By B. Kafa. Southwest Baptist University.

However 20 gr benzac with visa, to strengthen the causation order 20gr benzac amex, the change of the effect by a changing cause must also be shown quality benzac 20gr. Causation and the clinical question The two main components of causation are also parts of the clinical question order 20gr benzac otc. You will learn to use good 22 Essential Evidence-Based Medicine Table 3. Cause and effect relationship for most common types of studies Type of study Cause Effect Etiology, harm, or risk Medication, environmental, Disease, complication, or or genetic agent mortality Therapy or prevention Medication, other therapy, or Improvement of symptoms preventive modality or mortality Prognosis Disease or therapy Time to outcome Diagnosis Diagnostic test Accuracy of diagnosis searching techniques so that you find the study that answers this query in the best manner possible. The intervention, comparison, and outcome all relate to the patient population being studied. Primary clinical research studies can be roughly divided into four main types, determined by the elements of cause and effect. The nomenclature used for describing the cause and effect in these studies can be somewhat confusing and is shown in Table 3. They can also go in the other direction, starting from the presence or absence of the risk factor and finding out who went on to have or not have the outcome. Useful ways of looking at this category of studies is to look for cohort, Causation 23 case–control,orcross-sectional studies. In studies of etiology, the risk factor for a disease is the cause and the presence of disease is the outcome. In other studies, the cause could be a therapy for a disease and the effect could be the improvement in disease. There are special elements to studies of prognosis that will be discussed in Chapter 33. In general the clinical question can be written as: among patients with a particular disease (population), does the presence of a therapy or risk factor (intervention), compared with no presence of the therapy or risk factor (comparison), change the probability of an adverse event (outcome)? For a study of risk or harm, we can write this as: among patients with a disease, does the presence of a risk fac- tor, compared with the absence of a risk factor, worsen the outcome? We can also write it as: among patients with exposure or non-exposure to a risk factor, are they more likely to have the outcome of interest? For therapy, the question is: among patients with a disease, does the presence of an exposure to therapy, compared with the use of placebo or standard therapy, improve the outcome? The form of the question can help you perform better searches, as we will see in Chapter 5. Through regular practice, you will learn to write better questions and in turn, find better answers. Sir William Osler (1849–1919) Learning objectives In this chapter you will learn: r the scope and function of the articles you will find in the medical literature r the function of the main parts of a research article The medical literature is the source of most of our current information on the best medical practices. This literature consists of many types of articles, the most important of which for our purposes are research studies. In order to evaluate the results of a research study, you must understand what clinical research articles are designed to do and what they are capable of accomplishing. To be an intelli- gent reader of the medical literature, you then must understand which types of articles will provide the information you are seeking. In your medical career, you will read and perhaps also write, many research papers. All medical specialties have at least one primary peer-reviewed journal and most have several. One important observation you will make is that not all journals are created equal. For example, peer-reviewed journals are “better” than non–peer-reviewed journals since their articles are more carefully screened and contain fewer “prob- lems. As the consumer of this literature, you are responsible for determining how to use the results of clinical research.

However buy 20gr benzac amex, throughout the organism’s life discount 20gr benzac with mastercard, they maintain a multipotent differentiation potential generic benzac 20 gr mastercard. Amniotic fluid contains several cell types derived from the developing foetus (23) benzac 20gr lowest price. Anthony Atala’s group at the Wake Forest Institute showed the ability to isolate multipotent stem cells from amniotic fluid. In addition, these undifferentiated cells express some embryonic stem cell markers. Amniotic fluid derived cells expand extensively without a feeder layer, doubling every 36 hours, retaining long telomeres for over 250 population doublings. They showed the ability to differentiate into functional cells corresponding to each of the three embryonic germ layers (ectoderm, endoderm and mesoderm) giving rise to adipogenic, osteogenic, myogenic, endothelial, neuronal and hepatic cells (24). The ability to isolate genetically and phenotypically stable, pluripotent cells from such a widely and easily available source will positively have an impact on regenerative medicine. However, they are closer to the embryo and they possibly retain some pluripotent characteristics. When transplanted, these cells show low immunogenicity and can even have localised immunosuppressive functions. This source of stem cells has the advantage of being normally discarded, with no morbidity to both mother and newborn. This leads to a limitless supply with the possibility of isolation of huge numbers of cells with no or few ethical considerations. The word “stroma” is derived from Greek and the Oxford dictionary defines it as “anything spread or laid out for sitting on” (27). The bone marrow stroma supports haemopoiesis and is made up of a network of fibroblast like cells. Among these stromal cells there is a subpopulation of multipotent cells able to generate the mesenchyme – the mass of tissue that develops mainly from the mesoderm of the embryo. Bone marrow derived stem cells were isolated for the first time by Friedenstein and colleagues. They took bone marrow and incubated it in plastic culture dishes and after 4 hours they removed non-adherent cells. A heterogonous population of cell was retrieved with some adherent cells being spindle-shaped and forming foci of cells that then began to multiply rapidly. Thereafter, the group managed to differentiate the cells into colonies resembling deposits of bone or cartilage (30-35). Stem cells for regeneration still speculative to quantify the exact numbers of stem cells since not all the cell surface markers have been identified. These include synovia (40), tendons (41), skeletal muscles (42) and adipose tissue, including the fat pad of the knee joint (43). Soon these will be introduced in several fields which are currently experimental such as tendon and ligament injury. Despite improved procedures the recovery of these injuries is variable, especially in complex clinical situations. This leads to low quality tissue with a risk of rupture at the repair site or formation of fibrous adhesions. Several studies were conducted to study the possibility of cell-based regeneration. These constructs were also used to regenerate flexor Topics in Tissue Engineering, Vol. However, tenocytes have limited donor site availability and require long in-vitro culture. Clinical regeneration of a whole tendon/ligament construct might still have a long way to go, a more practical option is to augment and accelerate tendon healing following surgical repair. As stated to some degree these cells can be induced to differentiate to any connective tissue cell type (multipotency). These cells can be differentiated in vitro into various cell lines including osteogenic (52), chondrogenic (53,54) and neurogenic lineages (55-57). Myocytes and cardiomyocytes were also successfully obtained from fat tissue derived stem cells (58,59).

Born in Czechoslovakia he acquired a doctorate from Charles University and worked as a forensic toxicologist benzac 20 gr with visa. He had almost finished his medical studies when in 1968 20 gr benzac fast delivery, whilst he and his wife order benzac 20 gr visa, Vera generic benzac 20 gr line, were in Ireland, the Russians entered Prague. They decided to remain in Ireland and Petr enrolled in the College of Surgeons medical school and qualified at the Society of Apothecaries. After house officer posts he worked in the field of neuro- transmitters and became an authority on Substance P. He joined the Department of Community Health in Trinity Col- lege, Dublin in 1984, initially in a temporary capacity, aided by a grant from the Wellcome Foundation. He was sub- sequently appointed as a lecturer, then senior lecturer and finally associate professor. He was made a fellow of the college and a fellow of the Royal College of Physicians of Ireland. His last book, Follies and Fallacies in Medicine, written with James McCormick, has been translated into Danish, Dutch, French, German, Italian and Spanish. One of the smartest moves in my working life was to make the acquaintance of Petr Skrabanek. In 1968, when Russian troops invaded Prague, he and his wife Vera happened to be on holiday in Dublin. They opted to remain in Ireland, where they brushed up their English with the aid of a copy of Ulysses (Petr later became an international authority on the works of James Joyce). To his Czech qualification as a toxicologist, Petr added an Irish medical diploma; and by the mid-1970s he was. Increasingly his sharp pen was directed at population medicine and the apostles of lifestyle - those who preached the fallacy of cheating death. Among public health doctors and epidemiologists, Skrabanek became a name that aroused strong passions; so it was all the more astonishing and splendid when, ten years ago, he gained a post in the Department of Community Health at Trinity College Dublin. Visiting The Lancet, the alleged Bluebeard proved to be a gentle, humorous man of immense culture and learning - cigarette in mouth, gleam in eye. He joined our team of editorialists; and we soon found that others in medicine were speaking his name with affection rather than exasperation. The Death of Humane Medicine will restore Petr Skrab- anek to his favoured role of outsider. I am not such a pessimist; and I lean more to the liberal than to the libertarian. All totalitarian ideologies use the rhetoric of freedom and happiness, with false promises of a happy future for all. For those who do not, or do not wish to, recognise the Utopian nature of the health promotion movement, my cri- tique will be misinformed at best and misanthropic or malici- ous at worst. Healthism, however, was an ingredient of the totalitarian ideologies in Nazi Germany and Communist Russia. The first commentator who saw the danger of healthism in Western democracies was Ivan Illich and it is thus appropriate to start the debate where he left off. The second section, on lifestylism, proceeds from historical examples of individual pursuit of the chimera of health to the collective normalisation of behaviour as state policy. Modern lifestyle exhortations by health promotionists, though ostensibly based on science, bear a striking resemblance to these historical precedents. The perversion of language obscures the power motive behind the seemingly altruistic pursuit of health for all. This book is not about medicine but about a perversion of its ideals, especially in countries dominated by the Anglo- American medical ideology. Just as a sick sheikh will seek medical treatment in a Western hospital, rather than relying on local magic, so a rich potentate from a fundamentalist Islamic state will travel to an oil conference in a Western-built aircraft and not on a flying carpet. My special thanks go to Professor Renee Fox who, over years, has given me moral support which was always badly needed. He has been a permanent source of wise counsel and an oasis of calm when things got rough. It is not always easy to find publishers for books such as this and the most enthusiastic encouragement I have received from Dr Digby Anderson, who took it upon himself to find the resources and see the book through the final hurdles of meticulous editing, was the act of true friendship at the time of need.

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