By R. Roy. Voorhees College.
In October 1993 – at what was to become the ﬁrst in a series of annual Cochrane Colloquia – 77 people from 11 countries co-founded the Cochrane Collabora- tion order advair diskus 500mcg online. It is an international organization that aims to help people make well- informed decisions about health care by preparing generic advair diskus 500mcg overnight delivery, maintaining order 250mcg advair diskus otc, and ensuring the accessibility of systematic reviews of the effects of health-care interventions. Each database focuses on a speciﬁc type of information and can be searched individually or as a whole. In addition to complete reviews, the database contains protocols for reviews currently being prepared. Cochrane Methodology Register focuses on articles, books, and conference proceedings that report on methods used in controlled trials. HealthTechnologyAssessmentDatabase is a centralized location to ﬁnd com- pleted and ongoing health technology assessments that study the implica- tions of health-care interventions around the world. The interface that is linked directly from the Cochrane Collabora- tions homepage (http://www. While it is subscription based, it is possible to view the abstracts 50 Essential Evidence-Based Medicine without a subscription. Some countries or regions have subsidized full-text access to the Cochrane Library for their health-care professionals. The searcher can opt to search all text or just the record title, author, abstract, keywords, tables, or publication type. The advanced search feature allows you to search multiple ﬁelds using Boolean operators. There is no cost to register, although some services are fee-based, such as purchasing individual documents online through Pay-Per-View. Always check with your health sciences library ﬁrst prior to purchasing any information to ensure that it’s not available by another method. All potential information sources are reviewed by an in-house team of information experts and clinicians and external experts to assess quality and clinical usefulness prior to being included. Phrase searching is supported by using quotation marks, such as, “myocardial infarction. Once the search has been run, the results can further be sorted by selecting more specialized ﬁlters such as systematic reviews, evidenced-based synopses, core primary research, and sub- ject specialty. The PubMed Clinical Query results are also provided separately by therapy, diagnosis, etiology, prognosis, and systematic reviews. With a “My Trip” account, a keyword auto-search function can be set up that will provide one with regular clinical updates. These will automatically be e-mailed with any new records that have the selected keyword in the title. The main disadvantage is that although Trip uses carefully selected ﬁlters to ensure quality retrievals, you lose some of the searching control that you would have searching the original database. Speciﬁc point of care databases For information at the point of care, DynaMed, Clinical Evidence, and Essential Evidence Plus are fee-based databases designed to be provide quick, evidence- based answers to clinical questions that commonly arise at the bedside. The information is delivered in a compact format that highlights the pertinent infor- mation while at the same time providing enough background information for further research if required. DynaMed uses a seven-step evidence- based methodology to create topic summaries that are organized both alpha- betically and by category. The selection process includes daily monitoring of the content of over 500 medical journals and systematic review databases. This includes a systematic search using such resources as PubMed’s Clinical Queries feature, the Cochrane Library databases, and the National Guidelines Clearing- house. Once this step is complete, relevance and validity are determined and the information is critically appraised. DynaMed uses the Users’ Guides to Evidence- Based Practice from the Evidence-Based Medicine Working Group, Centre for Health Evidence as a basis for determining the level of evidence. DynaMed ranks information into three levels: Level 1 (likely reliable), Level 2 (mid-level), and Level 3 (lacking direction). All authors and reviewers of DynaMed topics are required to have some clinical practice experience. Individual topics can be searched or can be browsed by subject, database, and tools. The bottom line provides the conclusion arrived at to answer the clinical question and provides a level of evi- dence ranking based on the ﬁve levels of evidence ranking from the Centre for Evidence-Based Medicine in Oxford. Clinical Evidence, published by the British Medical Journal is available on their website at www. An international group of peer reviewers publish summaries of systematic reviews of important clinical ques- tions. It is primarily focused on conditions in internal medicine and surgery and does cover many newer technologies. The evidence provided is rated as deﬁnitely beneﬁcial, probably beneﬁcial, uncertain, probably not beneﬁcial, or deﬁnitely not beneﬁcial. Created in 1999, it has been redesigned and revised by an international advi- sory board, clinicians, patient support groups, and contributors. They aim for sources that have high relevance and validity and require low time and effort by the user. Their reviews try to show when uncertainty stems from gaps in the best available evidence. It has been translated into Italian, Spanish, Russian, German, Hungarian, and Portuguese. Efﬁcient searching at the point of care databases The searching techniques described in this chapter are designed to ﬁnd pri- mary studies of medical research. These comprehensive searching processes will Searching the medical literature 53 Fig. The practice- based learner must ﬁnd primary sources at the point of care and will not per- form comprehensive PubMed searches on a regular basis. They will be looking for pre-appraised sources and well done meta-analyses such as those done by the Cochrane Collaboration. Most clinicians will want to do the most efﬁcient searching at the point of care possible to aid the patient sitting in front of them. An increasing number of sites on the Internet are available for doing this point of care searching. David Slawson and Allen Shaughnessy proposed an equation to determine the usefulness of evidence (or information) to practicing clinicians. They described the usefulness as equal to the relevance times validity divided by effort (to obtain). Always turning to primary sources of evidence whenever a clinical ques- tion comes up is very inefﬁcient at best and impossible for most busy practi- tioners.
The new Mayo Clinic hospital on the Jacksonville campus is a state-of-the-art 214 bed facility with 16 operating rooms purchase advair diskus with a visa, transplant and epilepsy units purchase advair diskus 500mcg without prescription, and advanced cardiac and neurosurgery facilities generic advair diskus 250mcg mastercard, provides essential inpatient care experiences for students and trainees. Campus activity is centered around the interconnected Davis, Mayo, and Cannaday buildings. The advanced Birdsall Medical Research Building allows researchers to investigate neurological diseases such as Alzheimer’s and Parkinson’s. The campus includes modern education facilities, including classrooms, lecture halls, and an extensive library and computer lab. Mayo Clinic Health System - Since its inception in 1992, Mayo Clinic Health System has grown from a new idea to one of the most successful regional health care systems in America. The Mayo Clinic Health System family of clinics, hospitals and other health- care facilities serves over 70 communities in Minnesota, Iowa and Wisconsin, and is expanding into several locations in the southwest and southeast. Mayo Clinic Health System links the expertise of Mayo Clinic with health care providers in local communities to offer patients a full spectrum of health care options along with additional clinical experiences for medical students. Patients receive quality health care at their local clinic or hospital, and, when needed, can receive highly specialized care at Mayo Clinic. Rice Lake Barron Cameron Prairie Farm Chetek Glenwood City Colfax Bloomer Chippewa Falls Minnesota Menomonie Eau Claire Lakeville Farmington Ellsworth Elmwood Wisconsin Belle Plaine New Prague Elko New Market Mondovi Osseo Le Sueur Lonsdale North eld Cannon Red Wing Montgomery Falls Lake City Alma Spring eld St. Peter Faribault Wabasha Arcadia Mankato Waterville Zumbrota Lamberton Lake Crystal Kenyon Plainview Janesville Owatonna Rochester Holmen Sparta Tomah Waseca St. James Blooming Onalaska New Richland Prairie La Crescent Trimont Truman La Crosse Wells Alden Austin Fairmont Caledonia Adams LeRoy Clinic Sherburn Blue Earth Kiester Albert Lea Mabel Hospital and Clinic Lake Mills Armstrong Decorah Waukon Management Services Agreement Physician Services Iowa Charles City Agreement Prairie The colors on the map represent locations which du Chien operate under the same regional management structure. Rafq Zakaria Campus, Rauza Bagh, Aurangabad- 431001, Maharashtra, India Abstract Nanotechnology is the study of extremely small structures, having size of 0. An application of Nanotechnology in various felds such as health and medicine, electronics, energy and environment, is discussed in detail. Applications of nano particles in drug delivery, protein and peptide delivery, cancer are explained. Applications of various nano systems in cancer therapy such as carbon nano tube, dendrimers, nano crystal, nano wire, nano shells etc. The advancement in nano technology helps in the treatment of neuro degenerative disorders such as Parkinson’s disease and Alzheimer’s disease. Applications of nano technology in tuberculosis treatment, the clinical application of nanotechnology in operative dentistry, in ophthalmology, in surgery, visualization, tissue engineering, antibiotic resistance, immune response are discussed in this article. Keywords: Nano devices; Nano material; Nano medicine; Nano pharmaceutics; Drug delivery Introduction Advancement in the feld of nanotechnology and its applications to the feld of medicines and pharmaceuticals has revolutionized the twentieth century. Nanotechnology is the treatment of individual atoms, molecules, or compounds into structures to produce materials and devices with special properties. Nanotechnology works on matter at dimensions in the nanometer scale length (1-100 nm), and thus can be used for a broad range of applications and the creation of various types of nano materials and nano devices. History of Nanotechnology Te development in the feld of nanotechnology started in 1958 and the various stages of development have been summarized in Table 1. Nano scale and Nanostructures Figure 2: Schematic diagram of various types of pharmaceutical nano systems. Te nano scale is the place where the properties of most common things are determined just above the scale of an atom. Nano scale objects have at least one dimension (height, length, depth) that measures *Corresponding author: Department of Pharmaceutical Chemistry, Y. Rafq Zakaria Campus, Rauza Bagh, Aurangabad- 431001, Maharashtra, India, Tel: +91 9823619992, E-mail: Te brief explanation of pharmaceutical nano system is as follows: [email protected] Feynman initiated thought process 1974 The term nanotechnology was used by Taniguchi for the frst time. Feynman Prize in Nanotechnology was awarded for modeling the molecular and electronic structures of new materials and for integrating single molecule 2003 biological motors with nano-scale silicon devices. First center for nano mechanical systems was established, Feynman Prize in Nanotechnology was 2004 warded for designing stable protein structures and for constructing a novel enzyme with an altered function. Liposomes: Tese have been extensively explored and most developed nano carriers for novel and targeted drug delivery due to their small size, these are 50-200 nm in size. It fnds application as long circulatory and in passive and active delivery of gene, protein and peptide. It contains three diferent regions: core moiety, branching units, and closely packed surface (Figure 5). Nano tubes have some special advantages over other drug delivery and diagnostic systems (Figure 3) due to their unique physical properties. Metallic nano particles: Metallic nano particles have used in drug delivery, especially in treatment of cancer and also in biosensors. Materials manufacturing will be revolutionized by further assembling into larger structures with designed properties. Nanotechnology can beneft chemical catalysis due to the extremely large surface to volume ratio. Te various applications of nanoparticles in catalysis range from fuel cell to catalytic converters and photocatalytic devices. Modern revolution in catalysis is due to the availability of unlimited commercial quantities of zeolites. Figure 5: Schematic representation of a dendrimers showing core, branches, Applications of Nanotechnology and surface. Te diferent felds that fnd potential applications of nanotechnology are as follows: circulatory, controlled delivery of bioactive material, targeted delivery of bioactive particles to macrophages and liver targeted delivery. Transportation Nano materials can be classifed dimension wise into following categories: d. Nanotechnology in health and medicine • Tubes, fbers, platelets have dimensions less than 100 nm. Even today various disease like diabetes, cancer, Parkinson’s • Particles, quantum dots, hollow spheres have 0 or 3 Dimensions disease, Alzheimer’s disease, cardiovascular diseases and multiple < 100 nm. Nano- phases can be classifed as, medicine is an application of nanotechnology which works in the feld of health and medicine. Nano-medicine makes use of nano materials, • Te nano material is called single phase solids. In the future, nano medicine will amorphous particles and layers are included in this class. Te medical area of nano science • Matrix composites, coated particles are included in multi-phase application has many projected benefts and is potentially valuable for solids. Certain nano scale particles are used as tags and labels, Manufacturing Approaches biological can be performed quickly, the testing has become more Te two major approaches  to get nano materials are -one is the sensitive and more fexible. Gene sequencing has become more efcient bottom up and the other is top down approach. Enormous amount of information With the help of nanotechnology, damaged tissue can be reproduced could be stored in devices build from the bottom up. Advanced biosensors with novel features can be developed with the help of Carbon nano tubes.
Linking Patients to Care For some diseases buy advair diskus master card, it is desirable to have a surveillance system closely involved in ensuring the linkage of persons who have new diagnoses to health-care services 250 mcg advair diskus visa, often called case management (Fleming et al buy generic advair diskus 100mcg online. For viral-hepatitis surveillance, linking patients who have recent diagnoses to comprehensive viral-hepatitis programs may be indicated to ensure ac- cess to appropriate services, including clinical evaluation, regular followup Copyright © National Academy of Sciences. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Chapter 5 will provide more detail on issues related to screening and identifcation. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Therefore, in investigating acute symptomatic infections, it is important to identify outbreaks so that preventive measures can be undertaken and, in the case of hepatitis B, to identify and screen close contacts who might beneft from the hepatitis B vaccine. Such information is needed if surveil- lance staff is to determine which cases are newly diagnosed, the result of recent exposure, or chronic (Fleming et al. Classifying acute cases of hepatitis B and hepatitis C requires a complex integration of clinical data, positive and negative laboratory data, and prior or repeat testing (see Boxes 2-2 and 2-3). Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Because auxiliary test results are not systematically reported to health departments, surveillance staff must actively follow up with health-care providers to obtain them and other clinical indicators of acute disease. If the data cannot be obtained, either because the proper tests were not ordered or because there is insuffcient staff to conduct followup, cases will be classifed ambiguously as nonacute infections. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Most important, when applying the most sensitive algorithm (the algorithm that detected the greatest number of cases of acute hepatitis B), the study found that only four of the eight cases of acute hepatitis B were in the state’s surveillance system and only one of the four was correctly classifed as acute; this suggests that 88% of acute hepatitis B cases may be missed if current reporting algorithms are used (Klompas et al. Similarly, detection of acute hepatitis C can be challenging because no single case defnition is either sensitive or specifc for it. In summary, the identifcation of acute hepatitis infection is inherently fawed because the vast majority of cases are asymptomatic and patients do not seek medical care or testing. Such persons would be identifed only in prospective studies that include routine serial testing of liver enzyme concentrations, such as those previously conducted to identify the incidence of transfusion-associated hepatitis. Thus, the estimates of the incidence of acute hepatitis in the United States are based solely on symptomatic cases. The majority of those cases may be missing from the surveillance system because of poor access to health care, underreporting, and misclassifca- tion. Taken together, published surveillance summaries of reported cases of acute viral hepatitis substantially underestimate the number of cases; these Copyright © National Academy of Sciences. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Identifying Chronic Infections Given that both hepatitis B and hepatitis C infections are largely asymptomatic, most people do not receive a diagnosis until the infection is chronic. For hepatitis B, the chance of developing a chronic infection varies with age at the time of infection. However, hepatitis B infections become chronic in over 90% of infants who are infected at birth or in the frst year of life and in 30% of children who are infected at the age of 1–5 years (Pungpapong et al. An accurate diagnosis of chronic hepatitis B may therefore require the report- ing of multiple serologic markers at more than one time (Koff, 2004). Although states govern laboratory-reporting requirements in their jurisdictions, negative test results are generally not reportable and must be actively obtained. In adults, about 15–25% of acute hepatitis C infections resolve spontaneously (Villano et al. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. For the purposes of this case defnition, any positive result among the three laboratory tests mentioned above is acceptable, regardless of other test- ing results. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. However, many have chronic liver disease, which can range from mild to severe including cir- rhosis and liver cancer. Case classifcation: Confrmed: a case that is laboratory confrmed and that does not meet the case defnition for acute hepatitis C. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. The process leads to incomplete diagnoses and inaccurate reporting of the number of chronic cases. In an economic analysis of immunization strategies to prevent hepatitis B transmission in the United States, Margolis et al. Routine hepatitis B vaccination of infants would provide additional savings of $19. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Two major problems occur in the identifcation and management of possible cases (see Box 2-6). Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. The second problem involves a lack of resources to follow up on all potential and known cases and their contacts in a timely manner. Other Challenges for Hepatitis B and Hepatitis C Surveillance Systems Repeat testing in high-risk populations can confuse the number of sus- pected acute versus chronic infections. Those cases could mis- takenly be classifed as chronic infections based on antibody results alone. Structural and political barriers, stigma, and fear of legal repercussions contribute to the limitations on their access. Finding ways to ensure that patients receive comprehensive and cul- turally appropriate care and referrals not only would increase the likelihood of improving their health outcomes but is likely to affect surveillance-data collection favorably. Finally, because of the chronic nature of viral hepatitis, it is important that surveillance staff communicate well between jurisdictions. Persons with chronic disease can be misclassifed as having acute cases if earlier diagnoses made in other jurisdictions are not identifed. Not infrequently, a previous diagnosis has been reported in another state or jurisdiction. The ability of state and local surveillance-program staff to track cases across jurisdictions is hampered by various factors, including inadequacy of staff resources, nonstandardized surveillance software systems, and the lack of a national database that could be used to identify potential matches in other jurisdictions. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. As a result, surveillance data do not provide accurate estimates of the current burden of disease, are insuffcient for program planning and evaluation, and do not provide the information that would allow policy-makers to al- locate suffcient resources to address the problem. No funding is provided for viral-hepatitis testing, hepatitis B immunizations, or other services. Given that the guide- lines cover three distinct and complex diseases (hepatitis A, hepatitis B, and hepatitis C), they lack the detail necessary to create surveillance practices that are consistent among jurisdictions.
Ether Time (drops per minute) (minutes) 12 1 24 2 48 3 96 4-15 50 15-30 20-30 after 30 It is difficult to induce anaesthesia in an adult using the “open-drop” technique due to problems reaching high enough concentrations around the mask advair diskus 500 mcg sale. This is essentially a metal column which sits over the mask discount advair diskus 100mcg online, holding the vapour at a higher concentration close to the face which increases the concentrations being breathed in buy advair diskus 500mcg with mastercard. It is also worth getting the patient used to the smell of ether first as it is highly potent and can cause coughing fits. It can take a considerable period for a patient to wake up after an ether anaesthetic. It is reasonable to stop administering it slightly before the operation is finished. Ether also causes excess production of secretions in respiratory system and this potentially can cause problems with breathing – where possible Atropine should be administered to prevent this from occurring. It tends to give a much smoother induction but also can cause more cardiovascular instability. Less is required than with ether; with chloroform the gauze is damp, with ether it’s saturated. This limits your options with light sources somewhat in that open flames are a potential hazard. It is possible to use ether safely - 107 - Survival and Austere Medicine: An Introduction with open flames if you have no alternatives by keeping the ether and naked flame as separate as possible and ensuring adequate ventilation. Provided there is air circulating the ether is going to very rapidly be diluted with the surround air. A certain concentration of ether is required to induce anaesthesia (about 5%) which exceeds the flammable concentration (about 1. A safe minimum distance to exposed flames would be 50 cm in a well-ventilated room but the process still carries a small risk. Static electricity from the operating team also provides a potential ignition source and should be considered. All in all – if you possibly can avoid using ether with naked flames – the risks probably outweigh the benefits. Physical therapy focuses on maintaining and rehabilitating musculoskeletal function – stretching, massage, and muscle-strengthening exercises. Occupational therapy is focused on rehabilitating people to perform the activities required to look after themselves – eating, dressing, and personal hygiene. It is beyond the scope of this book to discuss either in great detail – but if your goal is to rehabilitate a seriously injured or ill person back to full function within your community this aspect of care cannot be underestimated. Most communities will not be able to carry many people who cannot contribute meaningfully to the group. The goal of physical and occupation therapy is to maximise a patient’s physical functioning, and get them to a point where they can look after themselves, and contribute. If you have a group member who has suffered a serious injury or illness early on you should focus on what they are likely to be able to do and tailor their rehabilitation to being able to perform that role. You also need to decide as a group how many people you can support who cannot contribute to the group and who may require significant care and resources to survive with no return. Fortunately with therapy most people are able to perform some meaningful work to “earn their keep”. The only book we have found specifically aimed at Physical and Occupational therapy in an austere environment is Disabled Village Children by David Werner author of Where There Is No Doctor which is available as a hardcopy or online. The book is primarily focused on the rehabilitation of patients with childhood disabilities and diseases but has much to offer regarding the rehabilitation of anyone who has suffered serious illness or injury - 108 - Survival and Austere Medicine: An Introduction rd and the focus is on practice in 3 world environment which translates well to an austere or survival situation. Other therapies Discussed elsewhere in this book (Chapter 17) and of potential use in a long-term austere situation are rectal fluid administration, honey, and sugar as antimicrobials and maggot therapy for infected wounds. Euthanasia We know this an extremely uncomfortable topic for many and for others totally abhorrent from a religious perspective but it does merit discussion. Death can at times be protracted, and extremely painful, and distressing to the patient and others. Modern medicine has for years focused on easing the death process with pain management and other medication to control symptoms. In a protracted survival situation you will need to consider your approach to dealing with death and the process of dying. In certain cases, such as a slow death from cancer, without access to reliable painkilling medication then euthanasia may be an option for some. The current first world maternal death rate (and this is not just pregnancy and birth related problems, it includes accidents as well) is about 1:10,000. In many third world countries maternal rates of 1:100 and foetal rates of 1:10 are still common. If you work in the third world today you will see daily maternal and foetal/newborn deaths. In part this is due to poor hygiene and maternal condition as much as the process of childbirth in these countries. But even excellent low tech midwifery care delivered with excellent hygiene practices to a healthy well nourished mother will still have a significantly increased incidence of maternal and newborn deaths. While it is often overused modern obstetric care saves lives and its absence will be missed. The perception of low-risk childbirth has only come about through the development of expert midwifery and obstetric care in the last 50 years. For the majority of women childbirth will be very straight forward but don’t underestimate the risk. In an austere situation there may be good reasons to avoid childbirth particularly for women who have already had a caesarean section or a complicated pregnancy before the collapse. In addition, a new baby is literally another mouth to feed, a breastfeeding mother has a higher nutrient requirement, and the child will grow, and need an increasing proportion of the food resource. Contraception Contraception is important; preventing pregnancy may be desirable for many reasons as discussed above – maternal risk or lack of resources for the child. Both condoms and the oral contraceptive pill (combined and proestrogen only) store relatively well in a cool dry environment – like other drugs their effectiveness will decline beyond their expiry dates but how much and over what time period isn’t known. When used consistently natural family planning is also a reasonably reliable option (http://www. However, this hasn’t proved overly successful in the past so there is no reason to think it would in a stressful future environment! As is the case with food storage in that you should “store what you eat and eat what you store” the same is true for contraception. You should stick with the method you know – a time of crisis is no time to be trying out natural family planning for the first time, when you have used condoms for the last 10 years. While you are manufacturing your suture material you can also whip up a few condoms. The process is fairly simple; the gut is soaked, turned inside out, macerated in an alkaline solution, scraped, exposed to sulphur vapour, washed, blown up, dried, cut to length, and given a ribbon tie for the base. It was necessary to soak them to render them supple enough to put on and they weren’t disposable. The alternative method from early last century was to dip a wooden mould into melted rubber, let it dry and set, and then roll it off. Childbirth This is not the forum to discuss the mechanics of pregnancy, labour, or delivery.