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By T. Ningal. University of Massachusetts at Dartmouth.

Surely the public should be able to trust that such public bodies do not 1 Mehdi T cheap 250mg mildronate mastercard, Wagner-Rizvi T. Feeding fiasco—pushing commercial infant foods in favour commercial interests over public health. University of Cape Town said to industry representa- Penang:International Baby Food Action Network,1998. Violationsoftheinternationalcodeofmarketingofbreastmilk Research Organisation: "There is a hidden agenda in substitutes:prevalence in four countries. Getting research findings into practice Using research findings in clinical practice S E Straus, D L Sackett In clinical practice caring for patients generates many This is the fifth questions about diagnosis, prognosis, and treatment Summary points in a series of that challenge health professionals to keep up to date eight articles with the medical literature. A study of general analysing the Practising evidence based medicine allows practitioners in North America found that two gap between clinicians to keep up with the rapidly growing clinically important questions arose for every three research and body of medical literature patients seen. General Evidence based medicine improves clinicians’ physicians who want to keep up with relevant journals skills in asking answerable questions and finding NHS Research and face the task of examining 19 articles a day 365 days a the best evidence to answer these questions Development 2 Centre for Evidence year. Based Medicine, One approach to meeting these challenges and Evidence based medicine can provide a Nuffield framework for critically appraising evidence Department of avoiding clinical entropy is to learn how to practise evi- Clinical Medicine, dence based medicine. Evidence based medicine Oxford Radcliffe Practising evidence based medicine encourages Hospital NHS Trust, involves integrating clinical expertise with the best Oxford OX3 9DU clinicians to integrate valid and useful evidence available clinical evidence derived from systematic S E Straus, 3 with clinical expertise and each patient’s unique deputy director research. Individual clinical expertise is the profi- features, and enables clinicians to apply evidence D L Sackett, ciency and judgment that each clinician acquires to the treatment of patients director through clinical experience and practice. Best available Correspondence to: clinical evidence is clinically relevant research which Dr Straus may be from the basic sciences of medicine, but sharon. The box at the bottom of BMJ 1998;317:339–42 evidence based medicine is and how it can be practised the next page illustrates the five steps necessary to the by busy clinicians. Four components of the question must be specified: the patient or problem Clinical findings being addressed; the intervention being considered (a Which is the most accurate way of diagnosing ascites cause, prognostic factor, or treatment); another on physical examination: fluid wave or shifting intervention for comparison, when relevant; and the dullness? To illustrate how many questions may arise in the Differential diagnosis In a patient with cirrhosis and ascites which is most treatment of one patient consider a 65 year old man likely to cause gastrointestinal bleeding, variceal with a history of cirrhosis and ascites secondary to haemorrhage or peptic ulcer disease? On In a patient with suspected alcohol abuse is the use of examination he is disoriented and looks unwell but is the CAGE questionnaire specific for diagnosing afebrile.

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Products were produced to the specification of the manufacturer 500mg mildronate free shipping, and then customers were sought. A "here is our product, take it or leave it" approach charac- terized most industries during this period. The mind-set was that a good product would sell itself; thus, there would be no need for marketing even if the field had existed. In the days before the standardization of production, there was enough variation among products offered by dif- ferent producers that the differences generally spoke for themselves (with- out benefit of marketing). Furthermore, until the prosperity of the 1950s, the concept of consumer was poorly developed. The existence of a weak consumer segment lacking consumer credit and an acquisitive mind-set was not conducive to the development of the marketing enterprise. Stage One: Product Differentiation and the Consumer Mentality The postwar period witnessed the emergence of a wide variety of new prod- ucts, particularly in the consumer-goods industries. Newly empowered con- sumers demanded a growing array of goods and services, even if existing goods and services had adequately served previous generations. This development contributed to the emergence of marketing for at least two reasons. First, consumers had to be introduced to and educated about these new goods and services. Second, new market entrants introduced a level of competition unknown in the prewar period. This meant that mecha- nisms had to be developed to both make the public aware of a new prod- uct and to distinguish that product from those of competitors’ in the eyes of potential customers. Consumers had to be made aware of purchase opportunities and then convinced to buy a certain brand. The standardization of existing products that occurred during this period further contributed to the need to convince newly empowered consumers to purchase a particular good or service. These developments resulted in a shift away from a seller’s market to a buyer’s market.

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As the procedure can be undertaken with local anaesthesia it has the advantage of allowing real-time monitoring of the efficiency of the lesioning cheap mildronate 500 mg with visa. Further development of the technique took place mainly in pain clinics, but with the major improvements DR E Z 86 2 et al. Papaver somniferum opiates opioids Actions of the opioid drugs Analgesia Slowed gastric emptying Bradycardia Euphoria/Dysphoria Increased intestinal tone Sedation Decreased peristalsis Addiction Spasm of the sphincter of Oddi Itching (especially of face and nose) can occur with any opioid, delivered by any route Decrease in production of trophic Increased tone in: Generalised pruritus is most common hormones (lower plasma Ureter with neuraxial delivery of drugs testosterone and cortisone) Detrusor muscle Varies between drugs Increase in plasma growth hormone Urinary sphincter Most marked with morphine, less and prolactin Increased amplitude of ureteral with fentanyl and its coeruleus contractions Analgesia Most marked with large doses of Nausea and vomiting Reduction in peripheral resistance fentanyl and alfentanil Miosis (resultant hypotension) Mechanism unknown Respiratory depression Analgesia GI: gastrointestinal; CVS: cardio vascular system. It has proven the ability of a drug to reduce seizures does not efficacy in animal models of neuropathic pain. Anticonvulsants work in a number of different ways, • has several relevant actions including all of which have relevance to their effect on pain. The evidence for its efficacy in ber of mechanisms may be contributing to an individ- pain therapy is contradictory. Polypharmacy, ple neuronal GABA transporter in the cortex and using different anticonvulsants or anticonvulsants in hippocampus. By slowing the re-uptake of synap- conjunction with other classes of medication (partic- tically released GABA, it prolongs inhibitory post- ularly antidepressants), represents a rational synaptic potentials. Its of other actions: mechanism of action is unclear, since although it Phenytoin inhibits glutamate release pre- was developed as a structural GABA analogue, it • synaptically, modulates calcium current which has has no interaction with GABA receptors or GABA activity at the NMDA receptor and increases metabolism. It appears to have an inhibitory action gamma amino butyric acid (GABA) concentration. It NMDA-activated events involved in central sensi- remains the treatment of choice in trigeminal neur- tization. Its effectiveness in post-herpetic neural- algia, with about 70% of patients getting signifi- gia and diabetic neuropathy has been demonstrated cant pain relief.