This document discusses evidence-based laboratory medicine and the need to support clinical decision-making with robust evidence. It notes that while laboratory medicine is perceived as scientific, evidence for many diagnostic tests is limited or flawed. An evidence-based approach can help improve education, guidelines, decision-making and resource allocation. The challenges include a lack of evidence demonstrating the impact of diagnostic tests on patient outcomes. Health technology assessment and outcomes research are important tools to develop high-quality evidence and address the current pressures on healthcare systems.
The document discusses HLA typing and its implications. It begins with a brief history of the discovery of the major histocompatibility complex (MHC) in mice and humans. It then describes the structure and functions of the MHC, including the class I, class II, and class III regions. The document discusses methods of HLA typing, including serological testing using microcytotoxicity and molecular methods. It notes some implications of HLA typing, such as its role in organ transplant matching and susceptibility to autoimmune disease.
Webinar Series on Demystifying Phases in Clinical Trials & COVID-19 Updates organized by Institute for Clinical Research (ICR), NIH
Speaker: Dr. Alan Fong Yean Yip, Consultant Cardiologist & CRC head of Sarawak General Hospital and Mr. Chew Chun Keat, Technical Head of Centre for Clinical Trial, ICR
More information please visit: https://clinupcovid.mailerpage.com/resources/r0x8r9-webinar-series-on-demystifying-cl
This document discusses protein microarrays, which allow large numbers of proteins to be analyzed in parallel. Protein microarrays can be either analytical or functional. Analytical microarrays use capture molecules like antibodies to probe complex protein solutions like cell lysates. Functional microarrays immobilize purified proteins to study biochemical activities and interactions on a proteome-wide scale. Applications of protein microarrays include diagnostics, proteomics, analyzing protein functions and interactions, characterizing antibodies, and developing new treatments.
Bioinformatics is an interdisciplinary field that uses computer science and information technology to analyze and interpret biological data. It involves developing databases to store biological information and computational tools to analyze data. The key aims of bioinformatics are to store biological data in organized databases, develop tools to analyze the data, and use these tools to interpret results in a biologically meaningful way. It has applications in areas like genome sequencing and annotation, gene expression analysis, protein structure prediction, and understanding biological pathways and networks.
Fundamental of mesenchymal stem cells as a promising candidate in regenerativ...Tee Huat
Mesenchymal stem cells (MSCs) are multipotent stromal cells that reside in connective tissues throughout the body. They are capable of differentiating into multiple mesenchymal lineages including bone, cartilage, and adipose tissues. MSCs also possess the ability to transdifferentiate into non-mesenchymal cell types. MSCs can migrate to sites of injury, inflammation, and tumors where they secrete soluble factors that can alter the tissue microenvironment. As such, MSCs show promise as a candidate for regenerative medicine applications given their differentiation potential and immunomodulatory properties.
Macrophages are tissue-resident immune cells that differentiate from circulating monocytes. They perform important functions in innate and adaptive immunity such as phagocytosis of pathogens and cellular debris, antigen presentation, and secretion of inflammatory signals. Macrophages exist in different types defined by their activation mechanisms and secretory profiles, including classically activated M1 macrophages which promote inflammation and alternatively activated M2 macrophages which suppress inflammation. They play roles in tissue homeostasis, repair, and immune regulation through their phagocytic, secretory, and adaptive functions.
#INTRODUCTION OF PPIs
#EXAMPLE OF PPIs
#CLASSIFICATION OF PPIs
#IDENTIFICATION METHOD OF PPIs
#YEAST TWO HYBRID SYSTEM
#DATABASE OF PPIs
#APPLICATIONS OF PPIs
#FACTOR AFFECTING PPIs
The document discusses HLA typing and its implications. It begins with a brief history of the discovery of the major histocompatibility complex (MHC) in mice and humans. It then describes the structure and functions of the MHC, including the class I, class II, and class III regions. The document discusses methods of HLA typing, including serological testing using microcytotoxicity and molecular methods. It notes some implications of HLA typing, such as its role in organ transplant matching and susceptibility to autoimmune disease.
Webinar Series on Demystifying Phases in Clinical Trials & COVID-19 Updates organized by Institute for Clinical Research (ICR), NIH
Speaker: Dr. Alan Fong Yean Yip, Consultant Cardiologist & CRC head of Sarawak General Hospital and Mr. Chew Chun Keat, Technical Head of Centre for Clinical Trial, ICR
More information please visit: https://clinupcovid.mailerpage.com/resources/r0x8r9-webinar-series-on-demystifying-cl
This document discusses protein microarrays, which allow large numbers of proteins to be analyzed in parallel. Protein microarrays can be either analytical or functional. Analytical microarrays use capture molecules like antibodies to probe complex protein solutions like cell lysates. Functional microarrays immobilize purified proteins to study biochemical activities and interactions on a proteome-wide scale. Applications of protein microarrays include diagnostics, proteomics, analyzing protein functions and interactions, characterizing antibodies, and developing new treatments.
Bioinformatics is an interdisciplinary field that uses computer science and information technology to analyze and interpret biological data. It involves developing databases to store biological information and computational tools to analyze data. The key aims of bioinformatics are to store biological data in organized databases, develop tools to analyze the data, and use these tools to interpret results in a biologically meaningful way. It has applications in areas like genome sequencing and annotation, gene expression analysis, protein structure prediction, and understanding biological pathways and networks.
Fundamental of mesenchymal stem cells as a promising candidate in regenerativ...Tee Huat
Mesenchymal stem cells (MSCs) are multipotent stromal cells that reside in connective tissues throughout the body. They are capable of differentiating into multiple mesenchymal lineages including bone, cartilage, and adipose tissues. MSCs also possess the ability to transdifferentiate into non-mesenchymal cell types. MSCs can migrate to sites of injury, inflammation, and tumors where they secrete soluble factors that can alter the tissue microenvironment. As such, MSCs show promise as a candidate for regenerative medicine applications given their differentiation potential and immunomodulatory properties.
Macrophages are tissue-resident immune cells that differentiate from circulating monocytes. They perform important functions in innate and adaptive immunity such as phagocytosis of pathogens and cellular debris, antigen presentation, and secretion of inflammatory signals. Macrophages exist in different types defined by their activation mechanisms and secretory profiles, including classically activated M1 macrophages which promote inflammation and alternatively activated M2 macrophages which suppress inflammation. They play roles in tissue homeostasis, repair, and immune regulation through their phagocytic, secretory, and adaptive functions.
#INTRODUCTION OF PPIs
#EXAMPLE OF PPIs
#CLASSIFICATION OF PPIs
#IDENTIFICATION METHOD OF PPIs
#YEAST TWO HYBRID SYSTEM
#DATABASE OF PPIs
#APPLICATIONS OF PPIs
#FACTOR AFFECTING PPIs
Mesenchymal stem cells (MSCs) show potential in treating various orthopaedic conditions. MSCs can differentiate into bone, cartilage, and other tissues, helping repair fractures and cartilage/meniscus injuries. They also secrete factors that promote angiogenesis, regulate inflammation, and induce tissue regeneration through paracrine effects. Clinical studies show MSCs may effectively treat non-union fractures, osteoarthritis, and femoral head necrosis by differentiating into local tissues or secreting factors that aid repair. However, larger high-quality studies are still needed to confirm efficacy, especially for late-stage conditions.
This document provides information about the Early Clinical Experience (ECE) program including topics, commitments, tutorials, workshops, and site visits. It discusses listening to patients, history taking, hand washing, consent, and confidentiality. Site visits include hospital and primary health care center tours led by coordinators who instruct students and ensure attendance is recorded. Feedback aims to be constructive while completing portfolio requirements.
Advances in diagnostic technology allow for more sensitive, specific, rapid and cost-effective diagnosis of diseases. New methods like PCR, real-time PCR, in situ hybridization, biosensors, infrared thermography, and ELISA have improved on classical diagnostic approaches by being able to detect minute amounts of pathogens, identify pathogens rapidly, and differentiate between field strains and vaccine strains. These advanced diagnostic techniques are important for disease control, treatment, and surveillance.
In the era of modern technology, health care delivery system involves so many different personnel and specialties that the caregiver must have an understanding and working knowledge of other professional endeavors, including the role of diagnostic evaluation.
Basically, laboratory and diagnostic tests are tools by and of themselves, they are not therapeutic.
In conjunction with a pertinent history and physical examination, these tests can confirm a diagnosis or provide valuable information about a patient status and response to therapy.
In addition to these, laboratory findings are essential for epidemiological surveillance and research purposes.
If the entire network of a laboratory service is to be effectively utilized and contribute to health care and disease prevention, every member of its work force need to:
Understand the role of the laboratory and its contribution to the nation’s health service;
Appreciate the need to involve all members in the provision of health service;
Follow professional ethics and code of conduct;
Experience job satisfaction and have professional loyalty.
Medical laboratory science is a complex field embracing a number of different disciplines such as
Microbiology,
Hematology,
Clinical Chemistry,
Urinalysis,
Immunology,
Serology,
Histopathology,
Immunohematology and
Molecular biology and others
Humoral immunity is mediated by antibodies and functions to neutralize extracellular microbes and toxins. B-cells respond to and produce antibodies specific for many molecule types. When a B-cell encounters an antigen, it becomes activated and differentiates into a plasma cell that secretes antibodies of that specificity. T-cell help is required for effective antibody responses against protein antigens and drives affinity maturation and isotype switching.
Stem cell therapy in neurological diseasesNeurologyKota
This document discusses stem cell types and their potential applications for treating neurological diseases. It describes embryonic stem cells as pluripotent and able to differentiate into almost any cell type. Adult stem cells are multipotent and can only produce a limited range of cell types. Neural stem cells are discussed as a promising source for cell replacement therapies for conditions like Parkinson's disease. Challenges and limitations of stem cell therapies are also outlined.
The document discusses predictions for the future of laboratory medicine in 3 key areas:
1) Laboratory organization and staffing will consolidate into large regional centers and networks, with reduced numbers of laboratories and increased outsourcing. Staff will focus more on consultative services and quality control.
2) Automation and robotics will continue to increase to make laboratories more cost efficient, though they still have limitations, especially in specialized areas like microbiology.
3) Point-of-care testing is predicted to become more common, integrated into patient care, and allow for more home testing using portable devices. Genomics and proteomics are also expected to be the basis for many new diagnostic tests in the future.
This document discusses personalized medicine and how genetic variations between individuals can impact disease susceptibility and drug response. It provides examples of how single nucleotide polymorphisms can influence conditions like heart disease and impact drug metabolism pathways involving cytochrome P450 enzymes. The document also discusses challenges like implementing pharmacogenomic testing, ensuring privacy of genetic data, and determining appropriate coverage and costs of personalized medicine approaches.
Initially, interleukins were thought to be produced by leukocytes and act on other leukocytes, leading to their name. Interleukins stimulate immune cell growth and differentiation and activate effector mechanisms. They are cytokines secreted by activated immune cells like macrophages and lymphocytes. Interleukins modulate immune and inflammatory responses.
Biomarkers are substances or processes that can be objectively measured and evaluated as indicators of normal biological processes, pathogenic processes, or pharmacological responses to therapeutic interventions. Biomarkers can be used for various purposes like early disease diagnosis, assessing disease prognosis, predicting treatment responses, and monitoring treatment efficacy. Some key types of biomarkers include molecular biomarkers, imaging biomarkers, diagnostic biomarkers, and biomarkers used for disease staging or monitoring treatment response. Biomarkers play an important role in areas like cancer research and medicine, where they can be used for tasks such as risk assessment, diagnosis, prognosis, monitoring treatment response, and developing new drug targets.
Cell death, or apoptosis, is a tightly regulated process that is essential for development and tissue homeostasis. It occurs through two main pathways: the death receptor pathway and the mitochondrial pathway. The balance between pro-apoptotic and anti-apoptotic BCL-2 family proteins determines whether a cell undergoes apoptosis. Caspases are cysteine proteases that are either initiators or executioners of apoptosis. Impaired apoptosis can lead to diseases like cancer, autoimmunity, and neurodegeneration. Necrosis was traditionally thought to be unregulated cell death, but recent evidence shows some forms of necrosis can be programmed.
This document provides guidance for implementing the Stepwise Laboratory Improvement Process Towards Accreditation (SLIPTA) in the African region. It describes the background and need for the initiative due to weaknesses in public health laboratory systems. The purpose is to guide countries in strengthening laboratory quality management systems using the SLIPTA approach. Key elements covered include the origins of SLIPTA, governance structure, the audit process, criteria for enrollment, evaluation approach using a checklist, process for recognition of improvements, and operational procedures. The definitions section clarifies important terms related to standards, certification, accreditation and related oversight bodies.
It is a presentation showing the process of doing a prokaryotic genome annotation using RAST server. It is a basic work in bioinformatics field. Genome annotation is total genome analysis of an organism. We can easily do it using bioinformatics tool like RAST server.
This document provides an overview of quality assurance and quality control processes in a clinical laboratory setting. It discusses key definitions of quality and quality management. It distinguishes between quality assurance and quality control, describing quality control as measurement to check analytical data quality while quality assurance guarantees integrity of overall data. The document outlines quality control selection criteria and evaluation methods. It also covers documentation requirements for a quality management system including classification of internal documents, external documents, and records.
This document discusses methods for identifying protein-protein interactions, including the yeast two-hybrid system and co-immunoprecipitation. It provides details on how each technique works and describes an example application investigating interactions in B cell receptor signaling pathways. Key proteins in the B cell receptor pathway are identified that could be used as baits in future experiments.
The document discusses how the immune system changes with age. As people get older, their immune system responds more slowly, vaccines may be less effective, and healing is slowed. The ability to detect and repair cell damage declines as well. Aging leads to oxidative stress that damages proteins in dendritic cells, impairing their ability to activate the immune response. While aging of hematopoietic stem cells reduces lymphocyte production and shifts balance toward myeloid cells, the aging environment also contributes to declining immune function in elderly individuals. Various strategies to rejuvenate the thymus through hormones and growth factors have shown potential but require further evaluation.
Cancer stem cells (CSCs) are rare cancer cells that have properties similar to normal stem cells, allowing them to both self-renew and differentiate into the other cell types that make up a tumor. CSCs are thought to drive tumor growth and relapse after treatment. The first evidence of CSCs came from studies in 1997 that isolated a subpopulation of leukemia cells capable of initiating new tumors. Since then, CSCs have been identified in several other cancer types based on their ability to form tumors from very few cells in animal models. CSCs may explain why conventional cancer treatments fail to cure cancers by mainly targeting differentiated cells rather than the tumor-initiating CSCs.
Cell and tissue regeneration involves cell proliferation driven by growth factors and the development of mature cells from stem cells. There are three types of tissues based on their proliferative capacity: labile tissues which continuously divide, stable tissues which have limited proliferation, and permanent tissues which do not regenerate. Liver regeneration is remarkable, with up to 90% resection compensated by hepatocyte proliferation induced by cytokines and growth factors. When hepatocytes are impaired, liver progenitor cells contribute to repopulation.
Cell migration, a key property of live cells, is the process by which cells move from one location to another. There are numerous ways to study cell migrations. Creative Proteomics offers tailored cell migration services and powerful analysis for your research.
https://www.creative-proteomics.com/services/cell-migration-assay.htm
CLINICAL GOVERNANCE SYSTEMS - AS A TOOL FOR IMPROVING PATIENT SAFETY Ruby Med Plus
This essay explores how Clinical governance as a process is interpreted,
understood and practiced for improving the quality of patient care and Patient
safety.
Specific Objectives-
1. To give an overview of corporate governance and Clinical governance and
to focus on Definition, principles, need, components, key features and
benefits of Clinical governance.
2. To Understand the principles and Pre-requisites of Governance and
clinical governance.
3. To comprehend Power Culture, Quality Assurance, Clinical Audit, and
Clinical Governance.
4. To analyse decision making, safety culture, Integrated pathways,
informed consent, right clinical information, Acrediation and Clinical
Governance.
This document discusses clinical governance practices regarding primary percutaneous coronary intervention (PPCI) and direct admission of high-risk non-ST-segment elevation myocardial infarction (NSTEMI) patients. It outlines some recurrent issues like monitoring, medications, communication, and delays. It also describes opportunities to learn from past cases without blame. Meeting and feedback structures are in place between teams. Referral processes and decision making are important, and several case studies illustrate lessons learned from reviews of past patient transfers and treatments. Open communication between ambulance and hospital staff is encouraged.
Mesenchymal stem cells (MSCs) show potential in treating various orthopaedic conditions. MSCs can differentiate into bone, cartilage, and other tissues, helping repair fractures and cartilage/meniscus injuries. They also secrete factors that promote angiogenesis, regulate inflammation, and induce tissue regeneration through paracrine effects. Clinical studies show MSCs may effectively treat non-union fractures, osteoarthritis, and femoral head necrosis by differentiating into local tissues or secreting factors that aid repair. However, larger high-quality studies are still needed to confirm efficacy, especially for late-stage conditions.
This document provides information about the Early Clinical Experience (ECE) program including topics, commitments, tutorials, workshops, and site visits. It discusses listening to patients, history taking, hand washing, consent, and confidentiality. Site visits include hospital and primary health care center tours led by coordinators who instruct students and ensure attendance is recorded. Feedback aims to be constructive while completing portfolio requirements.
Advances in diagnostic technology allow for more sensitive, specific, rapid and cost-effective diagnosis of diseases. New methods like PCR, real-time PCR, in situ hybridization, biosensors, infrared thermography, and ELISA have improved on classical diagnostic approaches by being able to detect minute amounts of pathogens, identify pathogens rapidly, and differentiate between field strains and vaccine strains. These advanced diagnostic techniques are important for disease control, treatment, and surveillance.
In the era of modern technology, health care delivery system involves so many different personnel and specialties that the caregiver must have an understanding and working knowledge of other professional endeavors, including the role of diagnostic evaluation.
Basically, laboratory and diagnostic tests are tools by and of themselves, they are not therapeutic.
In conjunction with a pertinent history and physical examination, these tests can confirm a diagnosis or provide valuable information about a patient status and response to therapy.
In addition to these, laboratory findings are essential for epidemiological surveillance and research purposes.
If the entire network of a laboratory service is to be effectively utilized and contribute to health care and disease prevention, every member of its work force need to:
Understand the role of the laboratory and its contribution to the nation’s health service;
Appreciate the need to involve all members in the provision of health service;
Follow professional ethics and code of conduct;
Experience job satisfaction and have professional loyalty.
Medical laboratory science is a complex field embracing a number of different disciplines such as
Microbiology,
Hematology,
Clinical Chemistry,
Urinalysis,
Immunology,
Serology,
Histopathology,
Immunohematology and
Molecular biology and others
Humoral immunity is mediated by antibodies and functions to neutralize extracellular microbes and toxins. B-cells respond to and produce antibodies specific for many molecule types. When a B-cell encounters an antigen, it becomes activated and differentiates into a plasma cell that secretes antibodies of that specificity. T-cell help is required for effective antibody responses against protein antigens and drives affinity maturation and isotype switching.
Stem cell therapy in neurological diseasesNeurologyKota
This document discusses stem cell types and their potential applications for treating neurological diseases. It describes embryonic stem cells as pluripotent and able to differentiate into almost any cell type. Adult stem cells are multipotent and can only produce a limited range of cell types. Neural stem cells are discussed as a promising source for cell replacement therapies for conditions like Parkinson's disease. Challenges and limitations of stem cell therapies are also outlined.
The document discusses predictions for the future of laboratory medicine in 3 key areas:
1) Laboratory organization and staffing will consolidate into large regional centers and networks, with reduced numbers of laboratories and increased outsourcing. Staff will focus more on consultative services and quality control.
2) Automation and robotics will continue to increase to make laboratories more cost efficient, though they still have limitations, especially in specialized areas like microbiology.
3) Point-of-care testing is predicted to become more common, integrated into patient care, and allow for more home testing using portable devices. Genomics and proteomics are also expected to be the basis for many new diagnostic tests in the future.
This document discusses personalized medicine and how genetic variations between individuals can impact disease susceptibility and drug response. It provides examples of how single nucleotide polymorphisms can influence conditions like heart disease and impact drug metabolism pathways involving cytochrome P450 enzymes. The document also discusses challenges like implementing pharmacogenomic testing, ensuring privacy of genetic data, and determining appropriate coverage and costs of personalized medicine approaches.
Initially, interleukins were thought to be produced by leukocytes and act on other leukocytes, leading to their name. Interleukins stimulate immune cell growth and differentiation and activate effector mechanisms. They are cytokines secreted by activated immune cells like macrophages and lymphocytes. Interleukins modulate immune and inflammatory responses.
Biomarkers are substances or processes that can be objectively measured and evaluated as indicators of normal biological processes, pathogenic processes, or pharmacological responses to therapeutic interventions. Biomarkers can be used for various purposes like early disease diagnosis, assessing disease prognosis, predicting treatment responses, and monitoring treatment efficacy. Some key types of biomarkers include molecular biomarkers, imaging biomarkers, diagnostic biomarkers, and biomarkers used for disease staging or monitoring treatment response. Biomarkers play an important role in areas like cancer research and medicine, where they can be used for tasks such as risk assessment, diagnosis, prognosis, monitoring treatment response, and developing new drug targets.
Cell death, or apoptosis, is a tightly regulated process that is essential for development and tissue homeostasis. It occurs through two main pathways: the death receptor pathway and the mitochondrial pathway. The balance between pro-apoptotic and anti-apoptotic BCL-2 family proteins determines whether a cell undergoes apoptosis. Caspases are cysteine proteases that are either initiators or executioners of apoptosis. Impaired apoptosis can lead to diseases like cancer, autoimmunity, and neurodegeneration. Necrosis was traditionally thought to be unregulated cell death, but recent evidence shows some forms of necrosis can be programmed.
This document provides guidance for implementing the Stepwise Laboratory Improvement Process Towards Accreditation (SLIPTA) in the African region. It describes the background and need for the initiative due to weaknesses in public health laboratory systems. The purpose is to guide countries in strengthening laboratory quality management systems using the SLIPTA approach. Key elements covered include the origins of SLIPTA, governance structure, the audit process, criteria for enrollment, evaluation approach using a checklist, process for recognition of improvements, and operational procedures. The definitions section clarifies important terms related to standards, certification, accreditation and related oversight bodies.
It is a presentation showing the process of doing a prokaryotic genome annotation using RAST server. It is a basic work in bioinformatics field. Genome annotation is total genome analysis of an organism. We can easily do it using bioinformatics tool like RAST server.
This document provides an overview of quality assurance and quality control processes in a clinical laboratory setting. It discusses key definitions of quality and quality management. It distinguishes between quality assurance and quality control, describing quality control as measurement to check analytical data quality while quality assurance guarantees integrity of overall data. The document outlines quality control selection criteria and evaluation methods. It also covers documentation requirements for a quality management system including classification of internal documents, external documents, and records.
This document discusses methods for identifying protein-protein interactions, including the yeast two-hybrid system and co-immunoprecipitation. It provides details on how each technique works and describes an example application investigating interactions in B cell receptor signaling pathways. Key proteins in the B cell receptor pathway are identified that could be used as baits in future experiments.
The document discusses how the immune system changes with age. As people get older, their immune system responds more slowly, vaccines may be less effective, and healing is slowed. The ability to detect and repair cell damage declines as well. Aging leads to oxidative stress that damages proteins in dendritic cells, impairing their ability to activate the immune response. While aging of hematopoietic stem cells reduces lymphocyte production and shifts balance toward myeloid cells, the aging environment also contributes to declining immune function in elderly individuals. Various strategies to rejuvenate the thymus through hormones and growth factors have shown potential but require further evaluation.
Cancer stem cells (CSCs) are rare cancer cells that have properties similar to normal stem cells, allowing them to both self-renew and differentiate into the other cell types that make up a tumor. CSCs are thought to drive tumor growth and relapse after treatment. The first evidence of CSCs came from studies in 1997 that isolated a subpopulation of leukemia cells capable of initiating new tumors. Since then, CSCs have been identified in several other cancer types based on their ability to form tumors from very few cells in animal models. CSCs may explain why conventional cancer treatments fail to cure cancers by mainly targeting differentiated cells rather than the tumor-initiating CSCs.
Cell and tissue regeneration involves cell proliferation driven by growth factors and the development of mature cells from stem cells. There are three types of tissues based on their proliferative capacity: labile tissues which continuously divide, stable tissues which have limited proliferation, and permanent tissues which do not regenerate. Liver regeneration is remarkable, with up to 90% resection compensated by hepatocyte proliferation induced by cytokines and growth factors. When hepatocytes are impaired, liver progenitor cells contribute to repopulation.
Cell migration, a key property of live cells, is the process by which cells move from one location to another. There are numerous ways to study cell migrations. Creative Proteomics offers tailored cell migration services and powerful analysis for your research.
https://www.creative-proteomics.com/services/cell-migration-assay.htm
CLINICAL GOVERNANCE SYSTEMS - AS A TOOL FOR IMPROVING PATIENT SAFETY Ruby Med Plus
This essay explores how Clinical governance as a process is interpreted,
understood and practiced for improving the quality of patient care and Patient
safety.
Specific Objectives-
1. To give an overview of corporate governance and Clinical governance and
to focus on Definition, principles, need, components, key features and
benefits of Clinical governance.
2. To Understand the principles and Pre-requisites of Governance and
clinical governance.
3. To comprehend Power Culture, Quality Assurance, Clinical Audit, and
Clinical Governance.
4. To analyse decision making, safety culture, Integrated pathways,
informed consent, right clinical information, Acrediation and Clinical
Governance.
This document discusses clinical governance practices regarding primary percutaneous coronary intervention (PPCI) and direct admission of high-risk non-ST-segment elevation myocardial infarction (NSTEMI) patients. It outlines some recurrent issues like monitoring, medications, communication, and delays. It also describes opportunities to learn from past cases without blame. Meeting and feedback structures are in place between teams. Referral processes and decision making are important, and several case studies illustrate lessons learned from reviews of past patient transfers and treatments. Open communication between ambulance and hospital staff is encouraged.
Automated analyzers have advanced diagnostic testing by increasing efficiency and accuracy while reducing human error. There are four basic approaches to automated analyzers: continuous flow analyzers, centrifugal analyzers, discrete auto analyzers, and dry chemical analyzers. Each type has its own principles and advantages such as processing multiple samples simultaneously, using small sample volumes, and eliminating manual steps. Automated analyzers have improved healthcare by providing faster, higher quality, and more standardized test results.
This document provides an overview of an evidence-based medicine (EBM) curriculum consisting of 3 modules: 1) Introduction to EBM, 2) Applying EBM to diagnosis, and 3) Applying EBM to treatment. It was prepared by faculty at Emory University School of Medicine and discusses the history and importance of EBM, how to formulate clinical questions and find the best evidence to answer them, and how to critically appraise and apply evidence to patient care.
The document describes the organizational divisions and sections within a clinical laboratory. It outlines the departments of pathology, including anatomical pathology, cytology, histology, cytogenetics, and clinical pathology. The clinical pathology department contains sections for hematology, chemistry, blood bank, serology, microbiology, and urinalysis. Each section is described in terms of its functions, common tests performed, and specimen requirements. The document also discusses laboratory personnel roles and requirements.
This document discusses a new drug development paradigm (NDDP) that aims to improve the efficiency and effectiveness of clinical drug development. It outlines several proposals that call for reforming the current drug development model, including using more modeling, adaptive trial designs, and integrating clinical trials into healthcare delivery systems. The NDDP proposes a more flexible framework with early patient/payer engagement, exploratory and confirmatory research phases using modern trial designs, and post-approval studies to establish relative value. Challenges for industry include conducting large simple trials, partnering to support more efficient trials, and having a clear evidentiary strategy tailored to different drug archetypes.
This document discusses the evaluation and regulation of biomarkers from a public health perspective. It makes the following key points:
1. New technologies have led to an unprecedented rate of development of new medical tests and biomarkers, but they require rigorous evaluation of their clinical validity and utility.
2. Existing regulatory frameworks focus mainly on analytical validity and safety, but commissioners need evidence of clinical effectiveness and improved outcomes before reimbursing tests.
3. A new body should be established to systematically evaluate diagnostic tests using frameworks like ACCE (analytical validity, clinical validity, clinical utility, ethical considerations).
4. While assays measure biomarkers, tests interpret those measurements for specific clinical purposes. Each test requires independent evaluation of performance
Novel Approaches to Clinical Trial Design and Implementationijtsrd
This document discusses novel approaches to clinical trial design and implementation, including adaptive designs, Bayesian techniques, and master protocol designs (basket and umbrella designs).
Adaptive designs allow modifications to trials after initiation without compromising validity. Bayesian techniques incorporate prior data to improve precision. Master protocol designs evaluate multiple drugs/diseases within one trial structure (basket evaluates one drug in multiple diseases; umbrella evaluates multiple drugs in one disease).
The document outlines advantages like accelerated development and reduced costs, and disadvantages like complexity. Overall, novel approaches can make trials more efficient while maintaining scientific integrity.
The document proposes a novel structure called a Patient-Centered Research Management Group (PCRMG) that would specialize in comparative effectiveness research. Key aspects are that it would incorporate significant patient input into study design and would facilitate collaboration between healthcare systems, pharmaceutical companies, patients, and other stakeholders. The goal is for research to better represent real-world clinical practice and patient preferences. Some benefits mentioned include exploring off-label drug uses, targeting medicines based on patient profiles, increased data sharing, and lower study costs. Pharmaceutical company involvement is argued to help develop personalized medicine and target drug development based on patient priorities.
The document discusses evidence-based nursing practice. It defines evidence-based practice as integrating the best research evidence, clinical expertise, and patient values and needs. The key steps in evidence-based practice are asking questions, acquiring evidence, appraising the evidence, applying it to a patient, and evaluating outcomes. Barriers to evidence-based nursing include lack of time and resources, as well as difficulties interpreting and applying research. Facilitators include administrative support and accessible, clearly written research. Maximizing evidence-based nursing requires overcoming barriers, incorporating different types of evidence, and accounting for issues beyond measurement like patient preferences.
This document discusses evidence-based surgery and how surgeons evaluate the strength of evidence for surgical practices. It covers:
1) Guidelines and secondary sources that surgeons can use to inform evidence-based practice, but notes individual surgeons must also evaluate primary studies.
2) Factors used to evaluate the validity of scientific studies, including internal validity (study quality), external validity (generalizability), and the influence of chance, bias, and confounding.
3) Hierarchies of evidence that rank study designs, with randomized controlled trials considered the strongest, but these systems have limitations and surgeons must make judgments.
Wallach interpretation of diagnostic tests 7th ed 2000mohanad samara
This document provides the preface and table of contents for the 7th edition of the book "Interpretation of Diagnostic Tests" published in 2000. The preface discusses the extensive updates made to this edition, including new laboratory technologies and tests added. It aims to organize information concisely and practically to help clinicians efficiently select and interpret useful diagnostic tests. The table of contents outlines the book's organization into sections on normal values, specific laboratory examinations, diseases of organ systems, and appendices.
The document discusses evidence-based medicine (EBM) and its role in healthcare decision making. Some key points:
- EBM involves systematically reviewing and appraising clinical research to determine the most effective treatments.
- Decisions about healthcare provision and resources are increasingly driven by evidence on clinical effectiveness and outcomes.
- Multiple sources of evidence are evaluated to establish levels of evidence, with randomized controlled trials considered the gold standard.
- Systematic reviews and meta-analyses that synthesize data from multiple studies can provide more precise estimates of treatment effects.
- EBM informs guidelines and policies at strategic, tactical and individual levels to encourage use of proven effective practices.
This document provides an agenda and overview from a conference on generating evidence and assessing the value of stratified medicines and diagnostic tests. The summary includes:
1. The conference discussed elements of value for diagnostic tests, including reducing adverse drug effects and uncertainty about treatment value.
2. Institutional arrangements for assessing diagnostic value were examined, including joint drug-diagnostic assessments and diagnostic-specific processes.
3. Generating evidence to link diagnostics to patient value and incentivizing uptake were areas of focus, with examples provided.
This document discusses the rise of evidence-based health care over the last decade. Key points:
- Evidence-based health care aims to minimize problems like overuse, underuse and misuse of treatments by basing clinical practice closely on scientific research evidence.
- During the 1990s, the concepts of evidence-based health care spread widely and began influencing health policymakers, providers and researchers.
- Advances have been made in managing and disseminating research findings through initiatives like the Cochrane Collaboration and clinical practice guidelines.
- However, integrating research evidence into everyday clinical practice remains a challenge and some critics argue evidence-based practice could stifle innovation.
This document discusses using real world data from healthcare databases to support adaptive biomedical innovation. It outlines four key principles - meaningful, valid, expedited, and transparent evidence (MVET) - that are necessary to generate evidence from healthcare databases that is fit for decision making. Meaningful evidence requires using relevant and high quality data sources to answer the research question. Evidence should be generated and shared in a transparent manner while protecting patient privacy. Following MVET principles can help produce rigorous evidence from real world data to support faster access to new medications through adaptive pathways, while maintaining evidentiary standards.
College Writing II Synthesis Essay Assignment Summer Semester 2017.docxclarebernice
College Writing II Synthesis Essay Assignment Summer Semester 2017
Directions:
For this assignment you will be writing a synthesis essay. A synthesis is a combination of two or more summaries and sources. In a synthesis essay you will have three paragraphs, an introduction, a synthesis and a conclusion.
In the introduction you will give background information about your topic. You will also include a thesis statement at the end of the introduction paragraph. The thesis statement should describe the goal of your synthesis. (informative or argumentative)
The second paragraph is the synthesis. You will combine two summaries of two different articles on the same topic. You will follow all summary guidelines for these two paragraphs. The synthesis will most likely either argue or inform the reader about the topic.
The conclusion paragraph should summarize the points of your essay and restate the general ideas.
For this essay you will read two research articles on a similar topic to the previous critical review essay as you can use this research in your inquiry paper. You will summarize both articles in two paragraphs and combine the paragraphs for your synthesis. In the synthesis you must include the main ideas of the articles and the author, title, and general idea in the first sentences.
This essay will be three pages long and the first draft and peer review are due June 15. You must turn them in hardcopy in class so you can do a peer review.
Running head: THESIS DRAFT 1
THESIS DRAFT 3Thesis Draft
Katelyn B. Rhodes
D40375299
DeVry University
Point-of-Care Testing (PoCT) has dramatically taken over the field of clinical laboratory testing since it’s introduction approximately 45 years ago. The technologies utilized in PoCT have been refined to deliver accurate and expedient test results and will become even more sensitive and accurate in order to dominate the field of clinical laboratory testing. Furthermore, there will be a dramatic increase in the volume of clinical testing performed outside of the laboratory. New and emerging PoCT technologies utilize sophisticated molecular techniques such as polymerase chain reaction to aid in the treatment of major health problems worldwide, such as sexually transmitted infections (John & Price, 2014).
Historic Timeline
In the early-to-mid 1990’s, bench top analyzers entered the clinical laboratory scene. These analyzers were much smaller than the conventional analyzers being used, and utilized touch-screen PCs for ease of use. For this reason, they were able to be used closer to the patient’s bedside or outside of the laboratory environment. However, at this point in time, laboratory testing results were stored within the device and would have to then be sent to the main central laboratory for analysis.
Technology in the mid-to-late 1990’s permitted analyzers to be much smaller so that they may be easily carried to the patient’s location. Computers also became more ...
This document discusses evidence-based medicine (EBM), including its definition, history, classifications of evidence, and criticisms. EBM aims to apply scientific methods and best evidence from research to medical practice. While randomized controlled trials are considered the gold standard, critics note limitations like ethical issues conducting some trials, lack of diversity in research, and potential for bias from funding sources influencing results. The document advocates for conducting rigorous randomized trials, being transparent about funding sources and roles, and using systematic reviews and meta-analyses to help address biases.
This document discusses evidence-based periodontology and decision making. It defines evidence-based periodontology as applying evidence-based healthcare to periodontology by integrating the best available evidence with clinical practice. The document outlines the steps of evidence-based periodontology, including asking questions using the PICO format, searching for and appraising evidence from systematic reviews and clinical practice guidelines, and applying the evidence to clinical decisions. It also discusses tools for critically assessing evidence, such as considering different levels of evidence and ensuring temporality between causes and effects.
Chapter 4 Knowledge Discovery, Data Mining, and Practice-Based Evi.docxchristinemaritza
Chapter 4 Knowledge Discovery, Data Mining, and Practice-Based Evidence
Mollie R. Cummins
Ginette A. Pepper
Susan D. Horn
The next step to comparative effectiveness research is to conduct more prospective large-scale observational cohort studies with the rigor described here for knowledge discovery and data mining (KDDM) and practice-based evidence (PBE) studies.
Objectives
At the completion of this chapter the reader will be prepared to:
1.Define the goals and processes employed in knowledge discovery and data mining (KDDM) and practice-based evidence (PBE) designs
2.Analyze the strengths and weaknesses of observational designs in general and of KDDM and PBE specifically
3.Identify the roles and activities of the informatics specialist in KDDM and PBE in healthcare environments
Key Terms
Comparative effectiveness research, 69
Confusion matrix, 62
Data mining, 61
Knowledge discovery and data mining (KDDM), 56
Machine learning, 56
Natural language processing (NLP), 58
Practice-based evidence (PBE), 56
Preprocessing, 56
Abstract
The advent of the electronic health record (EHR) and other large electronic datasets has revolutionized efficient access to comprehensive data across large numbers of patients and the concomitant capacity to detect subtle patterns in these data even with missing or less than optimal data quality. This chapter introduces two approaches to knowledge building from clinical data: (1) knowledge discovery and data mining (KDDM) and (2) practice-based evidence (PBE). The use of machine learning methods in retrospective analysis of routinely collected clinical data characterizes KDDM. KDDM enables us to efficiently and effectively analyze large amounts of data and develop clinical knowledge models for decision support. PBE integrates health information technology (health IT) products with cohort identification, prospective data collection, and extensive front-line clinician and patient input for comparative effectiveness research. PBE can uncover best practices and combinations of treatments for specific types of patients while achieving many of the presumed advantages of randomized controlled trials (RCTs).
Introduction
Leaders need to foster a shared learning culture for improving healthcare. This extends beyond the local department or institution to a value for creating generalizable knowledge to improve care worldwide. Sound, rigorous methods are needed by researchers and health professionals to create this knowledge and address practical questions about risks, benefits, and costs of interventions as they occur in actual clinical practice. Typical questions are as follows:
•Are treatments used in daily practice associated with intended outcomes?
•Can we predict adverse events in time to prevent or ameliorate them?
•What treatments work best for which patients?
•With limited financial resources, what are the best interventions to use for specific types of patients?
•What types of indi ...
This document discusses systematic reviews and their usefulness for busy dental practitioners. It introduces the problem of information overload for clinicians trying to stay up to date. Systematic reviews provide a solution by synthesizing large amounts of research into concise summaries. The key features that make systematic reviews reliable include having a clearly defined clinical question, conducting a comprehensive search for relevant studies, using explicit criteria to include/exclude studies, assessing study validity, analyzing inconsistencies, appropriately combining findings, and conclusions supported by evidence. Systematic reviews offer clinicians summaries of the best available evidence to inform patient care decisions.
This document defines evidence-based medicine (EBM) and outlines its key aspects. EBM involves integrating the best available research evidence with clinical expertise and patient values. It teaches physicians to apply clinical and epidemiological research studies to patient care. EBM aims to make individual decision making more objective and evidence-based. Pharmacists can play an important role in EBM by facilitating systematic reviews, interpreting research findings, developing guidelines, and transferring evidence-based information to clinicians and patients.
This document summarizes new concepts in hemostasis, which is the process of blood clotting and wound healing. It discusses three phases of coagulation - initiation, amplification, and propagation. The initiation phase begins when tissue factor is exposed by damaged blood vessels, forming a complex with factor VIIa that activates small amounts of factors IX and X. This generates low levels of thrombin, starting the amplification phase where feedback loops dramatically increase coagulation factor activity through activation of factors V and VIII. High levels of thrombin then propagate fibrin clot formation. The document also reviews platelet activation and interactions with endothelial cells that regulate thrombus formation and coagulation.
Hougie 2004-journal of-thrombosis_and_haemostasisLAB IDEA
The document provides historical context on the development of the cascade/waterfall hypothesis of blood coagulation. It discusses the landmark 1964 papers by Macfarlane and Davie & Ratnoff that independently proposed the cascade model. Macfarlane described coagulation as a "cascade" and "photochemical amplifier", while Davie & Ratnoff termed it the "waterfall" concept. Both proposed coagulation occurs through a series of enzymatic reactions between clotting factors. The collaboration between clinical researcher Ratnoff and biochemist Davie led to the influential "waterfall" paper.
El documento resume el sistema de coagulación, incluyendo la hemostasia secundaria, los componentes como plaquetas y factores de coagulación, y los mecanismos como la cascada de coagulación. También describe la regulación de la hemostasia a través de sistemas anticoagulantes como la antitrombina III y la proteína C, y la evaluación por laboratorio incluyendo pruebas como el tiempo de sangrado, recuento de plaquetas, y tiempos de protrombina y tromboplastina parcial activada.
Este documento resume información sobre parasitosis intestinales. Explica que los parásitos intestinales incluyen protozoos, helmintos y pueden causar cuadros clínicos variables, desde infecciones asintomáticas hasta afectar uno o más órganos. Describe en detalle la amibiasis intestinal causada por Entamoeba histolytica, incluyendo su ciclo de vida, manifestaciones clínicas, diagnóstico y tratamiento. También menciona brevemente la balantidiasis.
CLASE ASCITIS
DR. RAUL CARRILLO ORTIZ
MODULO MEDICINA INTERNA
ROTACIÓN PATOLOGÍA CLÍNICA
DEPARTAMENTO DE MEDICINA Y NUTRICIÓN
UNIVERSIDAD DE GUANAJUATO
Las enfermedades musculares esqueléticas incluyen una variedad de condiciones que causan debilidad muscular. El diagnóstico adecuado requiere historia clínica, marcadores musculares como enzimas y proteínas, electromiografía y biopsia muscular para diferenciar alteraciones musculares de las neurológicas. Existen diferentes mecanismos fisiopatológicos involucrados como fenómenos autoinmunes, y condiciones pueden ser congénitas o adquiridas. El laboratorio juega un papel importante en el
Este documento describe la enfermedad hepática grasa no alcohólica (EHGNA), también conocida como esteatosis hepática. Define la EHGNA como la acumulación de grasa en el hígado en ausencia de consumo excesivo de alcohol. Explica que la EHGNA puede evolucionar a esteatohepatitis no alcohólica, cirrosis y hepatocarcinoma si no se corrigen los factores de riesgo subyacentes. Finalmente, discute las opciones de tratamiento, que incluyen cambios en el estilo de
Historical perspective and future direction of coagulation researchLAB IDEA
This document provides a historical perspective on the advances made in coagulation research over the past 100 years. Remarkable progress has been achieved, starting from early clinical observations of rare bleeding disorders to current understanding involving complex reaction pathways. Key developments include the discovery of coagulation factors and inhibitors through study of patient plasma, development of laboratory tests enabling factor assays, and evolving cascade models incorporating new knowledge. Recent technologies like gene targeting and stem cells promise further insights. Close collaboration between basic scientists and clinicians has been important to research progress and clinical applications. Future areas may include gene and cell-based therapies building on past successes translating basic research into improved patient care.
Lipoprotein (a) [Lp(a)] levels are strongly associated with cardiovascular disease risk. Lp(a) consists of an LDL-like particle bound to apolipoprotein(a) [apo(a)]. Apo(a) is produced in the liver and its production rate is the main determinant of plasma Lp(a) levels. Recent studies show that ligands of the farnesoid X receptor can significantly lower Lp(a) levels by inhibiting apo(a) transcription. While lowering Lp(a) may reduce cardiovascular risk, consensus reports have been cautious about routinely measuring Lp(a) due to lack of intervention studies demonstrating that lowering Lp(a) reduces hard endpoints and lack of effective medications to lower Lp(
This document summarizes the pathophysiology, diagnosis, and management of metabolic acidosis. It describes how metabolic acidosis is characterized by a reduction in serum bicarbonate and secondary decreases in arterial carbon dioxide partial pressure and blood pH. Acute metabolic acidosis lasting minutes to days is more common and often due to organic acid overproduction, while chronic metabolic acidosis lasting weeks to years usually reflects bicarbonate wasting or impaired renal acidification. Diagnosing the cause involves calculating the serum anion gap to classify disorders as normal or elevated. Adverse effects differ between acute and chronic forms. Treatment of acute metabolic acidosis with base administration is controversial due to lack of benefit and potential complications, while chronic metabolic acidosis treatment
El documento describe la alcalosis metabólica. Explica que es un trastorno metabólico frecuente en pacientes hospitalizados que causa un aumento de los niveles de bicarbonato en la sangre. Las causas incluyen la infusión de bicarbonato, pérdidas gástricas o renales de ácidos, y el uso de diuréticos. El tratamiento se enfoca en corregir la causa subyacente, restaurar los niveles de cloro y tratar las complicaciones como la hipopotasemia.
El documento describe los tres sistemas principales que regulan la concentración de iones de hidrógeno (H+) en el cuerpo: 1) los sistemas amortiguadores químicos de los líquidos orgánicos, 2) el centro respiratorio, y 3) los riñones. Los sistemas amortiguadores químicos reaccionan en segundos, el aparato respiratorio actúa en minutos, y los riñones tienen la respuesta más lenta en horas o días. Los riñones juegan un papel clave al secretar iones de hid
El documento resume los conceptos clave de acidosis y alcalosis, incluyendo las definiciones de acidosis y alcalosis, las causas de acidosis metabólica, y formulas y medidas utilizadas para evaluar trastornos del equilibrio ácido-base como el anión gap, gap osmolal urinario y brecha delta.
La lesión renal aguda (LRA) se define como la pérdida rápida de la función renal dentro de las 48 horas, lo que resulta en la retención de desechos en la sangre como la creatinina y la urea. La LRA puede ser prerrenal, causada por una perfusión renal inadecuada; intrínseca, causada por daño al riñón; u obstructiva posrenal, causada por una obstrucción del tracto urinario. El diagnóstico incluye exámenes clínicos y de laboratorio como la medición de creatin
El documento resume varios artículos y libros sobre lesión aguda renal, incluyendo Waikar S.S., Bonventre J.V. (2016) que discute la lesión aguda renal en el libro Harrison. Principios de Medicina Interna, 19e. También se mencionan artículos de Kidney International Supplements (2012) y Lancet (2012) que tratan sobre este tema.
TRASTORNOS DE LA COAGULACION EN HEPATOPATIASLAB IDEA
Este documento describe los trastornos de la coagulación que pueden ocurrir en pacientes con enfermedad hepática, incluyendo alteraciones plaquetarias, disminución en la síntesis de factores de coagulación, disfibrinogenemia e hiperfibrinólisis. Explica que estos trastornos ocurren cuando los niveles plasmáticos de los factores de coagulación están por debajo del 30-40% de los niveles normales. Finalmente, resume los tratamientos utilizados para corregir estos trastornos, como
El documento describe la hepatitis B, un virus que causa inflamación del hígado. El virus de la hepatitis B es un DNA envuelto que puede causar infección aguda o crónica. La transmisión ocurre principalmente a través del contacto con sangre o fluidos corporales. La infección aguda generalmente se resuelve espontáneamente, mientras que la infección crónica puede conducir a cirrosis o cáncer de hígado. El diagnóstico se realiza mediante pruebas serológicas y la carga viral. No existe un tratamiento
Fasting is not routinely required for determination of a lipid profileLAB IDEA
This document provides a joint consensus statement from the European Atherosclerosis Society and European Federation of Clinical Chemistry and Laboratory Medicine regarding fasting vs. non-fasting lipid profiles. It finds that observational data indicate maximal mean changes after meals are small and not clinically significant. It recommends the routine use of non-fasting lipid profiles to improve patient compliance, while fasting may be considered if non-fasting triglycerides are over 5 mmol/L. Abnormal non-fasting concentrations that should be flagged are outlined.
La trombocitopenia idiopática es un trastorno caracterizado por la producción de autoanticuerpos contra las plaquetas. Puede presentarse en niños de 2 a 4 años después de infecciones respiratorias o en adultos, especialmente mujeres entre 15 y 40 años. Los síntomas incluyen petequias, equimosis y sangrado de las encías. El tratamiento incluye corticoesteroides, inmunoglobulina o esplenectomía.
Adhd Medication Shortage Uk - trinexpharmacy.comreignlana06
The UK is currently facing a Adhd Medication Shortage Uk, which has left many patients and their families grappling with uncertainty and frustration. ADHD, or Attention Deficit Hyperactivity Disorder, is a chronic condition that requires consistent medication to manage effectively. This shortage has highlighted the critical role these medications play in the daily lives of those affected by ADHD. Contact : +1 (747) 209 – 3649 E-mail : sales@trinexpharmacy.com
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by...Donc Test
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Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
2. 1042 Price: Evidence-based Laboratory Medicine
diagnostic tests we know that early intervention improves overall patient
It has always been recognized that the use of a diagnostic outcome.
test is an intervention (13 ). A diagnostic test should be
requested only when a question is being posed and when health technology assessment
there is evidence that the result will provide an answer to Health technology assessment is a tool that examines
the question. There are several reasons why a physician systematically the consequences of the application of
will order a diagnostic test (14 ); however, the nature of health technology to support decision-making in policy
the question being asked and the decision to be made and practice. Technology encompasses drugs, devices,
often will depend on the clinical setting in which the and procedures together with the organizational and
patient is found. support systems, therefore including diagnostic tests and
differing modalities of delivery. However, the assessment
outcomes research focuses on the way in which the test or device is used
Outcomes research, an important facet of evidence-based rather than on whether it “works”; the latter is assumed
laboratory medicine, has been the subject of debate and is the remit of another evaluation process (e.g., the
(13, 15, 16 ) over the past three decades. An outcome can Medical Devices Agency in the United Kingdom). The key
be defined as the result of an intervention and may be a principles of health technology assessment are outlined in
health outcome or an economic outcome (17, 18 ). This Table 1.
definition of an outcome may, in light of the limited Health technology assessment can be seen as the means
perception of the contribution made by a diagnostic test by which evidence is developed to support decision-
(11 ), be a contributing factor to the paucity of good making, and it embraces much of the discipline of health
evidence on the effectiveness or benefit of diagnostic services related or applied research. It may require origi-
procedures in laboratory medicine. nal or primary research on the one hand, or a systematic
The expectations for outcomes may be different for review of established literature.
healthcare providers and patients (16 ). The patient is
Context of the Evidence-based Culture
interested in receiving prompt and effective treatment,
There are several reasons advanced for the development
the relief of symptoms, and improvement in the quality of
of a more evidence-based culture in medicine and the
life. The service provider will also focus on the delivery of
increasing commitment to outcomes research and health
effective care, with the promptness of delivery varying
technology assessment. Not surprisingly these reflect the
between different countries but within the framework of
demands made on healthcare systems today (22 ), includ-
optimum use of resources and minimization of long-term
ing some of the pressures listed in Table 2. All of these
costs. Recognizing that any outcome will be a cascade of
pressures translate into a common currency of cost pres-
many synergistic decisions and actions, it may be more
sures. It is worth exploring some of these pressures in a
appropriate to focus greater attention on the use of little more detail, focusing on issues related to implemen-
diagnostic tests in the individual elements of the decision- tation of new technology, decision-making, quality, and
making process. This may help to tease out the key cost.
constraints to delivering the desired patient outcomes There is no doubt that healthcare professionals are
while highlighting the value of the diagnostic test. In a expected to deal with an increasing burden of knowledge
recent editorial, Scott (19 ) stressed the importance of as well as having access to increasing amounts of new
identifying a measurable outcome linked with the diag- technology, both diagnostics and interventions. Earlier
nostic procedure in question [point-of-care testing (POCT) commentators have pointed to the numbers of scientific
in this case] (20 ). journals published each year and the limited time given to
decision-making
Thus, the outcome of a diagnostic test can be considered Table 1. Key principles of health technology assessment.
as any part of the decision-making process that leads to an Partnership Recognize needs of purchasers,
improved outcome. This approach was first described by providers, and practitioners
Fryback and Thornbury (21 ), who set out the elements of Scientific credibility Must meet high scientific
standards
clinical decision-making in relation to the efficacy of
Independence Free from influence of
diagnostic tests. Thus, in terms of clinical benefit a test stakeholders
may improve the diagnostic process and/or the therapeu- Accountability Ultimately to the patient
tic strategy, and thus the overall health outcome. The Responsiveness To perceived needs in a timely
outcome of a diagnostic test may be an operational or an manner
economic benefit. Thus, in the example of the patient with Effectiveness Audit to ensure process is
chest pain, the first “questions” or decisions to be made effective
Visibility Transparent to all parties
relate to the recognition of cardiac pain and the urgency
Accessibility Available to all parties
for referral. These early decisions are appropriate because
3. Clinical Chemistry 46, No. 8, 2000 1043
demonstrating the central role of good evidence in deci-
Table 2. Major pressures on healthcare systems that lead
sion-making (33 ).
to the demand for an evidence-based approach to practice.
Increased innovation New technologies
How to Practice
Greater knowledge New treatments, diagnostics,
and rationales Practicing evidence-based laboratory medicine has four
Population changes Aging population, social dimensions: (a) identification of the question; (b) critical
changes assessment of the best evidence available, embodying the
Increasing workload More patient visits, more principles of health technology assessment; (c) implemen-
complex testing tation of best practice; and (d) maintaining best practice;
Increasing spending Salary costs, drug costs the latter embodies the principles of clinical audit (34 ).
Patient expectation Greater knowledge (e.g., This is summarized in Fig. 1, which illustrates this as
from the Internet), greater
litigation being a continuous process. There are many publications
that provide guidelines on evaluation of the effectiveness
of interventions (35, 36 ), although there are few that deal
specifically with diagnostic tests. However, guidelines for
updating of knowledge (23 ). One of the strongest argu-
the systematic review of diagnostic tests help by provid-
ments for maintaining a health technology assessment
ing information on the critical appraisal of evidence
program is the recognition that the process of evaluation (37– 40 ).
and implementation of new technology is cumbersome,
with long delays between clinical effectiveness being define the question
established and adoption into routine practice (24 ). There The starting point is the identification of the clinical
are examples in the literature, e.g., the implementation of question that is being asked; the ability, with the aid of the
thrombolytic therapy (25 ), that also demonstrate the test result, to make a decision is therefore the outcome.
importance of maintaining a continuous awareness of There are many examples to illustrate this point, but it is
developments in the field to avoid unnecessary delays in not always recognized that a test can be used to make a
the implementation of an effective new technology. It “rule in” or “rule out” decision. Much of the literature in
might also be argued that a lack of awareness of current laboratory medicine has focused on “rule in” decisions,
literature leads to wastage of resources on additional but “rule out” can often be an important step in a
evaluation projects when the answer is known. There are decision-making cascade. Silverstein and Boland (41 )
also examples in the literature where a new technology have suggested that when medical care costs are ana-
has been implemented (“technology creep”) and subse- lyzed, the focus is directed to “high cost decisions”; they
quently considered to be ineffective or to lead to unnec- give the example of the decision to admit a patient. This
essary interventions (26 ). may be a decision faced regularly by the primary care
Quality in clinical practice has risen on the political physician and may be addressed through a “rule in” or
agenda (22, 27 ), and the evidence-based culture has be- “rule out” question, depending on the actual diagnostic
gun to play a greater role in policy-making on a global performance of the test. However, few diagnostic tests
scale (28 ). The practical implications of the quality agenda have been evaluated for the effectiveness in a “rule out”
have been a stronger focus on training and assessment of decision strategy. Examples where this approach has been
competence (29 ), on continuing education for mainte- proposed include urine testing for leukocyte esterase and
nance of competence (30 ), and the introduction of clinical nitrite, which can be effective in “ruling out” urinary tract
guidelines (31 ). infection but not “ruling in”; such a test can then be used
The rising cost of healthcare is also a topic high on the
agenda of many governments and which is thought to
contribute to the reduction in the number of hospital beds
and the downsizing of laboratories (22, 32 ). It is also
undoubtedly a stimulus for the literature on the appro-
priateness of laboratory testing and the demands for
proper evaluation of new technology as a prerequisite for
introduction into the healthcare system. However, it is
also true that resource management is a major problem in
the overall context of healthcare delivery, with little
evidence that value for money plays a part in determining
the investment in laboratory medicine for a given patient
episode or disease state. For example, an examination of
the economic impact of introducing a molecular-based
test for Chlamydia and the influence on disease prevalence
illustrates the complexity of resource allocation while Fig. 1. The elements of evidence-based laboratory medicine.
4. 1044 Price: Evidence-based Laboratory Medicine
to determine what samples are sent to a central laboratory diagnostic performance
for culture—with important operational and economic Diagnostic performance provides an assessment of the
implications (42 ). Similarly it has been suggested that test in terms of the objective for using the test, namely the
myoglobin could be used to “rule out” myocardial infarc- sensitivity, which defines the proportion of people who
tion, but not to “rule in” (43 ); in the past myoglobin has are correctly identified by the test as having the disease,
not been considered a useful marker of myocardial dam- and the specificity, which defines the proportion of peo-
age because of its lack of tissue specificity. This also ple who are correctly identified by the test as not having
illustrates the point that scientific reasoning may not the disease. Although these are parameters of any test
always yield the correct interpretation in relation to irrespective of the population on which the test is used,
clinical outcome—a point illustrated in the case of thera- the significance of the test is also determined by the
peutic interventions (44 ). The clear identification of a prevalence of the condition in the population being stud-
question can be particularly important when comparing ied. It has been suggested by Irwig et al. (38 ) and Moore
the potential of a new test. Thus, the fact that serum (23 ) that the likelihood ratio combined with the pretest
cystatin C demonstrates a correlation with a reference probability is a clearer way of identifying post test prob-
clearance test superior to that of serum creatinine in itself ability and thereby integrating the relevant information
does not prove that the test will offer a clinical benefit into a clinical decisions pathway. Batstone (47 ) has sug-
(45 ). gested that the number needed to diagnose (NND), de-
rived from 1/[sensitivity (1 specificity)], provides a
hierarchy of evidence useful comparison between tests and helps to encompass
Evidence on the performance of a diagnostic test can be the financial implications in decision-making.
considered in a hierarchy, all of the elements of which are
important to making a decision (Fig. 2). This approach clinical benefit
was first proposed for a diagnostic test by Fryback and However, it is the clinical impact or benefit of the test and
Thornbury (21 ) and applied to diagnostic radiology (41 ). the contribution to decision-making that provide the
greatest challenge; the majority of evidence available in
technical performance the literature on the use of diagnostic tests deals with
The foundation of any evidence is technical performance, technical and diagnostic performance. For example,
and this can have an important bearing on diagnostic Hobbs et al. (48 ), in a systematic review on POCT in
performance. In addition to precision, accuracy, analytical general practice (primary care), found that few papers
range, and interferences, other pre-analytical factors such addressed clinical impact, the majority focusing on tech-
as biological variation and sample stability can influence nical performance.
the utility of a test. In general terms, laboratory profes- The clinical impact can be divided into the effect that
sionals are extremely good at validating technical perfor- use of a test or procedure will have (a) on the diagnostic
mance, although pre-analytical factors are less commonly strategy, i.e., compared with the use of other tests, in
documented (46 ). Pre-analytical factors can limit the improving diagnostic performance; (b) on the therapeutic
benefits of a test in routine practice, e.g., the biological strategy, i.e., use of therapies, optimization of therapy,
variation in the markers of bone resorption. avoidance of harm, and so forth; and (c) on the health
outcome. Thus, one can evaluate the impact of the detec-
tion of microalbuminuria in terms of (a) earlier detection
of diabetic nephropathy and (b) better management of
diabetes and co-morbid conditions, e.g., hypertension,
with a view to (c) reducing the rate of development of
renal failure. Some more examples of clinical impact are
given in Table 3.
operational benefit
The use of a diagnostic test may have an operational, as
distinct from a clinical, impact; this often is considered an
economic impact, which it may be because use of re-
sources always resolves down to economic consider-
ations. However, identification of an operational question
may help to determine the optimal organizational aspects
of a care strategy, e.g., disposition of staff and use of beds,
as part of a wider economic analysis. Operational benefits
may include reduced length of hospital stay, reduced staff
time utilization, reduced utilization of estate (facilities),
Fig. 2. Evidence of performance designed to facilitate decision-making. and reduced utilization of other resources. It may be
5. Clinical Chemistry 46, No. 8, 2000 1045
deed, it could be argued that ongoing systematic review
Table 3. Examples of potential improved clinical benefit.
can provide a robust means of maintaining awareness of
Diagnostic strategy
developments in a specific field. The benefits of a system-
“Rule out” of urinary tract infection
atic review are summarized in Table 4 and are mainly
Triage of patients with acute chest pain
concerned with handling of large amounts of data, mini-
Screening tests
Therapeutic strategy
mizing the effects of bias introduced into individual
Improved compliance with therapy
studies, and increasing confidence in the result.
Bone markers vs DEXA and bisphosphonate therapy in patients A systematic review of current evidence through the
with osteoporosis use of meta-analysis can identify methodological deficien-
POCT for anticonvulsant drugs cies as well as provide an up-to-date systematic review
POCT for HbA1C (51 ). The summary ROC curve can be used to combine
Reduced risk of toxicity of therapy studies, illustrating differences that may exist and deter-
Cyclosporin monitoring in transplant patients mining their potential level of significance (52 ). Good
Monitoring of lithium therapy examples of the use of summary ROC curve analysis for
Clinical outcome two clinical decisions are given in the reports by Guyatt et
Reduced rate of onset of complications al. (53 ) and Olatidoye et al. (54 ). The work of Olatidoye et
Regular monitoring of glucose in patients with diabetes mellitus al. (54 ) demonstrates that the variability in diagnostic
(including gestational diabetes)
performance can be large and that this can present a
Detection of microalbuminuria in patients with diabetes
dilemma to the evaluator. It also illustrates the need for
Monitoring of proteinuria in patients at risk of preeclampsia
Screening tests
multiple studies. Variability in performance may reflect
Testing for substance overdose, e.g., acetaminophen, salicylate
differences in design, choice of patients, and clinical
setting, all of which can lead to significant bias in the
results (5, 55 ).
important to focus very specifically on the decisions that
can follow from the identification of such a benefit, e.g., quality of evidence
length of stay in relation to bed requirement. The deci- Given that evidence informs a decision to be made, then it
sion-making will probably address two issues, namely will be robust only if the evidence is of good quality.
bed utilization and clinical risk associated with early There have been many publications describing the quality
discharge. Rainey (49 ) considered length of stay as a of evidence that is acceptable (5, 40, 56 –59 ) and identify-
medical outcome; however, this “definition” lacks the ing ways in which evidence can be gathered free of bias.
clarity of the decisions that need to be made. In broad terms, bias can be introduced into evidence
either from the choice of study population, the design of
economic benefit the experimental work, or the way in which the results are
The economic impact of the use of a diagnostic test and reported. The key priorities in designing a study to
the broader issues of cost-benefit analysis are poorly generate good quality evidence are summarized in Table
understood tools in decision-making in healthcare. How- 5.
ever, this is extremely important when the new test or The selection of the patient population for study has a
procedure is more expensive than the existing modality of critical bearing on the results produced and should be
testing, as often is the case. It is also a wasted opportunity relevant to the question being asked. Thus the diagnostic
if the test brings real benefits to the patient and the accuracy of a test will be overestimated in a group of
healthcare organization. In these considerations, it is patients already known to have the disease when com-
important not to focus solely on the test but on the pared with a group of healthy individuals (59 ). Bias may
complete patient episode or outcome (19, 50 ), determin- also be introduced if the selection of patients for a trial is
ing where the investment is required and the gain
achieved.
Table 4. Benefits to be gained from a systematic review of
Evidence available evidence.
Although the outcome of any evaluation of a test has to be Integrates information
recognition of the benefit, the starting point has to be Reduces data to manageable level
identification of the question (or the clinical need). How- Identifies limitations in methodology
ever, many studies fail to address the question, whereas Limits effects of bias
others suffer from the use of poor methodology. Prevents proliferation of studies
Enhances confidence in overall result
Systematic Review Reduces delay between discovery and implementation
Establishes generalizability of data
Whereas the validation of a new test requires primary
Identifies causes of inconsistency
research, the accumulation of data from several studies in
Identifies new research questions
a systematic review can provide additional benefits. In-
6. 1046 Price: Evidence-based Laboratory Medicine
related to outcomes has been investigated more in relation
Table 5. Key study design criteria for achieving good
to the use of a pharmaceutical intervention than a diag-
quality evidence.
nostic intervention. Thus, Moore and Fingerova (64 ) have
Explicit identification of question
identified other characteristics of study design that will
Appropriate choice of patients and setting
introduce bias to the results. The ideal approach, how-
Application of reference standard to patients and controls
ever, is identical whether it is a diagnostic or a therapeutic
Use of robust measure of outcome
Blind comparison of method against reference or outcome
intervention and whether it is an assessment of diagnostic
Exclusion of confounding variables
performance or outcome, and that is the use of prospec-
Description of methodology that can be reproduced tive blind comparison of test and reference procedure in a
consecutive series of patients from a relevant clinical
population (60 ).
not randomized or if some patients are excluded from the Studies designed to assess clinical, operational, and/or
trial; the latter may be the very patients on whom the economic outcomes require a clear definition of the out-
quality of the decision hinges and may differentiate one come measure. In certain clinical studies, this may require
test from another. Lijmer et al. (55 ) in a study of bias in 11 the use of a surrogate because the true outcome can only
meta-analyses on 218 studies of diagnostic tests found be assessed over several decades; examples include the
that the largest effect on diagnostic accuracy occurred in use of hemoglobin (Hb)A1C as a surrogate for normogly-
case-control studies, suggesting that the mild cases, which cemic control and the DEXA scan for normal bone mineral
are difficult to diagnose, were excluded, thereby causing density. An alternate outcome may be the “avoidance of
overestimates of the sensitivity as well as specificity. disease” as was used in the Diabetes Control and Com-
When assessing the diagnostic performance of a test, it plications Trial (65 ); the approach currently underpins
is important to use a robust reference method. The refer- our assessment of wellness. It is also important to be
ence method should be used in both the test and the aware of confounding factors that might also influence
control populations; this requirement cannot always be the outcome measure; thus in the study by Kendall et al.
met, sometimes for ethical or cost reasons. However, it is (66 ) on the use of POCT in the emergency room, the “time
recognized that failing to apply verification can lead to to result” was reduced, but the “length of stay” in the
bias in the results. In some situations, to overcome this emergency room (potentially a very relevant outcome
problem different reference methods have been applied to measure) was not influenced. The demonstration of re-
the test and control populations; again this can introduce duced time to result, however, is still valid and points to
bias, and it generated the second largest effect in the study another step in the process as being the impediment to
by Lijmer et al. (55 ). As an example, in a study on the use reducing the length of stay.
of C-reactive protein (CRP) in the diagnosis of appendi- It is also clear that publication of results also introduces
citis, surgery and pathology were used as the reference for bias; there is a greater tendency to publication of positive
patients with high CRP, whereas verification was limited findings. Easterbrook et al. (67 ) showed in a study of a
to clinical follow-up in the patients with low CRP concen-
trations (60 ).
It has also been suggested that blinding the evaluator
of the new method to the results of the reference method
will also improve the validity of the result. However, in
the study by Lijmer et al. (55 ), it had little impact on the
diagnostic accuracy of a test; conversely, in situations
where the reference procedure is imperfect this effect may
be increased. Valenstein (61 ), however, urged that rather
than use an imperfect reference standard, one should
focus on a more practical and measurable outcome; he
used the example of the imperfect means of predicting the
condition of a patient’s myocardium, urging the use of a
measurable outcome such as response to therapy or death
in hospital. An imperfect reference procedure raises the
prospect of interoperator variation, which can also con-
tribute to bias (62 ). A good example is the diagnosis of
myocardial infarction, where the evaluation of new bio-
chemical markers introduces the bias associated with the
use of other markers in the diagnostic triad but also
recognizes the fact that there is interoperator variation in Fig. 3. Evidence-based laboratory medicine at the core (*) of continu-
the ultimate reference procedure—the autopsy (63 ). ous quality improvement.
It is evident from the literature that study design R & D, research and development.
7. Clinical Chemistry 46, No. 8, 2000 1047
large number of submissions to a local ethics committee UK, will improve implementation because both initiatives
that eventual publication was more prevalent in studies are founded on the culture of evidence-based practice.
where there were significant findings. Dickersin et al. (68 )
also found that there was an association between signifi- clinical audit
cant results and publication, the bias originating with the The establishment of a new practice, as well as established
authors rather than journal editors. Chalmers et al. (69 ) practice, should always be subject to regular audit (72 );
have defined three stages of publication: (a) organizing this underpins the commitment to maintenance of good
and undertaking of the research; (b) acceptance or rejec- practice, one of the important tenets of clinical gover-
tion of a manuscript depending on the presentation of nance. The audit will assess whether the new technology
positive or negative findings; and (c) the bias that may has been implemented satisfactorily and whether the
result from interpretation, reviews, and meta-analyses. outcomes found bear out the findings of the original
The authors also make recommendations on how publi- research. The outcome of the audit may identify the need
cation bias can be minimized. to modify practice or may lead to the identification of a
new research question. Experience has shown that audit-
Application ing established practice as, for example, a means of
Reference has already been made to the fact that there controlling demand for a laboratory service, can identify
often are delays in the implementation of new technolo- unmet clinical needs as well as abuse and inappropriate
gies despite the availability of good evidence, whereas on use of laboratory services. Thus, evidence-based labora-
the other hand, technologies are implemented in the tory medicine in all its facets is the foundation of a
absence of evidence. It is acknowledged that even when continuous quality improvement program (Fig. 3).
there are health technology assessment programs set up
to resolve some of these problems, the implementation of Implications of an Evidence-based Culture
findings is still one of the major problems in the effective- The foregoing discussion has been focused primarily on
ness of the programs (70 ). There may be several reasons decision-making, but it is quite clear that the practice of
for this, including (a) the absence of formal continuing evidence-based laboratory medicine can have an impor-
education programs, and (b) the mechanisms for allocat- tant influence on many aspects of professional practice.
ing resources. It is possible that initiatives that have been
set up to identify and implement good practice, such as training and maintaining performance
the National Institute for Clinical Excellence (71 ) coupled It has been suggested that the principles of evidence-
with the development of clinical governance (27 ) in the based medicine will provide a better foundation for
Fig. 4. Evidence-based laboratory
medicine and the achievement of
value for money.
EBLM, evidence-based laboratory medicine;
R & D, research and development.
8. 1048 Price: Evidence-based Laboratory Medicine
training because it focuses more on the evidence to embodied in the principles of laboratory accreditation
support the type of decision-making required in clinical (78 ), professional self-regulation (79 ), and ultimately clin-
practice (73 ). It is also clear that performance deteriorates ical governance (27 ), representing commitment to provi-
with age (74 ) and that traditional means of continuing sion of the highest quality of service to the patient.
education are less effective than an evidence-based ap-
proach (75 ). Thus, through participation in activities to Conclusions
maintain the evidence database and participation in audit Application of the principles of evidence-based medicine
activities, professional performance can be maintained to laboratory medicine highlights the importance of es-
and kept up to date. tablishing the role of diagnostic procedures in clinical
decision-making. The discipline is crucial to creating and
research and development agenda delivering the research and development agenda in the
The continuous process of practice review, the generation laboratory while also providing a foundation for the
of new knowledge, and the availability of new technology training of laboratory professionals. The continuing ap-
combine to generate a powerful development agenda. The plication of an evidence-based approach to practice will
use of evidence-based practice guidelines will ensure that also meet the quality expectations of patients.
an effective program can be developed to meet patients’
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