Copyright © , , , Lippincott Williams & Wilkins, a Wolters Step-up to medicine / editors Steven S. Agabegi, Elizabeth D. Agabegi. . dedication in bringing this and previous editions of Step Up to Medicine to fruition . Now in its fourth edition, Step-Up to Medicine has been completely revised based on We hope that the new edition of Step-Up to Medicine continues to be a. Step-Up to Medicine is your lifeline for the clinical years of medical school. This book was originally written by third-year medical students searching for the.

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The girl was confirmed to have paucibacillary leprosy on clinical examination , while the boy was kept under observation by the District leprosy team.

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Case history: The girl, found positive for leprosy, was 16 years old with no apparent contact history. She gave history of migration from a Southern district in Tamil Nadu 2 years back. She had noticed the lesion a year back for which she consulted a local doctor who prescribed local antifungal ointment, which she applied for nearly a month. However, there was no improvement in the condition.

Figure 1: Two hypopigmented patches under the chin. Click here to view Since , after the WHO Global Strategy Plan, the active search for leprosy cases has been stopped and the program now focuses primarily on passive case detection only. Evidences from non experimental studies comparative research, case study , according to some, for example Textbooks.

Evidences from experts and clinical practice. The principle of EBM emphasizes, above all, that the foundation of any medical decisions regarding the optimal diagnostic or therapy procedure are scientific evidences from clinical research, and clinical experience and intuition are of great help, but not the main basis in decision-making. New in the application of EBM is that making decisions about treatment for each individual patient is a complex process that allows doctors and patients to select the best possible solutions for each individual patient.

Professor Archie Cochrane, a Scottish epidemiologist, through his book Effectiveness and Efficiency: Random Reflections on Health Services and subsequent advocacy, caused increasing acceptance of the concepts behind evidence-based practice. However, the founder of EBM is considered to be English epidemiologist Archie Cochrane, who lived in the 19th century and which has already pointed out the impossibility of monitoring all the new discoveries in medical science.

During the last ten years in the world rapidly is growing the interest in the application of EBM.

The reason for this is the application of electronic records, the Internet phenomenon, an increasing number of different clinical tests that doctors cannot track, as well as increase in cost of health care 7. Today, in almost all western countries doctors apply EBM in treatment for every patient with the support of the governments of these countries, the ministries of health and pharmaceutical industry.

This includes practical guidelines for different diseases, a database with the best scientific evidence from each category, which is edited by special experts and which is continuously updated with new data, medical journals and literature available with the latest objective information. It is a long list of procedures that appeared useful at one moment, and afterwards shown to be inefficient or even harmful. Example of this is the application of thalidomide during pregnancy and as consequence of that children was born with anomalies.

Group for Evidence Based Medicine Resource from McMaster University identified the approach in 5 steps that each individual physician in the application of this approach must follow. Step 1. Defining problem Each doctor several times a day is in the position of making various medical decisions. Often in the process of medical decision-making occur questions such as: for and against the use of certain therapies, whether to use a diagnostic test or screening procedure, the risk or prognosis of a particular disease or cost-effectiveness of specific interventions.

It is clear that the already busy doctor, will not be able to answer in this way all the questions that come in practice and therefore must resort to the process of determining priorities, as well as refining issues that needs to be asked.

Good clinical question must be clear, directly focused on the problem, and answerable by searching the medical literature. PICO format: the patient or problem — who are the relevant patients, what kind of problem we try to solve? Type of clinical question The most common type of clinical question is about how to treat a disease or condition. Such questions are questions about intervention. Types of clinical questions: questions about etiology and risk factors questions about frequency and rate questions about diagnosis questions about prognosis and prediction question about cost-effectiveness question about phenomena 7.

Step 2.

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Search for wanted sources of information After formulating the clinical question, which stems from a concrete patient, the next step is to search for relevant evidence that will provide the answer to the question. This is not always easy, especially in Family medicine, in which the problems caries the poorlydefined problems in the start.

However, there are numerous sources of information that may be of assistance, including medical journals, which treat certain problems in the field of Family medicine, search of electronic databases and communication with colleagues. The ideal information source is valid contains high quality data , relevant clinically applicable , comprehensive has data on all benefits and harms of all possible interventions , and is user-friendly is quick and easy to access and use.

Step 3.

Critical evaluation of the information When we decide which magazine to read, it is important to read it carefully, because not all the published information is of equal importance and value.

Critical assessment of the articles is a process that involves careful reading and analysis of methodology, contents and conclusions.

Step 4. Application of information of the patient The fourth step in the process of the use of Evidence Based Medicine in practice is the decision how to apply acquired information on the special circumstances pertaining to each patient.

This is probably a crucial step in the process, if not the most complex. Now it is necessary to decide whether there is something in relation to our patient because of which it would be necessary to discard the acquired information.

The questions that we should ask before the decision to apply the results of the study are: Are the participants in the study similar enough to my patient?

Is the treatment available and is health care system prepared to fund it?

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What alternatives are available? Do the potential side effects of the drug or procedure outweigh the benefits? Are the outcomes appropriate to the patient? If something does not exist, it is necessary to weigh the potential harm from the benefit and do all that in partnership with the patient, where our decision in the end, in fact, will be shared. The Guidelines include a preamble, 47 guidelines, and a commentary.

All are based on the human rights principles set out in the Universal Declaration of Human Rights, the international right to the highest attainable standard of health codified in numerous national constitutions and human rights treaties, and other widely accepted standards such as some of those adopted by the World Health Organisation WHO [2].

Emerging from a long process of research and consultation with pharmaceutical companies and others—a process outlined in the UN report of —the Guidelines recognise some important realities.

For example: governments have the primary responsibility for increasing access to medicines; many health systems are failing, constituting a grave obstacle to increasing access to medicines; the pharmaceutical sector helps to save lives and reduce suffering; and pharmaceutical companies have a responsibility to enhance shareholder value. But the Guidelines also reflect another equally important reality: pharmaceutical companies have human rights responsibilities.

Critically, the Guidelines give content to these responsibilities, with two vital implications. First, the Guidelines can and should help to shape corporate policies, and second, they provide right-to-health standards in relation to which companies can and should be held accountable. The 47 guidelines are grouped in themes Box 1 contains examples.

Box 1. Human Rights Guidelines for Pharmaceutical Companies in Relation to Access to Medicines Based on the human rights principles set out in the Universal Declaration of Human Rights, the international right to the highest attainable standard of health codified in numerous national constitutions and human rights treaties, and other widely accepted standards, the 47 guidelines are organised into themes.

Other guidelines apply transparency to the theme of public policy influence, advocacy, and lobbying guidelines 17— Guidelines 26—32 address patents and licensing, including the vital role of commercial and noncommercial voluntary licences. Guidelines 33—37 address pricing, such as differential pricing between and within countries.

Other themes include management, monitoring, and accountability; neglected diseases; corruption; clinical trials; ethical promotion and marketing; and public—private partnerships. Although distinct, the two projects—the Guidelines and the GSK report—informed each other. While the Guidelines apply to innovator, generic, and biotechnology companies, the GSK report had a particular preoccupation with the right-to-health duties of innovator i.

The report emphasises that a pharmaceutical company, having developed a life-saving medicine, has performed a vitally important medical, public health, and right-to-health function. However, the company is granted a patent under express and implied terms. Society has legitimate expectations of a company holding the patent on a life-saving medicine.


On the basis of the goals of dignity and well-being of individuals and communities, as well as of globally recognised standards, the right to health clarifies, and gives substance to, these terms and expectations.

The agreement between society and the patent holder of a life-saving medicine grants privileges to, and places responsibilities on, the patent holder Box 2. Box 2. Right-to-Health Responsibilities of Patent Holders of Life-Saving Medicines The seminal right-to-health responsibility is to take all reasonable steps to make the medicine as accessible as possible, as soon as possible, to all those in need, within a viable business model.

Engaging Public Health in End-of-Life Issues: It Is Time to Step Up to the Plate

For example, as soon as the new medicine is marketed at higher prices usually in high-income countries , the patent holder has a right-to-health responsibility to put in place a range of mechanisms, such as differential pricing between and within countries, to enhance access for all those who cannot afford those prices.Apr In reality, it's probably more like two months for Step 1, 1 month for.

Colleague's E-mail is Invalid. What we observe — the observation — is a representation in our mind, which comes to us via our senses and any scientific instrument we are using, of the real thing that is being observed. Also, the patent holder has a right-to-health responsibility to develop formulations for children, the elderly, pregnant and lactating women, and extremes of climate.

The agreement between society and the patent holder of a life-saving medicine grants privileges to, and places responsibilities on, the patent holder Box 2. Studies are ranked in the hierarchy of evidence.

GILMA from Washington
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