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For the “users rabeprazole 20mg with amex,” the 5S schema of Haynes is a construct to help focus the skills of Information Mastery cheap rabeprazole 20mg mastercard. The highest level is that of systems, which are decision support tools inte- grated into the daily practice of medicine through mechanisms such as com- puterized order entry systems or electronic medical records. The system links directly to the high quality information needed at the point of care and seam- lessly integrated into the care process. The next level is synthesis, which are critically appraised topics and guidelines. Many of these are through publishing enterprises such as Clinical Evidence pub- lished by the British Medical Journal. This print-based resource summarizes the best available evidence of prevention and treatment interventions for commonly eoncountered clinical problems in internal medicine. The primary ones in the category are from the Cochrane Database of System- atic Reviews, described earlier in the book as a database of systematic reviews authored and updated by the worldwide Cochrane Collaboration. Finally, the lowest level is “Expert Opinion” or Replication level, which is not considered bona fide evidence, but only anecdote or unsubstanti- ated evidence. No matter how thorough a search strategy is, inevitably some resources will be missed and the process will need to be repeated and refined. Use the results of an initial search to retrieve relevant papers which can then be used to further refine the searches by searching the bibliographies of the relevant papers for arti- cles missed by the initial search and by performing a citation search using either Scopus or Web of Science databases. These identify papers that have cited the identified relevant studies, some of which may be subsequent primary research. These records can be used to design a strategy that can be executed within a more specialized database. Always remember that, if the information isn’t found in the first source consulted, there are a myriad of options available to the searcher. Finally, 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. 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.

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The high variability is attributable to biological differences in body composition and technical differences in experimental conditions and methods rabeprazole 20 mg online. Significant differences between breast-fed and formula-fed infants have been reported at 3 and 6 months (Butte generic rabeprazole 10 mg, 1990; Butte et al. Schofield compiled approximately 300 measurements from Benedict and Talbot (1914, 1921), Clagett and Hathaway (1941), Harris and Benedict (1919), and Karlberg (1952) to develop predictive models based on weight and length (C Schofield, 1985). These observations support the view that some of the observed energy expenditure is due to the metabolic costs of tissue synthesis. The amount of energy re- quired to maintain normal body temperature is greater at lower than at higher temperatures (Sinclair, 1978). The neonate responds to mild cold exposure with an increase in nonshivering thermogenesis, which in- creases metabolic rate and may be mediated by increased sympathetic tone (Penn and Schmidt-Sommerfeld, 1989). Increased oxidation of fatty acids in brown adipose tissue located between the scapulae and around major vessels and organs of the mediastinum and abdomen is thought to make the most important contribution to nonshivering thermogenesis in infants (Penn and Schmidt-Sommerfeld, 1989). Shivering thermogenesis occurs at lower ambient temperatures when nonshivering thermogenesis is insuf- ficient to maintain body temperature. Much understanding of the energy cost of growth has been derived from preterm infants or children recovering from malnutrition (Butte et al. In practicality, the energy cost of growth is an issue only during the first half of infancy when energy deposition contributes significantly to energy requirements. In this report, the energy content of tissue deposition was computed from rates of protein and fat deposition observed in a longitudinal study of infants from 0. The energy content of tissue deposition (kcal/g) derived from the above study was applied to the 50th percentile of weight gain published by Guo and col- leagues (1991) as shown in Table 5-15 for infants and children 0 through 24 months of age. Total energy requirements of infants and young children have thus been shown to vary by age, gender, and feeding mode. Total energy requirements increase as children grow and are higher in boys than girls. Energy requirements (kcal/kg/d) were 7, 8, 9, and 3 percent higher in formula-fed than human milk-fed infants at 3, 6, 9, 12 months, respectively. The differences in energy requirements between feeding groups appeared to diminish beyond the first year of life. Because the data included repeated measurements of individuals, dummy variables were used to link those individual data. This energy deposition allowance is the average of energy deposition for boys and girls of similar ages. The estimated energy deposition is the average of boys and girls taken from Table 5-15. Their estimates were 95, 85, 83, and 83 kcal/kg/d at 3, 6, 9, and 12 months, respectively. Infants receiving human milk for this period would have an energy intake of some 500 kcal/d based on an average volume of milk intake of 0. Children Ages 3 Through 8 Years Evidence Considered in Determining the Estimated Energy Requirement Basal Metabolism. Validation of the Schofield equations has been undertaken by com- paring predicted values with measured values (Torun et al. It is recognized that the energy content of newly synthesized tissues varies in childhood, particularly during the childhood adiposity rebound (Rolland-Cachera, 2001; Rolland-Cachera et al. Growth refers to increases in height and weight and changes in physique, body composition, and organ systems. Maturation refers to the rate and timing of progress toward the mature biological state. Developmental changes occur in the reproductive organs, and lead to the development of secondary gender characteristics and to changes in the cardiorespiratory and muscular systems leading to an increases in strength and endurance. In adolescents, changes in occupational and recreational activities further alter energy requirements. The effect of age on basal metabolism is a function of changes in body composition through adolescence. Physical activity reflects the energy expended in activities beyond basal processes for survival and for the attainment of physical, intellectual, and social well-being. Dietary energy recommendations include recommendations for physical activity compatible with health, pre- vention of obesity, and appropriate social and psychological development. The assessment of habitual physical activity and its impact on the energy needs of adolescents is difficult because of the wide variability in lifestyles. Physical activity is generally viewed as having a favorable influence on the growth and physical fitness of youth, but longitudinal data addressing these relationships are limited. Regular physical activity has no apparent effect on statural growth and biological maturation (i. Data suggesting later menarche in female athletes are associational and retrospective, and do not control for other factors that influence the age at menarche (e. It is also associated with greater skeletal mineralization, bone density, and bone mass (Bailey and McCulloch, 1990). However, excessive training associ- ated with, or causing, sustained weight loss and maintenance of excessively low body weights may contribute to bone loss and increased susceptibility to stress fractures (Dhuper et al.

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Managing stress with mindfulness • Let the world wake you up: when you notice a This habit of living for tomorrow is a fawed coping strategy: it phone ring discount rabeprazole 10 mg free shipping, a door slam buy rabeprazole 20mg with visa, and so on, take a is based on the false premise that tomorrow is more real than moment to sense where you are and how you today. Clearly, the content of this moment is always • Sign up for a class on meditation, yoga, tai chi, shifting and new; however, whatever happens, we experience it etc. Cultivating mindful- weeks to delay, and eventually eliminate, the binging ness through regular formal practise extends the habit of episodes. The resident also begins to question these nega- being present into our daily activities. Try this for the next tive self-judgments and seeks counselling for the eating few breaths. The resident discloses abdomen moving in and out with each breath and stay with these challenges and fears to a close friend and feels less that sensation. Before long your mind will likely drift off into isolated and less anxious about life in general. The resident thoughts about this experience, or about something completely plans to continue with regular meditation. When you notice that your mind has drifted into thinking, let go of the thoughts and come back to the sense of breathing. It’s simple and yet Self-acceptance diffcult to stay present: it takes discipline to train our minds As we become mindful of uncomfortable feelings and the to simply be in the moment when our tendency is to want to habitual patterns they trigger, we may become self-critical: control it. Cranky Making friends with fear or tired, sexually restless or serene, what matters is that we Stress arises from our attempt to create certainty in an uncer- can deepen our capacity to notice, and to be with, whatever tain world. Such activities might take the edge off ing of our quirks and foibles, we also naturally become more our anxiety momentarily, but when anxiety has the upper hand accepting of others. In medical practice there is no greater in our lives the activities that are motivated by anxiety become kindness we can offer our patients than our attention and deeply entrenched habits. Key references In a state of mindfulness we allow ourselves to feel whatever Hassed C, de Lisle S, Sullivan G, Pier C. Whether we are feeling overwhelmed by anger the health of medical students: outcomes of an integrated or lost in boredom we simply allow ourselves to be aware of mindfulness and lifestyle program. Wherever You Go, There You Are: Mindfulness of thoughts and feelings may food through us, our patience Meditation in Everyday Life. New York: Oxford can learn to stay present with our feelings and let go of the University Press. Through narrative, practitioners beliefs, and hence our responses to situations, and can better understand the experiences of their patients as well • demonstrate how writing can help us slow down, focus, as their own journeys as physicians (Charon 2004). Case A journal of the grieving process A second-year resident began their cardiology rotation two Dr. She was distressed by the loss of two young patients, ful week with more than the usual number of admissions. She began to write intermittently in a journal, old architect to the coronary care unit with the diagnosis describing her thoughts and interpretations of these dif- of a second myocardial infarction. She purposefully wrote without much fore- well until shortly before his 49th birthday, when he began thought, letting the words fow, letting her feelings bubble to experience anginal pain. His recovery proceeded without com- plication, and he returned to work within approximately She described the rooms where Jason and Steven had died three months. This second heart attack, four years later, and was surprised at how vividly she remembered certain has caused the patient a great deal of anxiety, and he no details: Jason’s fsh tank, the morning light fltering through longer wants to adhere to any treatment regimens. The resident feels threatened and uncertain about how to proceed, given the patient’s apathy. During cardiology She recalled how she had bought a large bouquet of helium rounds with the staff cardiologist, various medical data balloons on her way home from work the day after Jason are reviewed and a vigorous debate ensues among team died. She was coming home to her two-year-old daughter, members regarding the appropriate thrombolytic therapy and to her son, who was Jason’s age. The resident realizes during the course of to her own children some emblem of joyfulness and hope, daily assessments and interactions with the patient that, as and something that pointed toward heaven. This process The following week, overtired but determined, the resident allowed her to refect on her responses and to consider her fnally breaks through. The resident ends up asking the personal reasons for feeling so overwhelmed at the time. She also began to speak with Introduction a more experienced colleague about how she was handling Medical practice has always been grounded in life’s intersubjec- things. It unfolds in a series of complex clinical encoun- to her, and that the act of writing them down, had given ters involving narratives—stories in which one human being her more insight, more acceptance of her emotions, and a listens and extends help to another. Physicians engaged Case resolution in clinical care are inevitably affected by the complexities of The patient hesitated but then, with relief, talked about his patient care: joy, suffering, courage, loss and love. He spoke of his anger practitioners, we learn to identify and interpret our emotional and resentment of being afficted with a life-threatening responses to patients and in doing so are able to “make sense illness so early in his productive years. He did not want of their life journeys and grant what is called for—and called people’s sympathy, nor did he want to be a burden to forth”—in facing ill and vulnerable patients (Charon 2006). By the time the resident was completing the car- diology rotation and was following the patient in cardiac On some level, physicians grieve along with their patients; they rehabilitation, the patient was noticeably better in terms are “aware of how disease changes everything, what it means, of mood and in his acceptance that lifestyle changes what it claims, how random is its unfairness and how much would be permanent.

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