Summary and Critical Appraisal of:
Jacobs et al,"Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial" Resuscitation 82 (2011) 1138– 1143
The CDC recently released guidelines regarding the use of opioid medications in the treatment of chronic pain. The CDC recommends that clinicians should consider nonpharmacologic therapies like medical foods as a first line therapy to safely and effectively treat chronic pain.
I performed a presentation to the board of directors in Labib Medical Center on the Early Warning Score with a view to introducing this tool which has been standardised across centers in the UK. The evidence states that this tool reduces mortality and morbidity rates and also reduces admissions into Intensive Care Unit.
Questioning the Use of Epinephrine to Treat Cardiac ArrestEmergency Live
"The role of epinephrine drug therapy during cardiac arrest:A properly evaluation of this traditional therapy seems necessary"
Clifton W. Callaway, MD, PhD on JAMA, dec 2012
The CDC recently released guidelines regarding the use of opioid medications in the treatment of chronic pain. The CDC recommends that clinicians should consider nonpharmacologic therapies like medical foods as a first line therapy to safely and effectively treat chronic pain.
Similar to Journal Club - EMS - "Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial"
I performed a presentation to the board of directors in Labib Medical Center on the Early Warning Score with a view to introducing this tool which has been standardised across centers in the UK. The evidence states that this tool reduces mortality and morbidity rates and also reduces admissions into Intensive Care Unit.
Questioning the Use of Epinephrine to Treat Cardiac ArrestEmergency Live
"The role of epinephrine drug therapy during cardiac arrest:A properly evaluation of this traditional therapy seems necessary"
Clifton W. Callaway, MD, PhD on JAMA, dec 2012
Similar to Journal Club - EMS - "Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial" (20)
Journal Club - Mortality after Fluid Bolus in African Children with Severe In...Farooq Khan
Critical Appraisal of:
Maitland K, Kiguli S, Opoka RO, et al. Mortality after fluid bolus in African children with severe infection. N Engl J Med 2011;364:2483-95
Research in International Emergency Medicine: Scope, Impact and Challenges
EBM Topic: Subgroup Analysis
Journal Club - Utility of Absolute and Relative Changes in Cardiac Troponin C...Farooq Khan
Critical Appraisal of:
Reichlin et al. Utility of Absolute and Relative Changes in Cardiac Troponin Concentrations in the Early Diagnosis of Acute Myocardial Infarction.Circulation. 2011;124:136-145
Novel High-sensitivity Troponin Assays
EBM topic: ROC curves
Journal club - Disease progression in hemodynamically stable patients present...Farooq Khan
Critical appraisal of:
Glickman SW et al. Disease Progression in Hemodynamically Stable Patients Presenting to the Emergency Department With Sepsis. Acad Emerg Med. 2010 17:383-90
Interactive quiz on early goal-directed therapy, surviving sepsis guidelines and EBM topic of prognosis studies.
Introduction to Injury Prevention - An interactive discussion for senior and ...Farooq Khan
Introducing concepts of Injury Prevention to mid-level Emergency Care Providers in the District Hospital setting in rural Sub-Saharan Africa.
An interactive lecture made for the Global Emergency Care Collaborative.
Emerging and Re-emerging Infectious DiseasesFarooq Khan
Overview of literature around the following emerging and re-emerging infectious diseases relevant to Canadian Emergency Physicians in terms of their epidemiology, recognition, and treatment:
- Community-acquired MRSA
- Non-vaccine serotype Pneumococcus
- Fusobacterium Necrophorum
Approach to evaluating patients' fitness to drive during an ED encounter.
Review of health advocacy and legal obligations from a Quebec standpoint
Audience: Medical students and residents in a small group environment
Approach to Fever in the Returning TravelerFarooq Khan
Quick diagnostic approach to return travelers presenting to the ED with fever.
Audience: Medical Students and Junior Residents in a small group environment
Approach to fever in the transplant patientFarooq Khan
Quick Approach to solid organ transplant patients presenting to the ED with fever to guide initial work-up and managment.
Audience: Medical students and junior residents in a small group environment
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
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
DISSERTATION on NEW DRUG DISCOVERY AND DEVELOPMENT STAGES OF DRUG DISCOVERYNEHA GUPTA
The process of drug discovery and development is a complex and multi-step endeavor aimed at bringing new pharmaceutical drugs to market. It begins with identifying and validating a biological target, such as a protein, gene, or RNA, that is associated with a disease. This step involves understanding the target's role in the disease and confirming that modulating it can have therapeutic effects. The next stage, hit identification, employs high-throughput screening (HTS) and other methods to find compounds that interact with the target. Computational techniques may also be used to identify potential hits from large compound libraries.
Following hit identification, the hits are optimized to improve their efficacy, selectivity, and pharmacokinetic properties, resulting in lead compounds. These leads undergo further refinement to enhance their potency, reduce toxicity, and improve drug-like characteristics, creating drug candidates suitable for preclinical testing. In the preclinical development phase, drug candidates are tested in vitro (in cell cultures) and in vivo (in animal models) to evaluate their safety, efficacy, pharmacokinetics, and pharmacodynamics. Toxicology studies are conducted to assess potential risks.
Before clinical trials can begin, an Investigational New Drug (IND) application must be submitted to regulatory authorities. This application includes data from preclinical studies and plans for clinical trials. Clinical development involves human trials in three phases: Phase I tests the drug's safety and dosage in a small group of healthy volunteers, Phase II assesses the drug's efficacy and side effects in a larger group of patients with the target disease, and Phase III confirms the drug's efficacy and monitors adverse reactions in a large population, often compared to existing treatments.
After successful clinical trials, a New Drug Application (NDA) is submitted to regulatory authorities for approval, including all data from preclinical and clinical studies, as well as proposed labeling and manufacturing information. Regulatory authorities then review the NDA to ensure the drug is safe, effective, and of high quality, potentially requiring additional studies. Finally, after a drug is approved and marketed, it undergoes post-marketing surveillance, which includes continuous monitoring for long-term safety and effectiveness, pharmacovigilance, and reporting of any adverse effects.
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
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.
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
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Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Journal Club - EMS - "Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial"
1. Effect of adrenaline on survival in out-of-hospital cardiac
arrest: A randomised double-blind placebo-controlled trial
Ian G. Jacobs, Judith C. Finn, George A. Jelinek, Harry F. Oxer, Peter
L. Thompson
Resuscitation 82 (2011) 1138– 1143
Farooq Khan PGY3 FRCP-EM
McGill University
2. Article Summary - PICO
Population
Adult, out-of-hospital cardiac arrest of any cause 2006-
2009
Resuscitation commenced
Province of Western Australia with one major city:
Perth
Single EMS service (SJA-WA) with established policy
of no drugs during resuscitation protocols prior to
study
3. Article Summary - PICO
Intervention
1 mg of IV Epinephrine 1:1000 administered q3min during
resuscitation
In 10 cc syringe (total dose up to 10 mg) and followed by 30 cc
flush
Administered when indicated
i.e. After 3rd unsuccessful shock
After IV access established in non-shockable cases
By paramedics trained prior to study in
Pharmacology of adrenaline
Overview of trial protocol
Further practice in IV placement
Cardiac arrest simulation exercises
4. Article Summary - PICO
Comparison
Placebo controlled in identical 10 cc vials of NS
Computer generated randomization
Blinded to both paramedic and patient
No other drugs used
6. Rationale
ILCOR includes Epi in ALS resuscitation guidelines despite
there being no randomised placebo-controlled trials in
humans evaluating its efficacy in cardiac arrest
Animal studies have shown that Epi improves coronary and
cerebral perfusion
A meta-analysis of high dose versus standard dose Epi did
not include a comparison with placebo and showed some
benefit of high dose Epi on ROSC but not survival to
hospital discharge
Vandycke C, Martens P. High dose versus standard dose epinephrine in cardiacarrest—a meta-analysis.
Resuscitation 2000;45:161–6.
Some evidence that Epi is harmful to myocardial function
post arrest and cerebral microcirculation
7. Methods
RCT
Placebo controlled
Triple-Blinded
Data collection on
Paper PCR which is entered into SPSS statistical package
Linked to dispatch data
Compiled into WA Ambulance Service Cardiac Arrest
Registry
Outcomes assessed through state-based Emergency,
Hospital Morbidity and Mortality data systems
CPC score determined by independent blinded chart review
8. Methods
Data reporting consistent with the Utstein definitions
for reporting out of hospital cardiac arrest
Additional data not routinely part of the PCR,
Randomisation number
Total dose of Epi
IV access achieved or not
Total volume of IV fluids infused
Sample Size Calculation = 2213 patients per group
Planned enrolment of 5000 pts to account for loss to f/u
9. Statistics
Patient/study characteristics: proportions and means
using chi square and t-tests
Ambulance time intervals: means, medians and IQR
Primary and secondary outcomes: OR and 95% CI
Confounders: logistic regression
Subgroups (a priori)
Shockable
Non-shockable
10. Results
Randomization successful in terms
of
Age
Sex
Location of arrest
% cardiac etiology
Rates of Bystander CPR
Initial rhythm
Ambulance response interval
Airway management
Volume of trial drug
Volume of IV fluids
Placebo group had SS not CS
higher rate of
witnessed arrests by bystander
Epi group had SS not CS higher
rate of
witnessed arrest by paramedic
transport to hospital
12. Stated strengths
First human RCT design
as opposed to animal RCTs, observations and
nonrandomized/before and after
Placebo control
as opposed to high-dose vs low-dose
Population with no confounding drugs administered
(e.g. Atropine, amiodarone)
Epi administered in recommended q3min doses
as opposed to single dose
Effective Blinding
13. Stated Limitations
Did not meet sample size requirement (by an order of
magnitude) due to last minute drop out of 4 out of 5
EMS systems initially meant to participate in study
Cited reasons of ethical concerns to withhold “standard
of care” meds, despite clear equipoise and IRB approval
Political and Media pressure
Inability to assess the influence of CPR quality or
timing of Epi administration during resuscitation
Claim variations in the above reflect clinical practice
Blinding will limit the effect of these factors on outcome
14. Stated Limitations
Only 40% of eligible patients enrolled
Claim participation of only volunteer paramedics as the
cause for this
Potential for selection bias present but mitigated by
successful randomization (at least for parameters
measured)
15. Author’s conclusions
The use of adrenaline in cardiac arrest significantly
improves the proportion of patients achieving ROSC
prehospital, but failed to demonstrate a better survival
to hospital discharge, possibly due to inadequate
sample size.
Further studies on the role of adrenaline in cardiac
arrest are required to determine optimal dose and
timing for drug administration.
16. Appraisal
No conflicts of interest
Does the study answer a clear question?
Yes (see PICO)
Are the results internally valid?
Pros
Well randomized
Concealed, computer generated and groups similar at start
Mitigates selection biases, Hawthorne effects, etc.
Groups treated equally until admission
Good follow-up and ITT analysis
Triple blinded
17. Are the results valid?
Cons
Not powered sufficiently for primary outcome
Trend suggest increased survival to discharge but numbers are
too low
No measurement of CPR quality or time of Epi
Is their claim that this is not relevant justifiable when we
know that CPR quality is one of the main factors in
determining outcome?
40% eligible patients not enrolled to randomization
May not interfere with results but it would be useful to
analyze if they were much different from study sample
10% loss of records
18. Are the results generalizable?
50% bystander CPR rates may not be comparable to
our population
But their overall survival rates are
Can we apply to settings where most paramedics are
not trained in IV placement or have enough experience
or manpower to do so without compromising CPR?
19. Additional considerations
What kind of post-arrest care was employed in those that
survived?
Who received therapeutic hypothermia?
How many had an easily manageable underlying cause?
How adequately was organ perfusion managed?
How long was the admission post arrest?
Were nosocomial infections involved?
Why don’t more patients admitted to hospital alive = more patients
discharged alive and functional
Small numbers and no way to account for this in analysis
Maybe ROSC should be the primary outcome for EMS and
survival to hospital discharge is the hospital’s problem
Or does Epi lead to survival of more brain-damaged, lower
functioning and more susceptible individuals?