关于足球的绘画医学学术英语u1tb文章下雨天图片
健康百科In 1955, during the dawn of the modern era of randomized clinical trials, Thomas Chalmers and his colleagues published a remarkable paper.1 It was then and probably remains one of the most detailed reports of clinical trials ever published: it begins with a Table of Contents and runs on to a further 71 pages of small type. It is a model of how randomized trials should be reported, reflecting Marc Daniels' call for better reporting of clinical trials five years earlier,2 and anticipating by over four decades the reporting standards agreed and promulgated by the CONSORT Group.3
Tom Chalmers and his colleagues described the eligibility criteria of participants clearly, and their random allocation (with concealment of the next participant's assignment) into th eir 2?×?2 factorial trials,4 thus permitting comparisons of two regimens per trial. The similarity between treatment groups in respect of 34 other variables that might affect patient prognosis was confirmed. Experimental and control regimens were precily defined, and compliance with them was cloly monitored and reinforced. All patients wer
e accounted for at the end of the trials. Analys were clearly described and transparent. The ‘external validity’ of the trial results was tested by comparison with another, independent control group of patients. Finally, late effects of the treatment regimens were assd in a 10-year follow-up study.
老挝花梨I first came across this report in 1959. Although I failed to appreciate many of its methodological strategies and strengths at that time, it changed my career. I was a final-year medical student on a medical ward, where a teenager with ‘infectious hepatitis’ (now called ‘Type-A hepatitis’) was admitted to my care. He prented with vere malai, an enlarged and tender liver, and a colourful demonstration of deranged bilirubin metabolism that made me the envy of my fellow clerks. However, after a few days of total bed rest his spirits and energy returned and he asked me to let him get up and around.
In the 1950s, ever ybody ‘knew’ that such patients, if they were to avoid permanent liver damage, must be kept at bed rest until their enlarged liver receded and their bilirubin and enzymes returned to normal. And if, after getting up and around, their enzymes ro agai
n, back to bed they went. This conventional wisdom formed the basis for daily confrontations between an increasingly restless and rentful patient and an increasingly adamant and doom-predicting clinical clerk.
面试时如何说自己的优缺点We clinical clerks were expected to read material relevant to the care of our patients. I wanted to understand (for both of us) how letting him out of bed would exacerbate his pathophysiology. After exhausting veral unhelpful texts, I turned to the journals. PubMed was decades away, and the National Library of Medicine hadn't yet begun to help the Armed Forces Medical Library with its Current List of the Medical Literature. Nonetheless, it directed me to a citation in the Journal of Clinical Investigation (back in the days when it was a real clinical j ournal) for: ‘The treatment of acute infectious hepatitis. Controlled studies of the effects of diet, rest, and physical reconditioning on the acute cour of the dia and on the incidence of relaps and residual abnormalities.’1 Reading this paper not only changed my treatment plan for my patient, it forever changed my attitude toward conventional wisdom, uncovered my latent iconoclasm, and inaugurated my career in what I later labelled ‘clinical epidemiology’.磁带存储
暧爱The paper introduced me to Tom Chalmers, who quickly became my hero and, a decade later, my friend. Tom was a US Army gastroenterologist in the Korean War, and had become involved ina major outbreak of ‘infectious’ hepatitis among American recruits. The application of conventional wisdom on enforced bed rest was keeping affected soldiers in hospital for about two months and requiring another month's convalescence. Tom wrote: ‘This drain on military manpower, along with more recent [short-term metabolic] obrvations suggesting that strict bed rest might not be as esntial as heretofore thought, emphasized the need for a controlled study to determine the safety of a more liberal regimen of rest and less prolonged hospitalization’.
Employing what I increasingly came to recognize as ‘elegant simplicity’, Tom and his colleagues allocated soldiers who met pre-defined hepatitis criteria at random either to bed rest (continuously in bed, save for one trip daily to the bathroom and one trip to the shower weekly), or to be up and about as much as the patients wanted (with no effort made to control their activity save 1-hour rests after meals) throughout their hospital stay. The time to recovery (as judged by liver function testing) was indistinguishable between t
he comparison groups, and no recurrent jaundice was obrved.
Armed with this evidence, I convinced my supervisors to let me apologize to my patient and let him be up and about as much as he wished. He did, and his clinical cour was uneventful.倩碧水磁场
My subquent ‘clinical cour’ was far from uneventful. I became a ‘trouble-maker’, constantly questioning conventional therapeutic wisdom, and offending especially the subspecialists when they pontificated (I thought) about how I ought to be treating my patients. I had a stormy time in obstetrics, where I questioned why patients with vere pre-eclampsia received intravenous morphine until their respirations fell below 12 per minute. I gained unfavourable notoriety on the medical ward, where I challenged a consultant's recommendation that I should ignore my patient's diastolic blood pressure of 125 mmHg ‘becau it was esntial for his brain perfusion’. And I deeply offended a professor of paediatrics by publicly correcting him on the number of human chromosomes (they had fallen from 48 to 46 the previous month!).
