It’s estimated there are more than 6 million Americans who suffer from diabetes, but don’t know it. Going without treatment, these people face a whole host of complications from the disease. Many of these complications can be life threatening, or at least altering. With this in mind, it’s important that anyone be able to recognize the many different diabetes symptom possibilities.

The reason so many diabetes symptom possibilities are overlooked by the person who is suffering from them and even their friends and family is that they seem relatively harmless. They are nearly silent markers of the condition. But, if they are tied together early enough and help is sought, this condition can be controlled and regulated with a great deal of success. If they are not recognized and treatment isn’t sought, diabetes can bring with it such complications as blindness, kidney failure, heart disease and more. It’s not a condition that should be ignored.

The subtle diabetes symptom possibilities include such things as frequent urination, severe hunger and thirst, rapid weight loss, vision problems and even aching joints and irritability. As the body struggles with an excessive amount of sugar in the bloodstream, the symptoms can become more extreme. They might even include fatigue, excessive sweating and even an inability to satisfy thirst at all. Women might even notice more frequent yeast infections and thrush might present in men, women and even children.

If these diabetes symptom possibilities present in combination and cannot be attributed readily to other causes, it’s a very good idea to seek out medical help. There are some very simple blood tests that can be performed to identify diabetes or a predisposition for it. Those who suffer from the condition might find they need insulin therapy to keep the symptoms in check, but the overall inconvenience of regulation pales in comparison to the damage sugar can do to the body.

The truth is diabetes symptom possibilities can be very difficult to recognize. But, if one or more do present on a persistent basis, it’s a very good idea to get medical help. The course of treatment can help a person with diabetes live a relatively normal, trouble free life.

With some 6 million Americans going through daily life without even realizing they have a condition that can rob them of their eye sight, mobility and even lives, it’s very important for everyone to be aware of the subtle diabetes symptom possibilities. Knowing how to recognize them and draw lines to connect the dots can save a life – maybe even yours!

It is rarely for us to talk about joint pain and stiffness in the weather change situation. Arthritis symptom can be cause by many of the explanation that has been talk in the article before but I want to stress that the weather is one of the factor.

When the weather turns wet, the access amount of fluids will lubricate the joints and the tissue. The symptom start to occur and will affect one or more areas of the body. This all happened due to the change in the barometric pressure.Many people will agree that staying still to long ar been overly active is the major cause of this symptom while the weather come second. This is always different level and feel of the arthritis symptom happened for every individual but as the symptom affected , they will experience one common arthritis symptom which is stiffness and joint pain that is caused by inflammation of the joints.

For some people, the joints are affected when their body naturally develop calcium phosphate crystals or uric acid at the joint area. As consequences, it will cause an increase of limited mobility and pain.Beside it will affect the joints and the tissue, the symptom can affect the body,fatigue, anemia,result in weight and also affect the lungs, heart and your eyes.There are debate about the age of people that can be affected with this symptom. Majority agree that it will start at the age of thirty ad younger.

The most common forms of arthritis is osteoarthritis. This osteoarthritis can include degeneration of one or more of the joints that affect the cartilage and the lining around the bones.Other than that,it also can cause tears in the synovial joints. At this stage, if someone handle this symptom without care and precautions, they will feel much more pain that before.

Rheumatoid arthritis is one of the common form of the arthritis. The symptom of the Rheumatoid arthritis include line of the joints can become inflamed , caused stiffness and swelling on the tissue and the membranes of the line.In the long term, rheumatoid arthritis can cause deformity of the joints.In addition to these symptoms, but those involved in rheumatoid arthritis can also extreme fatigue, lack of appetite, and low-grade fever throughout the body.

It’s easy to immediately think of insomnia when one hears of the term sleep disorder. A lot of people may not know though that sleep apnea is also an equally distressing sleep disorder. The best way to secure oneself from the threat of apnea is to recognize a sleep apnea symptom.

Dangers of Sleep Apnea

The reason why one should be able to recognize a sleep apnea symptom is because it is a potentially life threatening condition. Aside from exhausting the body and retarding your functions, sleep apnea could lead to more serious conditions such as stroke, heart disease and gastroesophageal reflux disease to name just a few.

There are three types of sleep apnea. Central sleep apnea is when the brain fails to signal breathing. Obstructive sleep apnea is when the muscles in the air passage collapses or becomes blocked by tissues that prevent air from getting through. The third type is a mix of the two major apnea types. Although they may have their differences, they may share a similar sleep apnea symptom or two.

Symptoms

It is believed that the most common sleep apnea symptom is snoring. This sleep apnea symptom may begin immediately after falling asleep and can grow louder as sleep progresses. It has since been discovered though that sleep apnea may still occur even without this common sleep apnea symptom. It is also possible that one may be a loud snorer without necessarily having an apnea condition.

It is logical to therefore conclude that the cessation of breathing is a more determining sleep apnea symptom. Aside from this obvious sleep apnea symptom, an individual could also gasp and choke while asleep and may eventually wake up dazed and confused. Daytime sleepiness is an insomnia symptom that may also point to a sleep apnea condition.

Accompanying Conditions

It may also be a good idea to look for a sleep apnea symptom among the conditions caused by apnea itself. A person suffering from this condition could end up being depressed because apnea causes either light sleep or wakefulness that in turn causes tiredness and irritability.

Importance of an Observer

Often times, a person with a sleep apnea symptom doesn’t know that he has it himself. After all, a sleeping person cannot know what goes on during sleep. The responsibility of first noticing an apnea condition therefore falls on the shoulders of housemates or bed mates. Once a symptom like cessation of breathing becomes obvious a person who is believed to have apnea should be brought to a specialist for proper diagnosis. Housemates should also take note of personality changes brought about by disturbed sleep.

When a person goes through alcoholic rehabilitation he will have to deal with the inevitable alcohol detox symptom. This symptom is a side effect experienced by the person when he deprives himself of the substance his body once depended on. There are a few of symptoms a person might experience when going through alcoholic rehabilitation and the degree of severity of these symptoms will depend upon the degree of alcohol dependence.

Can We Skip Detoxification?

If the person seeking help is someone who has just started drinking and feels that he is starting to get addicted and wants change then he need not go through detoxification. It’s a matter of how much the alcohol has infiltrated their systems. However, if the patient has been an alcoholic for a long time then the answer is definitely no. Also called detox, detoxification is the process of purging the body of the unwanted substance, in this case alcohol. In other words, it constitutes the whole course of the rehabilitation. This controlled withdrawal of the substance from the body will cause the body to go through an alcohol detox symptom or two.

What Are Some of the Alcohol Detox Symptoms a Person Can Experience?

Headaches, nausea, insomnia and high blood pressure are common alcohol detox symptoms. Among the most dangerous symptoms are seizures and hallucinations. This is why it is important that a person does not try withdrawal on his own. With out the proper medical attention or careful supervision of family or friends, the withdrawal symptoms may go from unpleasant to life threatening.

The suffering caused by an alcohol detox symptom can be traumatic for the patient and it is common for him to not want to experience it again. Most of the time, it is this memory of excruciating pain that keeps the person sober.

Anxiety disorders cost the United States of America $46.6 billion every year. Anxiety disorders are the most common mental illness in America, even more common than depression. Generalized Anxiety Disorder is just one of these anxiety disorders. Generalized anxiety disorder symptoms affect approximately 4 million people in America alone on a regular basis. Interestingly enough, it also affects twice as many women as men.

In the past, generalized anxiety disorder treatment has been limited to medication and expensive ongoing psychological visits. This article will discuss the most common generalized anxiety disorder symptoms as outlined by the DM-IV, the effect a generalized anxiety disorder symptom has on its sufferers and relief available for generalized anxiety disorder symptom sufferers.

Generalized anxiety disorder is one of the more common anxiety disorders. Anxiety disorders cover a vast number of anxieties such as pathological anxiety, fear, phobia and nervous conditions. These disorders may come on without warning out of the blue or over many number of years and have an overwhelming impact on the lives of people who suffer from anxiety symptoms. One thing is clear and that is to be able to correctly diagnose a Generalized Anxiety Disorder and its symptoms (GAD) the Generalized Anxiety Disorder Symptom must be present more days than not for at least six months time. A Generalized Anxiety Disorder symptom can be difficult to diagnose at times because it is not as dramatic as some other anxiety disorder symptoms seen with other anxiety disorders.

Here is a guide to the diagnostic criteria for Generalized Anxiety Disorder symptoms according to the DM-IV:

Generalized Anxiety Disorder Symptom 1 - Excessive anxiety and worry (apprehension), occurring more days than not for a period of at least 6 months, about numerous events or activities;

Generalized Anxiety Disorder Symptom 2 - The person with GAD finds it hard to control the worry;

Generalized Anxiety Disorder Symptom 3 - The anxiety and worry are associated with three or more of the following six symptoms, with at least some symptoms are present for more than 6 months in most days than not (at least one is required for children):

Generalized Anxiety Disorder Symptom 4 - restlessness or feeling tense or on the edge

Generalized Anxiety Disorder Symptom 5 - easily fatigued

Generalized Anxiety Disorder Symptom 6- difficulty concentrating or mind going blank

Generalized Anxiety Disorder Symptom 7 - irritability

Generalized Anxiety Disorder Symptom 8- muscle tension and muscle aches

Generalized Anxiety Disorder Symptom 9 - difficulty falling or staying asleep, or restless unsatisfying sleep

Generalized Anxiety Disorder Symptom 10 - difficulty swallowing

Generalized Anxiety Disorder Symptom 11 - trembling, sweating

Generalized Anxiety Disorder Symptom 12 - nausea, light-headedness

Generalized Anxiety Disorder Symptom 13 - feeling out of breath

These generalized anxiety disorder symptoms cause significant impairment and distress to the social, occupational or other important areas of the lives of sufferers. Fortunately, through research supported by the National Institute of Mental Health and the industry effective treatments are now available to treat generalized anxiety disorder symptoms in the comfort and privacy of your own home - and not all of these involve medication or cognitive-behavioral therapy.

When I wrote “Urgent Updates to Prenatal Care,”1 it was my intent to share with the profession some specific information about treating pregnant women. I received several e-mails thanking me for the information I had shared, including a few with specific questions. I also received a few e-mails that greatly disagreed with my comment about not performing a side-posture adjustment on a pregnant woman. I usually keep my articles fairly short and to the point; however, clearly more detail was needed in my last article.

As I have stated before, what I write is in my opinion.2 In this instance, “Urgent Updates to Prenatal Care” was based upon a review of courses I had taken, the materials I had seen and OBs with whom I had discussed care. I believe what I wrote is reasonable. Let me also add that I have taken the class for hospital chiropractic, I have worked in a hospital, and I work now with two OB/GYNs. I am proudly a chiropractor, but I work with and understand the mindset of MDs. I know medical doctors are very careful about anything that could be contraindicated, and that to ignore any pertinent information is negligence. 1 did discuss rotational moves with the OBs I work with. They thought it made perfect sense not to do a rotational-type adjustment, as there is a potential risk. Shouldn’t midwives and OBs be the ones to advise us of the risks during pregnancy, since this is their entire patient base? If OBs and midwives suggest there is a potential risk, why isn’t that good enough? Why take the chance?

I do believe pregnant women need chiropractic. Facilitating a healthy pregnancy and restoring a normal physiological environment for natural birth is well within the chiropractic scope of practice.3 Pregnancy is perhaps the most traumatic experience a woman’s body will ever undergo.4 The body begins to change from the moment of conception. Given the progressive postural stresses and ligamentous laxity, pregnancy creates a myriad of distinct aches and pains. The most common of these is lower back pain, especially in the second and third trimester.5

“Because of these physiological and biomechanical compensations, practitioner care must be taken to select the specific analysis and adjustment most appropriate for the complex changes during the various stages of pregnancy. The increased potential for spinal instability in the mother and the resulting subluxations in the woman’s spine throughout pregnancy affect the health and well-being of both her and her baby.”6

Pregnant women are probably some of the best candidates for chiropractic. However, the normal battery of techniques is not always appropriate for care. “The obstetrician [physician in general includes chiropractor] must be aware of the normal physiology of pregnancy and the unique response of the pregnant patient to stress and trauma.”7

I did not state that side posture itself causes placental abruption. I said that rotational motion brings an increased risk for placental abruption. Since one or both of these can occur during an “aggressive” side-posture adjustment, I advise to adjust in a different way. To quote what I did say, “Using a higher-force technique can cause more problems than relief, so less force is the standard. Also, straightline-of-correction techniques should be used - Thompson, Activator or Nimmo. If you are in the habit of performing a diversified side-posture roll, it is time to learn a new technique. Remember, a pregnant body is chemically and biomechanically different from a nonpregnant body, and the usual battery of techniques is not always appropriate.”

I am aware that the Gonstead technique uses a straight line of correction when performing a side-posture adjustment. However, there are cautions about very careful patient positioning, as anything less would lead to insufficient correction or a negative response from the patient.” A chiropractor who practices nonforce technique said it like this: “DNFT achieves the goals of traditional chiropractic to relieve pain and discomfort created by structural misalignments without all the rack ‘em, stack ‘em and cracking force on the spine.”91 can recall a comment made in my technique classes at Palmer: “Anyone can make a back crack. Monkeys can be taught to do that. The art of chiropractic is knowing how to adjust, knowing when to adjust, and knowing when not to adjust.” A patient information brochure on pregnancy notes, “Modifications to the table or adjusting technique are made during each stage of pregnancy.”‘” Clearly, I am not alone in my belief that some degree of caution is reasonable and responsible.

Of course, I know that not all doctors adjust aggressively. I have no way of determining another doctor’s individual skill or level of aggressiveness. Again, I prefer to play it safe. There are enough other techniques available to the practitioner - why take the chance? The caution raised is not a question of force, it is a question of rotation of the pelvis during pregnancy. As I stated in my previous article, even prenatal exercise and yoga classes are now cautioning against rotational-type motions, as there is a risk of abruption.” “There are obvious concerns for uterine injuries in the pregnant woman. Particularly worrisome is the specter of placental abruption, which complicates 1 to 6 percent of minor injuries and up to 50 percent of major injuries. It is hypothesized that the abruption is likely caused by deformation of the elastic myometrium around the relatively inelastic placenta.”12

In this case report, an elderly combat veteran with a chronic course of post-traumatic stress disorder (PTSD) that was untreated for nearly 60 years was evaluated and treated with a combination of medication and graded exposure psychotherapy. To the best of our knowledge, there have been no reports on graded exposure in the elderly. The course of treatment lessened the key symptom domains of PTSD. Comorbid depression was also lessened. Although a single case report, it would appear that elderly patients do respond to psychotherapeutic techniques such as graded exposure therapy. Given the large percentage of the elderly population that has witnessed combat and due to the continuing military conflicts that the United States has been involved in over recent decades, treatments for PTSD in an aging population will be necessary.

It was only several years after the cannons of the American Civil War fell silent that Dr. Jacob Da Costa wrote an article describing “irritable heart” in former soldiers. A generation later, the phenomenon called “shell shock” was written about the horrific battles of World War I. Still later “combat neurosis” was used to describe this entity in World War II, until the Diagnostic and Statistical Manual of Mental Disorders III changed the name of this syndrome to post-traumatic stress disorder (PTSD). As PTSD became increasingly more relevant in the 20th century, figures in the field of psychology no less significant than Freud, Jung, and Piaget pondered the mechanisms of this disorder.1

At the dawn of the 21st century, PTSD continues to play an important role in the mental health care system. Temporally closer to our time will be the scourge of combat-related trauma victims of World War II, the Korean Conflict, and the Vietnam Conflict. Nonetheless, the generation that fought in the Persian Gulf War Conflicts and the War on Terror will quickly rise and present for treatment in increasing numbers over the coming years. Recent research has established that 25% of elderly men have experienced combat and that 50 to 70% of the general American population over a lifetime will experience a trauma meeting diagnostic criteria for PTSD.2 PTSD in the elderly population also has several distinguishing features that have been noted.

Despite the commonly held belief that PTSD symptoms ameliorate with age, retirement tends to worsen symptoms of PTSD.3 Factors involved in this are thought to be the loss of the ability to submerge the earlier trauma in the world of business or family life. Also, retirement age individuals experience other stressors such as the loss of friends to illness and death and a general decline in economic resources.3 Elderly patients with PTSD also are noted to suffer a greater burden of somatic complaints due to the illness.4 Anxiety disorders frequently affect the cardiovascular system, central nervous system, and endocrine system via the hypothalamic pituitary axis.4 Another aspect of PTSD in the elderly patient that bodes poorly is its persistence as a diagnosis.5

For the above reasons, as the general population continues to grow older, PTSD in the elderly will undoubtedly become more prevalent. Society will need newer and better treatment modalities as PTSD can prove to be a protracted and treatment-resistant disorder with significant morbidity, comorbidity in psychiatric and somatic health, and mortality.

Case Report

C.R. is an 82-year-old married Caucasian male with multiple medical problems who presented with a chief complaint of “nightmares and flashbacks of the Battle of the Bulge (Ardennes Offensive).”

History of Present Illness

C.R. served one term in the army from 1942 to 1946 in the European theater of World War II. He vividly remembers the campaign that began in the Ardennes Forest of Belgium during the winter of 1944 to 1945. During the interview, he expressed his fear of not surviving this battle and the horrors he experienced while in combat.

After his return from the war, he began re-experiencing explosions, witnessing dismembered or dead army soldiers, and running through the forests in the snow and ice. Another particularly disturbing memory that repeatedly surfaced was of a severely injured comrade asking for a “mercy killing” to “put him out of his misery.” He described these phenomena as “flashbacks” and stated that they occurred only occasionally since his discharge from active military duty in 1946 but intensified greatly during the early years of the Korean conflict.

C.R. reported frequent nightmares since the early 1950s that were usually about themes of the war-dogs chasing him through the forest, bullets whizzing nearby and striking trees, and dismembered corpses. Commonly, the dreams had no substance but he woke up with feelings of dread and terror and usually sweating and shaking. C.R. reported that the nightmares occurred about two nights per week since that time. These dreams continued in frequency and intensity up to the time he presented for treatment over 50 years later. He described these symptoms as “something I thought was normal for people who had been in battle and would have to deal with for the rest of my life.” It was his opinion that the exposure to men in military service during the Korean conflict exacerbated his symptoms and established their permanence. The patient admitted that he had difficulties discussing the trauma of the Ardennes Offensive and avoided the topic with his family. In addition, he has avoided sports events and malls which disappointed his wife who enjoyed sports and shopping. He described being bothered by loud noises and had given up hunting many years ago as the combination of being in a wooded location with loud firearms exacerbated his symptoms and triggered “flashbacks.” C.R. reported that he becomes startled easily and spoke of sitting in the corners of restaurants so other patrons would not be directly behind him. One major reason for his seeking treatment was due to his noticing an increasing irritability that he was concerned over as he had several times verbally “snapped” at his wife. The symptoms C.R. discussed-re-experiencing phenomena, avoidance, and hyperarousability-met diagnostic criteria for PTSD.

In May 2006, the Illinois Department of Public Health (IDPH) informed CDC about a possible increase in Acanthamoeba keratitis (AK) at an ophthalmology center in Illinois during the preceding 3 years. The University of Illinois at Chicago (UIC) was investigating this possible increase. In October 2006, IDPH updated CDC about the ongoing UIC investigation. At that time, CDC informally contacted multiple ophthalmology centers in the United States to assess whether the potential increase in cases extended beyond Illinois. Responses from the ophthalmology centers were inconclusive. In January 2007, CDC initiated a retrospective survey of 22 ophthalmology centers nationwide to assess whether cases were increasing throughout the United States. In March 2007, data received from 13 centers demonstrated an increase in culture-confirmed cases of AK with wide geographic distribution. The increase in cases had begun in 2004 and continued to the present. On March 16, 2007, CDC initiated a multistate investigation to look for risk factors associated with this increase in AK cases. This report summarizes recent preliminary results of that investigation, which, indicated an association with AK in soft contact lens wearers who used Advanced Medical Optics (Santa Ana, California) Complete[R] MoisturePlus[TM] (AMOCMP) multipurpose cleaning solution. CDC and the Food and Drug Administration (FDA) are taking steps to notify the public and the medical and public health communities of this preliminary association. The manufacturer has undertaken a voluntary recall of the product.

AK, a rare but potentially blinding infection of the cornea, is caused by a ubiquitous, free-living ameba (Acanthamoeba) that is found commonly in the environment, including water (e.g., tap and recreational water), soil, sewage systems, cooling towers, and heating/ventilation/air conditioning (HVAC) systems. AK primarily affects otherwise healthy persons who wear contact lenses; an estimated 85% of U.S. cases occur in contact lens wearers (including wearers who follow recommended contact lens-care practices) (1). Persons who improperly store, handle, or disinfect their lenses (e.g., by using tap water or homemade solutions for cleaning); swim, use hot tubs, or shower while wearing lenses; come in contact with contaminated water; have minor damage to their corneas; or have previous corneal trauma are at increased risk for infection (2). Based on an analysis of cases reported to CDC during 1985-1987, the incidence of AK in the United States has been estimated at one to two cases per million contact lens users (3,4). An estimated 30 million persons in the United States wear soft contact lenses (5).

Initial case finding for this investigation was facilitated through postings on the Epidemic Information Exchange (Epi-X), on ophthalmology/optometry/infection control listservs and websites, and through queries of clinical microbiology laboratories. As of May 24, 2007, a total of 138 patients with onset of symptoms on or after January 1, 2005, and positive Acanthamoeba cultures from corneal specimens had been reported to CDC by public health authorities and ophthalmologists from 35 states and Puerto Rico. Standardized telephone interviews of patients, ophthalmologists, and primary eye-care providers are being conducted by state and local health officials and CDC. Laboratory testing of clinical specimens, contact lenses, bottles of solution, and contact lens cases received from AK patients, including typing of Acanthamoeba spp. isolates, is ongoing. An initial analysis was conducted using data from the first 46 completed patient interviews.

Among the 46 culture-confirmed patients who were interviewed, the median age was 40 years (range: 15-77 years); six (13%) were aged <18 years. Twenty-seven (59%) were female. Of the 37 of these patients for whom clinical data were available, medical therapy was unsuccessful for nine (24%), and they were required or expected to undergo corneal transplantation. Of the 46 patients, 39 (85%) wore soft contact lenses, three (7%) wore rigid lenses, and four (9%) reported no contact lens use. Among the 42 contact lens users, 16 (38%) reported swimming while wearing contact lenses and 35 (83%) reported showering while wearing contact lenses during the month before symptom onset.

Among the 39 soft contact lens users, 36 reported using one or more specific types of contact lens solution, 21 of these (58%) reported any use of AMOCMP in the month before symptom onset, 20 (56%) reported using AMOCMP as their primary solution, and 14 (39%) reported using AMOCMP as their exclusive solution. Exposure data from the 36 patients who wore soft contact lenses and used any type of contact lens solution were compared with exposure data from controls who were interviewed as part of the 2006 CDC Fusariurn keratitis outbreak investigation (6). These controls, who were selected as geographically matched controls for the Fusarium keratitis cases, represented a sample of adult soft contact lens wearers from different U.S. states who were asked about product use and behaviors during March 2006 (6).

In Part I of this series, we described the problem of inappropriate care in the United States and how solutions to cost and quality in health care can be effectively dealt with at the organizational level.

We began a consideration of the sequential phases of evidence-based quality improvement work, starting out with readying an organization for evidence-based quality improvement. Now, let’s look at details of using the five A’s (1) of evidence-based medicine to identify and close quality and cost gaps in health care organizations.

Once an organization creates the structural components, such as committees and work groups, and establishes processes for those groups, and once it ensures that staff have the needed knowledge, skills and tools to carry out the five A’s of evidence-based clinical improvement (Asking, Acquiring, Appraising, Applying, A’s Again), each group can begin to identify “fixable” or “closable” quality, cost, satisfaction and uncertainty gaps in clinical care.

The sequential steps in this evidence-based process are outlined in Table 1.

The Institute of Medicine outlined six quality domains (Table 2) which are useful in determining areas within an organization where there may be quality gaps and where quality may be improved. (2)

The size of the gap should justify the effort it will take to close it. To determine the size of the performance gap in a potential work area, groups need to compare internal organizational data (usually obtained from organizational databases) with the best available evidence (obtained from content resources, such as sources for guidelines, clinical recommendations or the medical literature itself.)

All the data must be appraised for validity unless they come from a trusted source such as Cochrane, Clinical Evidence or the Database of Reviews of Effects (DARE)–and must be updated and assessed for usefulness.

In Part I of this series, we indicated that frequently physicians, as well as quality improvement professionals and other decision-making health care professionals, lack the skills to effectively and efficiently search for, critically appraise and synthesize scientific evidence using processes that yield valid, useful and usable content likely to improve desired outcomes.

Individuals doing quality improvement work may benefit from training that can successfully provide the skills and tools for evaluating the medical literature. Training should improve competencies in finding and utilizing studies with appropriate designs, valid methods and useful results.

An approach we have found useful is to teach these skills using the five “A”s of evidence-based medicine:

* Ask — How to construct effective clinical questions

* Acquire — Tips and strategies for systematically capturing potentially useful content through awareness of the best sources for information, application of successful search techniques and filtering strategies

* Appraise — Concepts and methods for evaluating content for validity, usefulness and usability, along with organizational considerations (e.g., cost, legal, marketing, public relations and other value considerations)

* Apply — Using valid and useful content, how to synthesize the body of evidence, creating information, decision and action aids for use by clinicians, patients and others

* “A”s Again — When and how to repeat the process to ensure information is current

These sequential steps are summarized in Table 3 and can be made easier by utilizing various tools.

After completing the evidence synthesis, we strongly recommend making evidence-based estimates regarding local quality and cost outcomes followed by the development of information, decision and action tools, implementation plans and measurement plans. We will describe the details of these steps in Part III of this series. (Watch for it in the May/June 2005 issue of The Physician Executive.)

The biomedical literature has exploded over the past 50 years. The purpose of this study was to track the growth of drug therapy literature using the online provider PubMed. We utilized the first 20 Disease [C] MeSH listed on the 2005 MeSH tree structures for our study. Drug therapy literature was searched using the disease MeSH with the ending / drug therapy or / chemically induced. Publication numbers were compiled each year from 1966 to 2003. Disease articles increased by 612% from 1966 to 2003. Drug therapy articles increased by 1,116% during the same period. As a percentage of all disease articles, drug therapy publications increased from 11% to 18% over this time period. Drug therapy review articles grew by 10,521% over the time period; drug therapy randomized clinical trials increased by 5,228%. Geriatric drug therapy articles increased at a greater rate than pediatric literature (1,210% vs. 637%). Infectious disease (14%), oncology (14%), immunologic diseases (10%), cardiovascular disease (9%), and neurologic/psychiatric diseases (8%) constitute the highest percentages of all drug therapy articles. Drug therapy literature is growing at a faster rate than the disease literature on PubMed. Drug therapy review articles alone are approaching 10,000 articles/year and are the fastest growing subsection of the drug therapy literature on PubMed.

It is impossible for any clinician to keep up with all the biomedical literature published today. Haynes et al. (1) stated the problem: “If physicians were to read everything of possible biomedical relevance, they would need to read 5,500 articles per day.” Of course, this statement was published in 1986, when there were approximately 20,000 biomedical journals published in the world. Today, there are over 40,000 journals, so a clinician now has to read over 10,000 articles per day to keep up (2). It seems clear that the biomedical literature is proliferating at an accelerated rate. But, does the entire body of literature grow uniformly? Are there subsections of the literature growing at a faster or slower rate? Obviously, there are scientifically “hot” areas that probably expand rapidly for a period of time. We were curious regarding the growth of the pharmacotherapy literature relative to the disease literature and the biomedical literature as a whole.

Bibliometrics can be defined as “the use of statistical methods in the analysis of a body of literature to reveal the historical development of subject fields and patterns of authorship, publication, and use” (3). Medical bibliometrics is often narrowly thought of as the use of citation analysis or impact factors to assess publication patterns (4-6). On the contrary, medical bibliometric methods have been used to evaluate the geography of biomedical publications (7-12) and the publication patterns of individual and therapeutic classes of drugs (13-15).

The purpose of this study was to utilize bibliometric methods to track the growth of drug therapy literature using the online provider PubMed.

METHODS

All searches were performed during the months of February and March 2005 using the online provider PubMed. We searched the first 20 Disease [C] Medical Subject Headings (MeSH®) listed on the 2005 MeSH tree structures [C01] through [C20], excluding [C21] through [C23] (Table 1). Literature was searched using the search strategies listed in Table 2. Search strategy 1 was used to search drug therapy-related articles; search strategy 2 was used for disease articles; and search strategy 3 was used to search for drug-induced disease articles. Searches were further classified using the limit fields “publication type” and “subsets” and publication dates. Additional qualifiers included English language and human selection on the PubMed limit search option. Publication numbers were compiled each year from 1966 to 2003. Data were converted to logarithms for graphical representation. We did not include 2004 data because some were still being indexed into the Medlars system in February and March 2005.

RESULTS

Figure 1 represents the growth of disease articles, drug therapy articles, and drug-induced disease articles from 1966 to 2003. Percentage increase over this time was greater for the subset of disease articles that are drug therapy articles (1,116%) than for all disease articles (612%) (see Table 3). The drug-induced disease literature appears to be a slower-growing subsection of the literature compared to, for example, review articles, randomized clinical trials, and acquired immunodeficiency syndrome (AIDS) or cancer drug literature. As a percentage of all disease articles, the subset of drug therapy has increased from 11% in 1966 to 18% in 2003. Figure 2 maps the growth of the cancer, AIDS, and complementary and alternative medicine drug therapy literature, along with the specialty practice areas of pediatric and geriatric drug literature. The AIDS drug literature follows the expected time course consistent with the identification of the disease and its growth (3,226%).