Does Evidence-Based Medicine Help the Development of Clinical Practice Guidelines: Promoting Guideline EffectivenessThe second factor that distinguishes clinical practice guidelines from earlier documents that guide clinical practice is a reliance on a formal method that explicitly outlines the guideline’s developmental process. Ideally, clinical practice guidelines provide within their texts documentation of the process by which recommendations emerge from an interaction between scientific data and professional judgment. Much as a methods section in a basic science or clinical research paper provides accountability and reproducibility for the scientific method, the methods section of a clinical practice guideline fulfills the reader’s expectations that the guideline contains more well-constructed and valid recommendations than can be generated through an informal, opinion-based process. This formal method has been emphasized by the Institute of Medicine in its definition of clinical practice guidelines, which are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. antibiotics online
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This article begins with the bias that all valid patient care guidelines derive more or less from the scientific evidence and that following their recommendations will increase the probability of producing the desired patient outcome. The article ends with the conclusion that concerns about using evidence-based medicine in guideline development result from a less-than-clear understanding of the nature of clinical practice guidelines and evidence-based medicine. These two processes for assisting clinical decision-making are well suited for each other and produce the most valid therapeutic and diagnostic recommendations that are possible at any particular time to ensure high-quality patient care. Read the rest of this entry »

Does Evidence-Based Medicine Help the Development of Clinical Practice Guidelines?It would appear at first glance self-evident that good clinical practice would derive its fundamental justification from high-quality investigative evidence. The traditional training of physicians in the scientific method and the pathophysiologic approach to disease management seem to provide an affirmative answer to the question in this article’s title: evidence-based medicine helps the development of clinical practice guidelines, insofar as we would like to think that scientific data drive most physician decisions. canadian pharmacy

But whether recognized or not, the harsh reality of medicine is that many, if not most, daily clinical decisions are not based on valid scientific fact. Despite extensive clinical investigations into the management of pneumonia, for instance, uncertainties remain regarding the ideal antibiotics for community-acquired pneumonia, when to switch patients from IV to oral antibiotics, and the role of diagnostic bronchoscopy with quantitative cultures for patients with suspected ventilator-associated pneumonia. Read the rest of this entry »

Our observational cohort study demonstrated that the placement of tracheotomy did achieve its clinical goal, ie, although practically all children with tracheotomies were colonized, they suffered significantly fewer infections (one of four patients). Some physicians may argue that this infection rate of 27% does not justify preventative interventions. Although the main problem was of primary endogenous origin, the exogenous pathway was found to be substantial. The 35% exogenous colonization and infection episodes may be traditionally interpreted as a huge crossinfection problem due to bad nursing practices. However, two observations were highlighted by this study that are in line with previous work in this particular patient population. First, despite high standards of hygiene, maintaining sterility of the lower airways in patients with tracheotomies seems impossible. Second, systemic antibiotics fail to sterilize the lower ainvays in these patients, once they are colonized or infected. Read the rest of this entry »

Impact of Tracheotomy on Colonization and Infection of Lower Airways in Children Requiring Long-term Ventilation: OutcomeThe prophylactic strategy of selective decontamination of the digestive tract (SDD) is based on the classification using the carrier state. The most important feature of SDD is the use of a combination of carefully selected nonabsorbable antimicrobials polymyxin, tobramycin, and amphotericin B These are given topically to the oropharynx and GI tract to prevent or eradicate, if initially present, oropharyngeal and GI carriage of PPMs. It is designed to prevent or minimize the impact of only endogenous, both primary and secondary infections, ie, those preceded by oropharyngeal and GI carriage. Read the rest of this entry »

The adult and pediatric populations differ in their PPMs colonizing and infecting the lower airways. The few adult longitudinal tracheotomy studies using serial paired surveillance and diagnostic samples invariably report colonization and infection by aerobic Gram-negative bacilli. Our study shows that half of all exogenous colonization and infection episodes in children with tracheotomy are caused by S aureus. There are two possible explanations related to either the host or the microorganism. In the adult studies, the external sources did not contain S aureus but only typical “environmental” bacteria such as Pseudomonas and Serratia. Perhaps these studies report outbreaks with a particular microorganism during the trial. Alternatively, the adults possess fewer receptor sites for S aureus. Most of the adults studied were older than 60 years and most suffered from chronic underlying conditions such as COPD, diabetes, alcoholism, and malignancies. These abnormalities have been associated with significantly higher rates of carriage and colonization by aerobic Gram-negative bacilli. Macrophages are thought to release elastase in response to these underlying chronic diseases. Read the rest of this entry »

Impact of Tracheotomy on Colonization and Infection of Lower Airways in Children Requiring Long-term Ventilation: Colonization episodesA total of 66 episodes of colonization and/or infection were diagnosed in 21 of the 22 children admitted to the PICU who subsequently received a tracheotomy. There were 23 episodes (15 of colonization and 8 of infection) in 15 children receiving ventilation via a transtracheal tube, while 43 episodes (34 of colonization and 9 of infection) occurred in 21 children after they were ventilated via a tracheotomy. During both types of artificial airways, ie, transtracheal intubation and via tracheotomy, the colonization and infection episodes of primary endogenous origin were predominant: 80% and 75% of all episodes of colonization and infection, respectively, in the pretracheotomy study. Posttracheotomy, these figures were 56% and 45%, respectively. Seven percent of all pretracheotomy colonization episodes were of exogenous development while 35% were observed following the placement of a tracheotomy (p=0.02) (Figs 1, 2). Read the rest of this entry »

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Health is the general condition of a person in all aspects. It is also a level of functional and/or metabolic efficiency of an organism, often implicitly human.

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