tients in. If compatible clinical software made it easier for physicians 86 Digital Medicine with a choice to use the facility that provided them the software, it might trigger fraud and abuse investigations. Tax laws provide another barrier to the sharing of clinical soft- ware between hospitals and physicians. The Internal Revenue Code and state laws forbid not-for-profit hospitals (recall that 85 percent of all community hospitals are not-for-profit) from giving physicians (or anyone else) anything of value. Competitive advantage for specific providers could be eliminated by regulation that requires clinical information systems developed by different vendors to interoper- ate (that is, to use common record formats, coding conventions, messaging standards, etc. This would mean that, once installed, physicians could use their clinical software in conjunction with any of the available local hospitals or retrieve information about their patients from any of them. The fact that software and services could be provided on a dial- in basis without significant capital expenditures by hospitals on the physicians’ behalf could help change some of the equation as well. The most expensive part of a physician office’s digital conversion is transferring all of its existing patient records to digital form so they can be used by the information system. If these costs can be surmounted and physicians can obtain password-protected access to computerized patient records and clinical decision support from their offices, it would be a major boost to overall computerization. Hospitals and Physicians Digitizing Patient Records Together Ideally, hospitals and physicians should move together to digitize patient records. Technical opportunities exist for hospitals to create Physicians 87 virtual private networks that segregate the physician’s clinical records from those of the hospital (as well as the rest of the Internet), protect the physician’s business autonomy and privacy, and still provide the transparency of information flow that is needed for optimal patient care. Physicians have to be willing to wade into the battle over how digital medicine is organized and be assured that their concerns about autonomy and privacy are recognized. When you sum the potential impact of various information tech- nologies across the physician’s world, the aggregate impact is im- pressive. Speed the flow of new knowledge to physicians and store it efficiently so physicians don’t have to rely on their memories 2. Guide and assist in patient care itself, wherever the physician or patient may be at the moment 3. Free physicians from paper records and bills, reducing their prac- tice expenses 4. Facilitate collaboration between physicians both in consultation and in learning As with hospitals, this progress will not come easily, quickly, or cheaply. Moreover, not all physicians will be able to realize all of these benefits at the same time.

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