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Zoning may be particularly useful where disease elimination is not feasible [►Section 3 cheap fluconazole 150 mg with mastercard. Buffers and barriers A buffer zone is an area of uninfected status (under surveillance) which surrounds the infected zone discount 150mg fluconazole mastercard. Its purpose is to facilitate prevention of disease spread into an uninfected sub-population. The buffer zone may be identified on the basis of: an absence of hosts an absence of disease vectors only immune hosts (e. An effective buffer zone may take the form of a geographical, hydrological or climatic barrier. These barriers may be natural such as rivers and lakes (for terrestrial hosts) or terrestrial habitat (for aquatic hosts), or unnatural features in the landscape such as roads, fences or cleared habitat. Such barriers have been shown to be effective in control of disease by either slowing or preventing spread. Artificial barriers can also be used to inhibit movements of hosts but can themselves have adverse ecological consequences, such as the prevention of movements of wild animals caused by foot and mouth disease fences in parts of southern Africa. Specific considerations for water-borne diseases Within wetlands, zoning for the control of water-borne diseases is particularly challenging but may still be a useful approach. The simplest zone is that of an area that derives its incoming water from an unshared source and thus may continue to function independently of any infected areas. In the instance of an inland area that shares common water sources, the minimum zone would apply to the entire catchment area. Larger catchment areas may require multi-national and transboundary cooperation and jurisdictions as disease management relies on all aspects of the water catchment zone being managed accordingly. Restrictions on domestic and international trade of animals and derived products, may apply to infected zones. Continued surveillance is needed to confirm the absence of infection in uninfected areas. Movement of animals between zones Conditions applying to the movement of animals (either domestic or translocated wildlife) between zones should be comprehensively described in a zoned management strategy. Conditions should also apply to movement of other materials which could facilitate mechanical transfer (e. Examples of barriers and buffer zones Foot and Mouth Disease: Several countries including Botswana and Zimbabwe have implemented effective disease control strategies which include dividing the country into risk zones. These zones are managed by means of appropriate disease surveillance, movement restrictions, livestock identification and vaccination. Ring vaccination may be required as an emergency measure for animals within a certain radius of a confirmed outbreak. Anthrax: Following an outbreak in cattle a buffer zone of a specified width can be established around infected areas. All animals inside this area which have been exposed can then be vaccinated and quarantined. The influence of veterinary control fences on certain wild large mammal species in the Caprivi, Namibia. In: Conservation and Development Interventions at the Wildlife/Livestock Interface: Implications for Wildlife, Livestock and Human Health. In order to control disease spread, it is therefore crucial to understand movement patterns of potential disease hosts at a national and international level and the associated disease risks. The risk of transmission and spread of disease can be minimised by following certain guidelines for releasing and moving animals. Such measures should be supplemented by an efficient surveillance network involving the health screening of animals, particularly when they are to be moved to another area. Given the global scale of animal movements in wildlife populations and the livestock and pet trades, international cooperation in maintaining standards of moving and releasing animals is vital in preventing and controlling disease spread and reducing the risk of outbreaks. Legislation and regulations National and international legislation and regulations are in place to control the movement of animals, although disease outbreaks still occur regularly as a result of both legal and illegal movements. It is, therefore, important to familiarise yourself with legislation and regulations and their enforcing regulatory bodies, where they relate to not only a wetland site, but also to the exporting country, the transit country and the importing country [►Section 3. Certification requirements for moving animals should also be fulfilled and should clearly outline the wishes of the importing country. For this, prior consultation between veterinary authorities of importing and exporting countries may be needed. The following international organisations and regulatory bodies are concerned with the movement and trade of animals and may be able to provide further guidance. Legislation, regulations and guidance relevant to the trade and movement of domestic and wild animals (from Fèvrea et al. Information should be available from government agencies, as well as other sources, to help inform the risk assessment and protocols for relocation.

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The use of multiple tests is a more challenging clinical problem than the use of a single test alone 200mg fluconazole with amex. In general discount fluconazole 50 mg fast delivery, a result that confirms the previous test result is considered confirmatory. A result that does not confirm the previous test result will most often not change the diagnosis immediately, and should only lead to questioning the veracity of the diagnosis. If the pretest probability is high and the initial test is negative, the risk of a false negative is usually too great and a confirmatory test must be done. If the pretest probability is low and the initial test is positive, the risk of a false positive is usually too great and a confirmatory test must be done. If the pretest probability is high, a positive test is confirmatory unless the specificity of that test is very low. If the pretest probability is low, a negative test excludes disease unless the sensitivity of that test is very low. Obviously if the pretest probabilities are either very high or very low, the clinician ought to con- sider not doing the test at all. In the case of very high pretest probability imme- diate initiation of treatment without doing the test should be considered as the pretest probability is probably above the treatment threshold. Similarly, in the case of very low pretest probability, the test ought not to be done in the first place since the pretest probability is probably below the testing threshold. It is relatively easy to learn to do the calculations necessary to determine post-test probabil- ity. However, in the clinical situation, “in the trenches,” it is often not very help- ful. Almost all clinicians will most often do what they always do and have been taught to do in a particular clinical situation when it is similar to other clinical encounters they have had in the past. Those actions should be based on these same principles of rational decision making, but are learned through training 294 Essential Evidence-Based Medicine and continuing education. However, in difficult cases, one will sometimes need to think about these concepts and go through the process of application of diag- nostic test characteristics and the use of Bayes’ theorem to one’s patient. There are some general rules that ought to be followed when using diagnostic tests. If the pretest probability of a diagnosis is high and the test result is positive there should be no question but to treat the patient. Similarly, if the pretest prob- ability is low and the test result is negative, there should be no question but not to treat the patient. However, if the suspected disease has a high pretest probability and the test is negative, additional tests must be used to confirm that the patient does not have the disease. If the second test is positive, that should lead to fur- ther investigation with additional tests, probably the gold standard to “break the tie. If the second test is negative, that should lead to further investigation with additional tests, probably the gold-standard test to “break the tie. In general, go with the results of the test if that result puts the post-test probability over the treatment threshold or under the testing threshold. Ideally they compare the tests in a sample of patients who have a diagnosis that we are certain is cor- rect. The reader must be aware of potential sources of bias in evaluating these studies. Overview of studies of diagnostic tests In order to find bias in studies of diagnostic tests, it is necessary to know what these studies are intended to do. When evaluating studies of a diagnostic test, it is useful to use a structured approach. In these cases, the question relates the diagnostic test, the intervention, to the gold standard, or the comparison. The patient population is those patients in whom the test would normally be done in a clinical setting and the target disorder is the disease that is attempting to be diagnosed. Is this diagnostic tool as accu- rate as the gold-standard pulmonary angiogram obtained by squirting dye into the pulmonary artery and taking an x-ray and is it better than the old standard 295 296 Essential Evidence-Based Medicine test, the ventilation–perfusion (V/Q) scan of the lungs? Studies of diagnostic tests should begin with a representative sample of patients in whom the reasonable and average practitioner would be looking for the target disorder. This may not always be possible since studies done with dif- ferent populations may result in different results of test characteristics, a result which cannot be predicted. In the ideal situation, the patients enrolled in the study are then all given the diagnostic test and the gold-standard tests without the researchers or the patient knowing the results of either test. As with any clinical study, there will be sources of bias in studies of diagnos- tic tests. Some of these are similar to biases that were presented in Chapter 8 on sources of bias in research, but others are unique to studies of diagnostic tests. You ought to look for three broad categories of bias when evaluating stud- ies of diagnostic tests. Selection bias Filter bias If the patients studied for a particular diagnostic test are selected because they possess a particular characteristic, the resulting operating characteristics found by this study can be skewed.

Primary clinical research studies can be roughly divided into four main types 50mg fluconazole sale, determined by the elements of cause and effect cheap 50 mg fluconazole with amex. 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. A partial list of common and important medical journals is included in the Bibliography. Usually, when asked about articles in the medical literature, one thinks of clini- cal research studies. These include such epidemiological studies as case–control, cohort or cross-sectional studies, and randomized clinical trials. These are not the only types of articles that are important for the reader of the medical liter- ature. There are several other broad types of articles with which you should be familiar, and each has its own strengths and weaknesses. We will discuss studies other than clinical research in this chapter, and will address the common types of clinical research studies in Chapter 6.

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