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You will learn to use good 22 Essential Evidence-Based Medicine Table 3 buy kamagra gold 100mg low cost erectile dysfunction clinics. Cause and effect relationship for most common types of studies Type of study Cause Effect Etiology discount 100 mg kamagra gold otc erectile dysfunction treatment in the philippines, harm, or risk Medication, environmental, Disease, complication, or or genetic agent mortality Therapy or prevention Medication, other therapy, or Improvement of symptoms preventive modality or mortality Prognosis Disease or therapy Time to outcome Diagnosis Diagnostic test Accuracy of diagnosis searching techniques so that you find the study that answers this query in the best manner possible. The intervention, comparison, and outcome all relate to the patient population being studied. Primary clinical research studies can be roughly divided into four main types, determined by the elements of cause and effect. The nomenclature used for describing the cause and effect in these studies can be somewhat confusing and is shown in Table 3. They can also go in the other direction, starting from the presence or absence of the risk factor and finding out who went on to have or not have the outcome. Useful ways of looking at this category of studies is to look for cohort, Causation 23 case–control,orcross-sectional studies. In studies of etiology, the risk factor for a disease is the cause and the presence of disease is the outcome. In other studies, the cause could be a therapy for a disease and the effect could be the improvement in disease. There are special elements to studies of prognosis that will be discussed in Chapter 33. In general the clinical question can be written as: among patients with a particular disease (population), does the presence of a therapy or risk factor (intervention), compared with no presence of the therapy or risk factor (comparison), change the probability of an adverse event (outcome)? For a study of risk or harm, we can write this as: among patients with a disease, does the presence of a risk fac- tor, compared with the absence of a risk factor, worsen the outcome? We can also write it as: among patients with exposure or non-exposure to a risk factor, are they more likely to have the outcome of interest? For therapy, the question is: among patients with a disease, does the presence of an exposure to therapy, compared with the use of placebo or standard therapy, improve the outcome? The form of the question can help you perform better searches, as we will see in Chapter 5. Through regular practice, you will learn to write better questions and in turn, find better answers. Sir William Osler (1849–1919) Learning objectives In this chapter you will learn: r the scope and function of the articles you will find in the medical literature r the function of the main parts of a research article The medical literature is the source of most of our current information on the best medical practices. This literature consists of many types of articles, the most important of which for our purposes are research studies. In order to evaluate the results of a research study, you must understand what clinical research articles are designed to do and what they are capable of accomplishing. To be an intelli- gent reader of the medical literature, you then must understand which types of articles will provide the information you are seeking. In your medical career, you will read and perhaps also write, many research papers. All medical specialties have at least one primary peer-reviewed journal and most have several. One important observation you will make is that not all journals are created equal. For example, peer-reviewed journals are “better” than non–peer-reviewed journals since their articles are more carefully screened and contain fewer “prob- lems. As the consumer of this literature, you are responsible for determining how to use the results of clinical research. You will also have to translate the results of these research studies to your patients. Many patients these days will read about medical studies in the lay press or hear about them on television, and may even base their decisions about health care upon what the magazine writers or journalists say. Your job as a physician is to help your patient make a more informed medical decision rather than just taking the media’s word for it. In order to do this, you will need to have a healthy skep- ticism of the content of the medical literature as well as a working knowledge of critical appraisal. Other physicians, journal reviewers, and even editors may not be as well trained as you. Non–peer-reviewed and minor journals may still have articles and studies that give good information. All studies have some degree of useful information, and the aforementioned articles are useful for reviewing and relearning background information.

The effect of ingestion of inulin on blood lipids and gastrointestinal symptoms in healthy females generic 100 mg kamagra gold amex erectile dysfunction medicine name in india. The effect of dietary guar on serum cholesterol cheap kamagra gold 100mg otc erectile dysfunction exercises dvd, intestinal transit, and fecal output in man. Cytological abnormalities in nipple aspirates of breast fluid from women with severe constipation. Effect of resistant starch on fecal bulk and fermentation-dependent events in humans. Oat bran concentrate bread products improve long-term control of diabetes: A pilot study. Intake of dietary fiber and risk of coronary heart disease in a cohort of Finnish men. Resis- tant starch: The effect on postprandial glycemia, hormonal response, and satiety. Effect of chitin and chitosan on nutrient digestibility and plasma lipid concentrations in broiler chickens. Hypolipidaemic, gastrointestinal and related responses of broiler chickens to chitosans of different viscosity. Broiler chicken body weights, feed intakes, plasma lipid and small-intestinal bile acid concentrations in response to feeding of chitosan and pectin. Overweight treated with energy restriction and a dietary fibre supplement: A 6-month randomized, double-blind, placebo-controlled trial. Effect of psyllium on gastric emptying, hunger feeling and food intake in normal vol- unteers: A double blind study. Vegetable, fruit, and cereal fiber intake and risk of coronary heart dis- ease among men. Comparative continuous-indirect-calorimetry study of two carbohydrates with different glycemic indices. Effect of dietary fibre on glucose control and serum lipoproteins in diabetic patients. Dietary fiber, inulin, and oligofructose: A review comparing their physiological effects. Reducing sulfur compounds of the colon impair colonocyte nutrition: Implications for ulcerative colitis. Dietary factors and risk of prostate cancer: A case-control study in Ontario, Canada. Ronco A, De Stefani E, Boffetta P, Deneo-Pellegrini H, Mendilaharsu M, Leborgne F. Vegetables, fruits, and related nutrients and risk of breast cancer: A case-control study in Uruguay. A dietary fibre supple- ment and weight maintenance after weight reduction: A randomized, double- blind, placebo-controlled long-term trial. Effects of polydextrose on serum lipids, lipoproteins, and apolipoproteins in healthy subjects. Dietary fiber, glycemic load, and risk of non-insulin-dependent diabetes mellitus in women. The effect of citrus pectin on the absorption of nutrients in the small intestine. Lack of effect of a low-fat, high-fiber diet on the recurrence of colorectal adenomas. Ileal recovery of starch from whole diets containing resistant starch measured in vitro and fermentation of ileal effluent. A high carbohydrate leguminous fibre diet improves all aspects of diabetic control. Influence of refined cellulose on human bowel function and calcium and magnesium retention. Energy balance and thermogenesis in rats consuming nonstarch polysaccharides of various fermentabilities.

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Epigenetic mechanisms underlie the developmental plasticity discount kamagra gold 100mg with amex erectile dysfunction questions, that is fundamental to the link between fetal development and risk of later disease [3] cheap kamagra gold 100mg otc impotence bike riding. There is evidence that maternal factors can modulate gene expression in their offspring thus influencing [8,28]. For example maternal malnutrition had led to altered gene methylation and increased risk of offspring metabolic syndrome in adult life [29]. In addition, recent studies have shown that prenatal exposure to gestational diabetes could lead to epigenetic alterations that increase the risk of type 2 diabetes later in life [30]. Influences of early development on satiety and food preferences suggest that, once set points are established in early life, it may be difficult or even impossible to reverse them. This might explain why lifestyle interventions in adult can have limited effects and are difficult to sustain [22]. Behavioural Mechanisms The health behaviors that people adopt will modify their risk of disease across the lifecourse. Childhood and adolescence are stages of the lifecourse when health behaviors become established [32,33]. These risk factors are responsible for considerable burden of disease on a global level [34]. They can have direct effects on health or can act by influencing the development of high blood pressure and elevated blood glucose and cholesterol levels, which will then raise the risk of chronic diseases such as cardiovascular disease and diabetes. There is also evidence that infants who are breastfed have reduced risk of obesity and diabetes in adulthood. Poor diet is common during childhood including iron and vitamin deficiencies during infancy and consumption of inappropriate energy-dense foods that increase the risk of obesity during childhood [36,37]. The way in which parents feed their children and control what they eat has a strong influence on children’s early eating patterns and risk of childhood obesity, and physical activity and sedentary behaviors in parents are often mirrored in the behaviors of their children [32]. Adolescence is a period of physical and psychological change and a phase when young people develop independence. New behaviors developed during adolescence can have positive or negative consequences for health [38]. Behaviors like smoking and alcohol use developed during adolescence will track into adult life, highlighting the importance of intervening during this period to prevent later disease. Pregnancy during adolescence is an important issue in both developed country settings and in the developing world. Pregnancy at a young age, and early marriage, not only affect the health Healthcare 2017, 5, 14 6 of 12 and human rights of girls but also disrupts their education and development of skills and social networks, all of these undermining their future health and wellbeing, along with the health of their children [39]. Adolescent pregnancy is associated with higher risk of adverse outcomes for both mother and child than pregnancies occurring when women are aged 20–30 years; stillbirths, neonatal deaths, preterm births, low birth weight and postnatal depression are all more common in adolescent pregnancies [40,41]. Pregnancies occurring at a younger age are often unplanned and so risk factors for adverse pregnancy outcome, such as low folic acid intake and alcohol use, are more likely. Interventions The observational and mechanistic evidence demonstrating the influence of maternal nutrition on the future health of their offspring, has led to a strong focus on the improvement of the health and nutrition of women of childbearing age. Nutritional supplementation (multiple micronutrient supplementation, and single vitamin supplements to correct deficiencies) and behavior change offer two approaches to improving the nutritional status of women during preconception and pregnancy [42]. For the correction of micronutrient deficiencies, such as vitamin D deficiency during pregnancy, traditional randomized controlled trials provide robust, well-controlled frameworks for theoretical and pragmatic evaluation of the candidate policy. In evaluations of behavior change interventions more complex strategies are required, and different evaluative models (such as complex intervention studies or natural experiments) need to be applied. Nutritional Supplementation Trials of nutritional supplementation include single vitamin supplements and multiple micronutrient approaches. The study was a double-blind design across three study centers (Southampton, Sheffield, Oxford) [20]. Thus, in a pre-specified analysis, amongst winter births, neonates delivered to mothers allocated vitamin D supplements had more than 0. For women in the intervention group the snack was made from green leafy vegetables, fruit, and milk, whereas women in the control group received a snack made up of low-micronutrient vegetables such as potato and onion. Women took the snacks daily from 90 days or more before pregnancy until delivery, in addition to the usual diet.

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