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By A. Tufail. Ferris State University.

When classifying variables by function we want to know what the variable does in the experiment buy generic kamagra effervescent 100 mg line. The independent variable is under the con- trol of or can be manipulated by the investigator buy kamagra effervescent 100mg free shipping. Generally this is the cause we 67 68 Essential Evidence-Based Medicine are interested in, such as a drug, a treatment, a risk factor, or a diagnostic test. The dependent variable changes as a result of or as an effect of the action of the independent variable. It is usually the outcome of exposure to the treatment or risk factor, or the presence of a particular diagnosis. We want to find out if chang- ing the independent variable will produce a change in the dependent variable. The nature of each variable should be evident from the study design or there is a serious problem in the way the study was conducted. When classifying variables by their nature, we mean the hierarchy that describes the mathematical characteristics of the value generated for that vari- able. The choice of variables becomes very important in the application of statis- tical tests to the data. One can assign a number to each of these categories, but it would have no intrinsic significance and cannot be used to compare one piece of the data set to another. Exam- ples of nominal data are classification of physicians by specialty or of patients by the type of cancer from which they suffer. There is no relationship between the various types of specialty physicians except that they are all physicians and went to medical school. Ordinal data are nominal data for which the order of the variables has impor- tance and intrinsic meaning. Typical examples of ordinal data include certain pain scores that are measured by scales called Likert scales, severity of injury scores as reflected in a score such as the Trauma Score where lower numbers are pre- dictive of worse survival than higher ones, or the grading and staging of a tumor where higher number stages are worse than lower ones. Common questionnaires asking the participant to state whether they agree, are neutral, or disagree with a statement are also examples of an ordinal scale. Although there is a directional value to each of these answers, there is no numerical or mathematical relation- ship between them. Interval data are ordinal data for which the interval between each number is also a meaningful real number. However, interval data have only an arbitrary zero point and, therefore, there is no proportionality ratio relationship between two points. One example is temperature in degrees Celsius where 64◦Cis32 C hotter◦ than 32◦C but not twice as hot. This makes the results take on meaning for both absolute and relative changes in the vari- able. Examples of ratio variables are the temperature in degrees Kelvin where 100◦ Kelvin is 50◦K hotter than 50◦K and is twice as hot, age where a 10-year- old is twice as old as a 5-year-old, and common biological measurements such Instruments and measurements: precision and validity 69 as pulse, blood pressure, respiratory rate, blood chemistry measurements, and weight. This is called the number of significant places, which is taught in high school and college, although it is often forgotten by students quickly thereafter. Height is an example of a continuous measure since a person can be 172 cm or 173 cm or 172. For exam- ple, a piano is an instrument with only discrete values in that there are only 88 keys, therefore, only 88 possible notes. Scoring systems like the Glasgow Coma Score for measuring neurological deficits, the Likert scales mentioned above, and other ordinal scales contain only discrete variables and mathematically can have only integer values. We commonly use dichotomous data to describe binomial outcomes, which are those variables that can have only two possible values. Obvious examples are alive or dead, yes or no, normal or abnormal, and better or worse. This has the effect of dichotomizing the value of the serum sodium into either hypernatremic or not hypernatremic. Measurement in clinical research All natural phenomena can be measured, but it is important to realize that errors may occur in the process. Random error leads to a lack of precision due to the innate variability of the biological or sociological system being studied. For example, in a given popula- tion, there will be a more or less random variation in the pulse or blood pres- sure. Many of these random events can be described by the normal distribution, which we will discuss in Chapter 9. An imprecise instrument will get slightly different results each time the same event is measured. For example, serum sodium measured inside rat muscle cells will show less random error than the degree of depression in humans. There can also be innate variability in the way that 70 Essential Evidence-Based Medicine different researchers or practicing physicians interpret various data on certain patients.

As part of performance improvement programs cheap 100 mg kamagra effervescent free shipping, attempts to achieve the ScvO2 or SvO2 goal are options generic 100 mg kamagra effervescent overnight delivery. Protocolized, quantitative resuscitation of patients with sepsis- induced tissue hypoperfusion (defned in this document as hypotension persisting after initial fuid challenge or blood lactate concentration ≥ 4 mmol/L). In patients with elevated lactate levels targeting resuscitation to normalize lactate (grade 2C). Routine screening of potentially infected seriously ill patients for severe sepsis to allow earlier implementation of therapy (grade 1C). Cultures as clinically appropriate before antimicrobial therapy if no signifcant delay (> 45 mins) in the start of antimicrobial(s) (grade 1C). At least 2 sets of blood cultures (both aerobic and anaerobic bottles) be obtained before antimicrobial therapy with at least 1 drawn percutaneously and 1 drawn through each vascular access device, unless the device was recently (<48 hrs) inserted (grade 1C). Use of the 1,3 beta-D-glucan assay (grade 2B), mannan and anti-mannan antibody assays (2C), if available and invasive candidiasis is in differential diagnosis of cause of infection. Administration of effective intravenous antimicrobials within the frst hour of recognition of septic shock (grade 1B) and severe sepsis without septic shock (grade 1C) as the goal of therapy. Initial empiric anti-infective therapy of one or more drugs that have activity against all likely pathogens (bacterial and/or fungal or viral) and that penetrate in adequate concentrations into tissues presumed to be the source of sepsis (grade 1B). Antimicrobial regimen should be reassessed daily for potential deescalation (grade 1B). Use of low procalcitonin levels or similar biomarkers to assist the clinician in the discontinuation of empiric antibiotics in patients who initially appeared septic, but have no subsequent evidence of infection (grade 2C). Combination empirical therapy for neutropenic patients with severe sepsis (grade 2B) and for patients with diffcult-to-treat, multidrug- resistant bacterial pathogens such as Acinetobacter and Pseudomonas spp. For patients with severe infections associated with respiratory failure and septic shock, combination therapy with an extended spectrum beta-lactam and either an aminoglycoside or a fuoroquinolone is for P. A combination of beta-lactam and macrolide for patients with septic shock from bacteremic Streptococcus pneumoniae infections (grade 2B). De-escalation to the most appropriate single therapy should be performed as soon as the susceptibility profle is known (grade 2B). Duration of therapy typically 7–10 days; longer courses may be appropriate in patients who have a slow clinical response, undrainable foci of infection, bacteremia with S. Antiviral therapy initiated as early as possible in patients with severe sepsis or septic shock of viral origin (grade 2C). A specifc anatomical diagnosis of infection requiring consideration for emergent source control be sought and diagnosed or excluded as rapidly as possible, and intervention be undertaken for source control within the frst 12 hr after the diagnosis is made, if feasible (grade 1C). When infected peripancreatic necrosis is identifed as a potential source of infection, defnitive intervention is best delayed until adequate demarcation of viable and nonviable tissues has occurred (grade 2B). Selective oral decontamination and selective digestive decontamination should be introduced and investigated as a method to reduce the incidence of ventilator-associated pneumonia; This infection control measure can then be instituted in health care settings and regions where this methodology is found to be effective (grade 2B). Similar consideration may be measurement of fow at the bedside (33, 34); however, the eff- warranted in circumstances of increased abdominal pressure cacy of these monitoring techniques to infuence clinical out- (17). Although the cause of tachycardia in septic patients senting with either hypotension with lactate ≥ 4 mmol//L, hypo- may be multifactorial, a decrease in elevated pulse rate with tension alone, or lactate ≥ 4 mmol/L alone, is reported as 16. Published observational studies have dem- septic patients with both hypotension and lactate ≥ 4 mmol/L onstrated an association between good clinical outcome in (46. Many studies support the value of early be a feasible option in the patient with severe sepsis-induced protocolized resuscitation in severe sepsis and sepsis-induced tissue hypoperfusion. Studies of patients with shock be used as a combined endpoint when both are available. While multicenter randomized trials evaluated a resuscitation strat- the committee recognized the controversy surrounding egy that included lactate reduction as a single target or a tar- resuscitation targets, an early quantitative resuscitation pro- get combined with ScvO2 normalization (35, 36). Screening for Sepsis and Performance improvement quality indicators, resuscitation target thresholds Improvement are not considered. However, recommended targets from the guidelines are included with the bundles for reference purposes. We recommend routine screening of potentially infected seriously ill patients for severe sepsis to increase the early C. We recommend obtaining appropriate cultures before anti- sepsis therapy (grade 1C). The early identifcation of sepsis and imple- nifcant delay (> 45 minutes) in the start of antimicrobial(s) mentation of early evidence-based therapies have been doc- administration (grade 1C). To optimize identifcation of caus- umented to improve outcomes and decrease sepsis-related ative organisms, we recommend obtaining at least two sets of mortality (15). Reducing the time to diagnosis of severe sepsis blood cultures (both aerobic and anaerobic bottles) before is thought to be a critical component of reducing mortality antimicrobial therapy, with at least one drawn percutaneously from sepsis-related multiple organ dysfunction (35). Lack of and one drawn through each vascular access device, unless early recognition is a major obstacle to sepsis bundle initiation. Cultures of other sites (preferably quan- ated with decreased sepsis-related mortality (15).

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With diarrhoeal illness – simple hand washing is usually sufficient for the caregiver 100mg kamagra effervescent mastercard. With febrile illnesses or those with respiratory symptoms then barrier precautions should be used – gloves kamagra effervescent 100 mg fast delivery, gown, facemask (N95), and goggles should be used. If this level of protection is not possible then some form of face mask is needed when with the patient and hand-washing, changing clothes (hot wash), and showering before contact with the healthy. For strangers arriving particularly during a pandemic consider 10-14 days isolation, followed by clothes burning and a through wash with soap before entering the community. There are no current infectious diseases with longer incubation times than 10-14 days. Provided the newcomer is symptom free at the end of this period you should be safe. However, among the current potential pandemic causes there are not currently carrier states although this needs to be considered. The recent tsunami in southern Asia clearly demonstrates how quickly public health can break down. Despite widespread knowledge even in developing third world countries about the basic principles of public health and hygiene latrines have been dug next to water supplies, water wasn’t being boiled, and in some places no effort was made to burn or dispose of rubbish, and it was just allowed to accumulate. While you can argue that some of this was due to “shell shock” from the disaster itself it just goes to show how the fundamentals can go out the window in a stressful situation. At present there is a heavy reliance on investigations; in a long-term austere situation history and examination will come into their own again. History taking and Examination: With very limited access to investigations the importance of clinical examination will again take on enormous importance. While modern doctors are competent at physical examination there is heavy reliance on special tests, and many of the skills of accurate physical examination have faded. The basics are easily learned from any clinical skills textbook (We recommend Talley and O’Connor, Physical Examination) and with a little practice. It is almost certain that in long-term austere situations that physical examination will come into its own again. The history 95% of the time is all that is required to know exactly what is going on. The examination and investigations may be used to confirm your thoughts, but it’s the history that usually gives you the diagnosis. Investigations: Laboratory tests: Lab tests which are possible in an austere environment are discussed in the Laboratory chapter. These include basic urine analysis, blood typing, and cross matching, and simple cell counts. There are several low-tech ways that are reasonably accurate in diagnosing fractures. Fractures of the long bones (tibia, fibula, femur, humerus, clavicle, ribs, etc), can be diagnosed by either percussion, or a tuning fork, and a stethoscope. A bony prominence on one end of the bone in question is tapped, or the base of a vibrating tunning fork is placed against it, and the stethoscope is applied to the other end. If a fracture exists on one side and not the other the gap in the bone at the fracture site will result in less sound being transmitted so the sound will be somewhat muted on the side of the fracture. To diagnose a hip fracture the sound source is applied to the patella (knee cap) and the stethoscope applied over the pubic symphysis. The technique is less effective on the obese as fatty tissue will absorb sound waves. For long bones running near the surface of the body a fracture can be localized by drawing the tuning fork along the bone slowly (>30 sec, but <60 sec) until a very localized source of pain is identified (<3 cm). A cone formed from rolled paper can act as a substitute for a stethoscope but is less than ideal. Once again, the reality will be that the most useful method for diagnosing fractures will be clinical examination. This is also the case for the clinical chest examination in patients who would previously have had a chest x-ray. Treatment The trick to learn for patient care in a truly austere situation is to do what you can do extremely well. You may not have access to many medications or much equipment but do what you are able to do well and you will save lives. The classic survival cliché is a simple scratch could result in you dying from gangrene infection of the leg. While at the extreme end of the spectrum this may be true cleaning the wound with copious amounts of water and keeping it covered will prevent most infections; if there are signs of infection further good basic wound care, resting the limb, and keeping it elevated for 48-72 hours will further the chances of serious infection all without antibiotics.

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