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K. Wenzel. Western Carolina University.

Appreciate the role physicians play in the inappropriate prescribing of antimicrobial agents and the public health ramifications purchase female viagra 50 mg online breast cancer awareness shirts. Demonstrate commitment to using risk-benefit buy female viagra without a prescription womens health vero beach, cost-benefit, and evidence- based considerations in the selection of diagnostic and therapeutic interventions for nosocomial infections. Recognize the importance of patient needs and preferences when selecting among diagnostic and therapeutic options for nosocomial infections. Demonstrate ongoing commitment to self-directed learning regarding nosocomial infections. Appreciate the impact nosocomial infections have on a patient’s quality of life, well-being, ability to work, and the family. Recognize the importance of and demonstrate a commitment to the utilization of other health care professionals in the diagnosis, treatment, and prevention of nosocomial infections. These conditions have been correlated with the development of medical conditions such as diabetes, hypertension, heart disease, and osteoarthritis. Mastery of the approach to patients who are not at an ideal body weight is important to general internists because they often deal with the sequelae of the comorbid illnesses. The etiology of obesity including excessive caloric intake, insufficient energy expenditure leading to low resting metabolic rate, genetic predisposition, environmental factors affecting weight gain, psychologic stressors, and lower socioeconomic status. How daily caloric requirements are calculated and the caloric deficit required to achieve a five to 10 percent weight reduction in six to 12 months. How to develop an exercise program and assist the patient in setting goals for weight loss. Treatment options, including nonpharmacologic and pharmacologic treatment, behavioral therapy and surgical intervention. History-taking skills: Students should be able to obtain, document, and present an age-appropriate medical history, including: • Reviewing the patient’s weight history from childhood. Differential diagnosis: Students should be able to generate a prioritized differential diagnosis recognizing specific history and physical exam findings that suggest a specific etiology of primary and secondary obesity. Laboratory interpretation: Students should be able to recommend when to order diagnostic and laboratory tests and be able to interpret them, both prior to and after initiating treatment based on the differential diagnosis, including consideration of test cost and performance characteristics as well as patient preferences. Communication skills: Students should be able to: • Communicate the diagnosis, treatment plan, and subsequent follow-up to patients. Management skills: Students should able to develop an appropriate evaluation and treatment plan for patients that includes: • Determining when to obtain consultation from an endocrinologist, dietician, or obesity management specialist. Demonstrate commitment to using risk-benefit, cost-benefit, and evidence- based considerations in the selection diagnostic and therapeutic interventions for obesity. Appreciate the impact obesity has on a patient’s quality of life, well-being, ability to work, and family. Recognize the importance of and demonstrate a commitment to the utilization of other healthcare professions in the treatment of obesity. Systematic review: an evaluation of major commercial weight loss programs in the United States. Many different specialties encounter pneumonia in the course of practice, the internist most particularly. The epidemiology, pathophysiology, symptoms, signs, and typical clinical course of community-acquired, nosocomial, and aspiration pneumonia and pneumonia in the immunocompromised host. Common pneumonia pathogens (viral, bacterial, mycobacterial, and fungal) in immunocompetent and immunocompromised hosts). The pathogenesis, symptoms, and signs of the complications of acute bacterial pneumonia including: bacteremia, sepsis, parapneumonic effusion, empyema, meningitis, and metastatic microabscesses. History-taking skills: Students should be able to obtain, document, and present an age-appropriate medical history that differentiates among etiologies of disease, including: • The presence and quantification of fever, chills, sweats, cough, sputum, hemoptysis, dyspnea, and chest pain. Physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease, including: • Accurately determining respiratory rate and level of respiratory distress. Differential diagnosis: Students should be able to generate a prioritized differential diagnosis recognizing specific history and physical exam findings that suggest a specific etiology of pneumonia and other possible diagnoses, including: • Common cold. Laboratory interpretation: Students should be able to recommend when to order diagnostic and laboratory tests and be able to interpret them, both prior to and after initiating treatment based on the differential diagnosis, including consideration of test cost and performance characteristics as well as patient preferences. Communication skills: Students should be able to: • Communicate the diagnosis, treatment plan, prognosis, and subsequent follow-up to the patient and his or her family. Management skills: Students should able to develop an appropriate evaluation and treatment plan for patients that includes: • Selecting an appropriate empiric antibiotic regimen for community- acquired, nosocomial, immunocompromised-host, and aspiration pneumonia, taking into account pertinent patient features. Demonstrate commitment to using risk-benefit, cost-benefit, and evidence- based considerations in the selection diagnostic and therapeutic interventions for the various types of pneumonia. Recognize the importance of patient preferences when selecting among diagnostic and therapeutic options for pneumonia. Appreciate the impact pneumonia has on a patient’s quality of life, well-being, ability to work, and the family. Recognize the importance of and demonstrate a commitment to the utilization of other healthcare professionals in the treatment of pneumonia. Appreciate the public health role of the physician when treating certain types of pneumonia (e. Management of community-acquired pneumonia in the home: an American College of Chest Physicians clinical position statement. This includes problems referring to specific joints as well as patients with systemic symptoms that are sometimes difficult to unify into a single diagnosis. A systematic approach to joint pain based on an understanding of pathophysiology to classify potential causes. The effect of the time course of symptoms on the potential causes of joint pain (acute vs. The distinguishing features of intra-articular and periarticular complaints (joint pain vs. The effect of the features of joint involvement on the potential causes of joint pain (monoarticular vs. Indications for performing an arthrocentesis and the results of synovial fluid analysis. The pathophysiology and common signs and symptoms of common periarticular disorders: • Sprain/stain. Typical clinical scenarios when systemic rheumatologic disorders should be considered: • Diffuse aches and pains. History-taking skills: Students should be able to obtain, document, and present an age-appropriate medical history that differentiates among etiologies of disease, including: • Eliciting features of joint complaints: o Pain. Physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease, including: • A systematic examination of all joints identifying the following abnormal findings: o Erythema, warmth, tenderness, and swelling. Differential diagnosis: Students should be able to generate a prioritized differential diagnosis recognizing specific history and physical exam findings that suggest a specific etiology: • Osteoarthritis.

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Tunc accipe dyaceraseos order female viagra australia womens health initiative study results, [ra] ceroneum female viagra 100mg fast delivery women's health center el paso texas, oxicroceum,t et ad inuicem puluerizentur. Hiis factis iniungatur requiesab et occium, utaturcalida et humida dieta,optimo uino et mediocriter rubeo, quod bibat quousque curetur. Et si lac minuatur, pultes de farina fabarum et similiter rizi, et de pane simulei et dej lacte et zuccara facte denturk ei ad sorbendum, quibusl lac augmentetur,m et parum seminis feniculi sit admixtum. Si uero lac eius fuerit grossum, nutrimentum eius est subtiliandum et ita cogatur laborare. Book on the Conditions of Women  let it be tied tightly with linen bandages, and thus let the limb of the patient sweat through one night; in the morning, let it be rubbed so that the spirits are aroused and flow to the painful part. This having been done, let the limb be rubbed with dialtea, thus composed: two parts dialtea and a third of lau- rel oil mixed together; and let the limb be anointed in the above-mentioned manner three or four times a day. These things having been done, let rest and leisure be ordered; let the patient have a warm and moist diet, with good quality, moderately red wine, which s/he should drink until s/he is cured. On Choosing a Wet Nurse *[] A wet nurse ought to be young, having a clear color, a woman who has redness mixed with white, who is not too close to her last birth nor too far removed from it either, who is not blemished, nor who has breasts that are flabby or too large, a woman who has a large and ample chest, and who is a little bit fat. She should not eat salty or spicy or pungent things, nor those things in which heat is strong, nor styptic things, nor leeks or onions, nor the rest of those spices which are added to foods for flavoring, such as pep- per, garlic, garden rocket, but above all garlic. And if her milk is diminished, let porridges made of bean flour and likewise of rice, and wheat bread and milk and sugar be given to her to drink, by which things the milk is augmented, and let a little fennel seed be mixed in. If, on the other hand, her milk be- comes thick, let her nutriment be made subtle, and so let her be compelled to work. If the milk becomes thin, let her nutriments be thick and strong, and let her get more sleep. If the bowel of the child is loose, let constipating things be given to the nurse. Si uerod in corpore pueri antrax apparuerit, detur nutrici aqua ordei, et quan- doque scarificetur. Cognoscitur etiam lac mu- lieris ita: gutta distillata super unguem, nec [va] nimis subtilee nec nimisf liquidum nec nimis grossum nec nimis coagulatumg debet esse, bonum odo- rem habensh et puram dulcedinem. Matrix enim quan- doque sua lenitatec preter naturam, sperma iniectumd retinere non potest. Si ergo pre nimia caliditate et siccitate,f hec eruntg signa:h labia habent ulcerosai et tamquam boreali uento excoriata,j maculas habent rubeas, sitim assiduam, casum capil- lorum. Inter has fumigationes sup- positoria et etiam pessaria uulue cum oleo musceleo et modico musco facies, ut matrix confortetur. Sed in die septimo post purgationem uel fumigatio- nem factam, accipe de trifera magna ad modum glandis et similiter inuolue in bombace, et inden suppositorium facies uulue, ut tot fumigationibus matrix recipiat aliquam confortationem, lenitatem et lanuginem, et beneficio talis suppositorii et talibus desicceturo fumigiis, et a talip medicina suscipiat con- fortationem. In sequenti uero die eam facies cum uiro coire, eadem autem cura sequenti septimana si expediat utarisq faciendo fumigationes predictas et cetera ¶a. Book on the Conditions of Women  On Pustules of Children *[] Small pustules arise in children, which ought to be dissolved with ground salt and tied with bandages so that they resolve; neither oily nor sweet things ought to be given to them. If a carbuncle appears in the body of the child, let barley water be given to the nurse, and occasionally let her be scari- fied. Also, the [quality of] the woman’s milk is recognized in this manner: a drop dropped onto the nail ought to be neither too thin nor too runny nor too thick nor too coagulated; it should have a good odor and a pure sweetness. Salty milk, however, or that which smells bad is not suitable nutriment for the infant. On Impediment of Conception *[] Conception is impeded as much by the fault of the man as by the fault of the woman. The fault of the woman is double: either excessive warmth or humidity of the womb. For the womb at times, because of its unnatural slip- periness, is unable to retain the seed injected into it. And sometimes she is unable to con- ceive because of the excessive heat of the womb burning the semen. If, there- fore, excessive heat and dryness is the cause, the signs will be these: their lips are ulcerated and excoriated as if from the north wind, they have red spots, unremitting thirst, and loss of hair. When, therefore, you see this, and if the woman is thirty years old and has suffered this for a long time, you will judge it to be untreatable. If she is young and the disease is not chronic, you should aid her in this way: take marsh mallow and mugwort, and cook them in water, and with such a decoction you should fumigate the patient three or four times. Between these fumigations you will make suppositories and also pessaries for the vagina with musk oil and some musk itself, so that the womb might be strengthened. But on the seventh day after her purgation or after the fumiga- tion has been made, take trifera magna49 in the size of an acorn and similarly wrap it in cotton, and from this you will make a suppository for the vagina, so that from the many fumigations the womb receives some strength, smooth- ness, and softness, and from the benefit of this suppository and these fumi- gations it will be dried out, and from this medicine she should receive some strength. On the following day, you will make her have sex with her husband, and if necessary you will use the same treatment the following week, making the above-mentioned fumigations and applying the other remedies, as noted. You should do this until the above-mentioned symptoms have subsided, and  Liber de Sinthomatibus Mulierum ut diximus beneficia adhibendo. Hoc faciasr quousques predicta sinthomata remittantur,t et eam bis uel ter faciasu coire in ebdomada, [ra] quia sic cicius poterit impregnari. Cum enim matrix cerebro per neruos alligata sit, necesse est ut cerebrum matrici compatiatur. Vnde si matrix in se habeat nimiam humiditatem, ex ea cerebrum impletur, que ad oculos redundans eosd inuoluntariose cogit emittere lacrimas. Et quiaf cere- brum matrici compatiatur,g signum est alienatioh mulierisi ex menstruorum retentione. Si uero matrix non bene purgata fuerit, in alio die pessarium eodem modol de trifera cum modico musco sibi facies. Hocm tam diu facias donec a super- flua humiditate euacuatam cognoscas, et postn accipe parum de musco cum oleo uel alioo o[rb]dorifero quod iterum per uuluam intromittas. Et si bene purgata fuerit, sentiet odorem in ore, et si quis eam osculatus esset, crederetp eam muscum in oreq tenere. Book on the Conditions of Women  you should make her have intercourse twice or three times a week, because thus more quickly will she be able to become pregnant. For because the womb is tied to the brain by nerves, it is necessary that the brain suffer with the womb. Whence, if the womb has within itself excessive humidity, from this the brain is filled, which [humidity], flowing to the eyes, forces them involuntarily to emit tears. And because the brain suf- fers together with the womb, the sign of this is mental distress of the woman [when she suffers] from retention of the menses. Afterward we prescribe that you make three or five pills of the same Theodoricon or of Paulinum,51 and also that you wrap them in cotton lest they dissolve, and insert however many you can via the genitals. If the womb has not been well purged, on the second day you will make a pessary in the same manner of trifera with some musk. You should do this for a long time until you see that she has been evacuated of the superfluous humidity, and afterward take a little bit of musk with oil or another odorif- erous substance which again you insert into the vagina. And if she has been well purged, she will sense the odor [of the musk] in her mouth, and if anyone should kiss her, hewill think that she is holding musk in her mouth. On Sterility on the Part of the Man *[] If conception is impeded because of the fault of the man, either this comes about from a defect of the spirit impelling the seed, or from a defect of spermatic humidity, or from a defect of heat.

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In 1924 cheap female viagra 50 mg with amex women's health clinic riverside campus, investigators at the Bayer pharmaceutical company in Germany synthesized a new antimalarial drug female viagra 50 mg online menstruation graph, pamaquine (Plasmoquine). Shortly thereafter, they synthesized other antimalarial compounds, includ- 52 R1 ing quinacrine (Atabrine). In 1932, Gerhardt Domagk, experimenting with syn- thetic dyes, discovered that Prontosil could cure mice challenged with lethal doses of hemolytic streptococci. In the 1930s and 1940s, Alexander Fleming, Howard Florey, and Ernst Chain at Oxford University conducted experiments that led to the demonstration that penicillin, a mold product, was effective against many pathogenic organisms. For the frst time, it was possible to effectively treat a wide range of infections, and this gave birth to the search for new antibiotics produced by organisms in nature or synthesized in the laboratory. Alexander Langmuir, grew dramatically to include surveillance of infectious and noninfectious diseases, the provision of expert scientifc advice on health issues to policy makers in the United States, serve as a reference laboratory to the states and inform the public about health issues through the Morbid- ity and Mortality Weekly Report. Although some vaccines were developed earlier, the number and impact of vaccines developed in the 1900s century was monumental. The renamed Centers for Disease Control and Prevention in 1999 published a review of the 10 great public health achievements in the United States during the 1900s. The vaccines developed and licensed to prevent vaccine-preventable diseases are shown in Table 1-3, and an estimate of their effect on reported infectious disease morbidity is shown in Table 1-4. During the previous century, the average life span of persons in the United States lengthened by about 30 years, and 25 years of this gain has been attributed to advances in public health. During the 1900s, infectious R1 disease mortality declined from about 800/100,000 population to under © Jones and Bartlett Publishers. The effectiveness of treatments and vaccines coupled with increased fnancial support fueled spectacular advances as the underlying science of diseases was unraveled. Since that time gradual progress in deciphering and manipulating the genetic code of animals and plants had occurred. Dolly the sheep, born July 5, 1996, was the frst higher animal to be cloned, and several other animals have followed. The project was completed ahead of schedule and in April 2003 the human genome was published in several articles in Nature and Science. The felds of genomics and proteomics, the study of protein expression, are rapidly evolving felds that hold great promise for understanding the interaction of humans with infec- tious pathogens. This genome will be informative for all grains, as rice, corn and wheat diverged from a common grass ancestor only 50,000 years ago. Earlier researchers manipulated the rice genome to insert a daffodil gene which added vitamin A to rice. Unfortunately, although genetically modifed foods hold great promise, they are also highly controversial. Hardier plants, enhanced with insect repel- lant genes or drought resistance, threaten to drive out native plants, which could ultimately reduce global genetic diversity. Highly successful seeds are patented, and this elevates the cost of seed beyond the reach of subsistence farmers. The concentration of ownership of seeds is severe, and only a handful of companies own the rights to most of the food seed sold in the world. The Infectious Diseases Challenge In the previous century, such spectacular progress was made in infectious disease control that many health professionals felt that antibiotics and vac- cines would soon eliminate infectious disease threats from most developed nations. Unfortunately, drug resistant strains of tuberculosis have also emerged making control even more diffcult. Several other diseases emerged, or reemerged, in the last of the previous century. The unfounded optimism of the mid-1900s has been replaced by greater resolve to solve some of the most intractable problems in infectious diseases. The remainder of this book will lay out the techniques and tools of infectious disease epidemiology and then describe some of the important infectious diseases. The book is not intended to be a comprehensive study of all infectious diseases, but we hope it will give the fundamental tools and knowledge necessary to advance the readers understanding of infectious disease epidemiology. An account of the bilious remitting fever as it appeared 1515 in Philadelphia in the summer of 1780. Observations Made During the Epidemic of Measles in the Faroe Island in the Year 1846. Nvove verme intestinalumano (Ancylostoma duodenale) constitutente un sestro gemere dei nematoide: proprii delluomo. Assadian O, Stanek G Theobald Smith—the discoverer of ticks as vectors of disease. Batelle Medical Technology Assessment and Policy Research Program, Center for Public Health Research and Evaluation. Ten great public health achievements—United States, 1900–1999, control of infectious diseases. Transgenic rice (Oryza sativa) endosperm expressing daffodil (Narcissus pseudonarcissus) phytoene synthase accumulates phytoene, a key intermediate of provitamin A biosynthesis. Improving the nutritional value of golden rice through increased pro-vitamin A content. Effects of vitamin A supplementation on immune responses and correlation with clinical outcomes. Kaposi’s sarcoma and Pneumocystis pneumonia among homosexual men—New York City and California. It is hard to tell what goes with what here, including the names of the scientists. If he’s part of the diphtheria crew then change the names to “Klebs, Loeffer, and Gaffky”. Either is appropriate here 10 Au: Is this supposed to be a note number citing a reference? This diffculty in emptying air out of the lungs (airfow obstruction) can lead to shortness of breath or feeling tired because you are working harder to breathe. Chronic bronchitis is a condition of increased swelling In emphysema, the walls of some of the alveoli have and mucus (phlegm or sputum) production in the been damaged. The diagnosis of chronic bronchitis is made based on symptoms of a cough that produces mucus or phlegm on most days, for three Microscopic view of months, for two or more years (after other causes for normal Alveoli the cough have been excluded). Emphysema is a condition that involves damage to the walls of the air sacs (alveoli) of the lung. Airway obstruction occurs in opportunities to share experience with other patients emphysema because the alveoli that normally support and families. Without their support, the breathing tubes The term chronic in chronic obstructive pulmonary collapse, causing obstruction to the fow of air. What to do… Surgical procedures such as lung volume reduction surgery or lung transplantation may be helpful for ✔ Stop smoking and avoid smoke exposure. The information appearing in this series is for educational purposes only and should not be used as a substitute for the medical advice one one’s personal health care provider. Two principal approaches to improving women’s nutritional status are outlined: nutritional supplementation and behavior change. They include cardiovascular disease, cancers, respiratory diseases, diabetes, obesity, and musculoskeletal disorders. Following birth, environmental exposures during infancy, childhood and adult life can then further modify the risk of developing these chronic diseases in later life.

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The modern era of surgery has led to open-heart surgery order 50 mg female viagra with amex women's health clinic abu dhabi, joint replacement order female viagra with visa women's health clinic in ottawa, and organ transplantation. Before the middle of the twentieth century, advances in medicine and conclusions about human illness occurred mainly through the study of anatomy and physiology. The case study or case series was a common way to prove that a treatment was beneficial or that a certain etiology was the cause of an illness. There were intense battles between those physicians who wanted to use statistical sampling and those who believed in the power of inductive reasoning from physiological experiments. This argument between inductive reasoning and statistical sampling contin- ued into the nineteenth century. Pierre Simon Laplace (1814) put forward the idea that essentially all knowledge was uncertain and, therefore, probabilistic in nature. The work of Pierre Charles Alexandre Louis on typhoid and diphtheria (1838) debunking the theory of bleeding used probabilistic principles. On the other side was Francois Double, who felt that treatment of the individual was more important than knowing what happens to groups of patients. The art of medicine was defined as deductions from experience and induction from phys- iologic mechanisms. The rise of modern biomedical research Most research done before the twentieth century was more anecdotal than sys- tematic, consisting of descriptions of patients or pathological findings. James Lind, a Royal Navy surgeon, carried out the first recorded clinical trial in 1747. In looking for a cure for scurvy, he fed sailors afflicted with scurvy six different treatments and determined that a factor in limes and oranges cured the disease while other foods did not. His study was not blinded, but as a result, 40 years later limes were stocked on all ships of the Royal Navy, and scurvy among sailors became a problem of the past. Research studies of physiology and other basic science research topics began to appear in large numbers in the nineteenth century. By the start of the twenti- eth century, medicine had moved from the empirical observation of cases to the scientific application of basic sciences to determine the best therapies and cat- alog diagnoses. Although there were some epidemiological studies that looked at populations, it was uncommon to have any kind of longitudinal study of large 8 Essential Evidence-Based Medicine groups of patients. There was a 200-year gap from Lind’s studies before the con- trolled clinical trial became the standard study for new medical innovations. It was only in the 1950s that the randomized clinical trial became the standard for excellent research. Beginning in the early 1900s, he developed the basis for most the- ories of modern statistical testing. Austin Bradford Hill was another statistician, who, in 1937, published a series of articles in the Lancet on the use of statisti- cal methodology in medical research. In 1947, he published a simple commen- tary in the British Medical Journal calling for the introduction of statistics in the medical curriculum. He showed that streptomycin therapy was superior to standard therapy for the treatment of pulmonary tuberculosis. Finally, Archie Cochrane was particularly important in the development of the current movement to perform systematic reviews of medical topics. He was a British general practitioner who did a lot of epidemiological work on respira- tory diseases. In the late 1970s, he published an epic work on the evidence for medical therapies in perinatal care. This was the first quality-rated systematic review of the literature on a particular topic in medicine. As Santayana said, it is important to learn from history so as not to repeat the mistakes that civilization has made in the past. The improper application of tainted evidence has resulted in poor medicine and increased cost without improving on human suffering. This book will give physicians the tools to evalu- ate the medical literature and pave the way for improved health for all. In the next chapter, we will begin where we left off in our history of medicine and statistics and enter the current era of evidence-based medicine. The most savage controversies are those about matters as to which there is no good evidence either way. Bertrand Russell (1872–1970) Learning objectives In this chapter, you will learn: r why you need to study evidence-based medicine r the elements of evidence-based medicine r how a good clinical question is constructed The importance of evidence In the 1980s, there were several studies looking at the utilization of various surg- eries in the northeastern United States. These studies showed that there were large variations in the amount of care delivered to similar populations. They found variations in rates of prostate surgery and hysterectomy of up to 300% between similar counties. The researchers concluded that physicians were using very different standards to decide which patients required surgery. Both clinicians and policy makers need to know whether the 9 10 Essential Evidence-Based Medicine Fig. Patient values conclusions of a systematic review are valid, and whether recommendations in practice guidelines are sound. This is a paradigm shift that represents both a breakdown of the traditional hierarchical system of medical practice and the acceptance of the scientific method as the governing force in advancing the field of medicine. Evidence-based medicine can be seen as a combination of three skills by which practitioners become aware of, critically analyze, and then apply the best avail- able evidence from the medical research literature for the care of individual patients. This set of skills will help you to develop critical thinking about the content of the medical literature. The application of research results is a blend of the available evidence, the patient’s preferences, the clinical situation, and the practitioner’s clinical experience (Fig. In response to the high variability of medical practice and increasing costs and complexity of medical care, systems were needed to define the best and, if pos- sible, the cheapest treatments. Individuals trained in both clinical medicine and epidemiology collaborated to develop strategies to assist in the critical appraisal of clinical data from the biomedical journals. In the past, a physician faced with a clinical predicament would turn to an expert physician for the definitive answer to the problem. This could take the form of an informal discussion on rounds with the senior attending (or consul- tant) physician, or the referral of a patient to a specialist. The answer would come from the more experienced and usually older physician, and would be taken at face value by the younger and more inexperienced physician. That clinical answer was usually based upon the many years of experience of the older physi- cian, but was not necessarily ever empirically tested. Evidence-based medicine has changed the culture of health-care delivery by encouraging the rapid and transparent translation of the latest scientific knowledge to improve patient care. This new knowledge translation begins at the time of its discovery until its gen- eral acceptance in the care of patients with clinical problems for which that knowledge is valid, relevant, and crucial. Most practitioners have to keep up by regularly reading relevant scientific journals and need to decide whether to accept what they read. Most health-care workers will spend a greater part of their time functioning as “users” of the medical evidence.