Clinical Signs: From 1 Different Sources
The physical manifestations of an illness elicited by a doctor when examining a patient – for example, a rash, lump, swelling, fever or altered physical function such as re?exes.
A controlled research study of the safety and effectiveness of drugs, devices or techniques that occurs in four phases, starting with the enrolment of a small number of people, to the later stages in which thousands of people are involved prior to approval by the licensing authorities (for example, the Food and Drug Administration).... clinical trial
A framework through which health organizations are accountable for continuously improving the quality of their services and safeguarding high standards of care.... clinical governance
A MEDICAL AUDIT carried out by health professionals.... clinical audit
The pulse, respiration, temperature and blood pressure.... vital signs
Clinical means literally ‘belonging to a bed’, but the word is used to denote anything associated with the practical study or observation of sick people – as in clinical medicine, clinical thermometers.... clinical
Professional specialized or therapeutic care that requires ongoing assessment, planning, intervention and evaluation by health care professionals.... clinical care
A diagnosis (e.g. myocardial infarct) or a patient state that may be associated with more than one diagnosis (such as paraplegia) or that may be as yet undiagnosed (such as low back pain).... clinical condition
Services provided to patients (history-taking, physical examination, preventive care, tests, procedures, drugs, advice) or information on clinical condition or on patient state used as a patient outcome.... clinical event
Systematically developed statements which assist clinicians and patients to decide on appropriate treatments for speci?c conditions. The guidelines are attractive to health managers and patients because they are potentially able to reduce variation in clinical practice. This helps to ensure that patients receive the right treatment of an acceptable standard. In England and Wales, the NATIONAL INSTITUTE FOR CLINICAL EXCELLENCE (NICE) is developing national guidelines with advice from health-care professionals and patients to improve clinical e?ectiveness of NHS care. Some doctors have reservations about guidelines because (1) health-care managers might use them primarily to contain costs; (2) in?exibility would discourage clinical innovations; (3) they could encourage litigation by patients. (See also HEALTH CARE COMMISSION; MEDICAL LITIGATION.)... clinical guidelines
An information system that collects, stores and transmits information that is used to support clinical applications (e.g. transmission of laboratory test results, radiology results, prescription drug orders). Electronic medical records are one method by which clinical information systems can be created.... clinical information system
Clinical information, excluding information about treatment and intervention. Clinical information that does not record an intervention is by nature a clinical observation. The observer may be the patient or related person (information about symptoms, family history, occupation or lifestyle) or a health care professional (information about physical signs, measurements, properties observed or diagnoses). While information about the nature of a planned or performed treatment is excluded by the definition, clinical observations may be recorded on the results of a treatment, on progress during the course of a treatment, or on the result of a treatment.... clinical observation
A multidisciplinary set of daily prescriptions and outcome targets for managing the overall care of a specific type of patient, e.g. from pre-admission to post-discharge for patients receiving inpatient care. Clinical pathways are often intended to maintain or improve quality of care and decrease costs for patients in particular diagnosis-related groups.... clinical pathway
An instrument that estimates the extent to which a health care provider delivers clinical services that are appropriate for each patient’s condition; provides them safely, competently and in an appropriate time-frame; and achieves desired outcomes in terms of those aspects of patient health and patient satisfaction that can be affected by clinical services.... clinical performance measure
A systematically developed statement to assist practitioner and patient decisions about appropriate health care for one or more specific clinical circumstances.... clinical practice guideline
A conclusion that an intervention has an effect that is of practical meaning to older persons and health care providers. Even though an intervention is found to have a statistically significant effect, this effect may not be clinically significant. In a trial with a large number of participants, a small difference between treatment and control groups may be statistically significant, but clinically unimportant. In a trial with few participants, an important clinical difference may be observed that does not achieve statistical significance. (A larger trial may be needed to confirm that this is a statistically significant difference).... clinical significance
The experiences of a patient as communicated to a doctor, for example, pain, weakness, cough. They may or may not be accompanied by con?rmatory CLINICAL SIGNS.... clinical symptoms
Environmental medicine. Treatment of allergies by natural medicines. The science that endeavours to bridge physics and chemistry; including such disciplines as homoeopathy, acupuncture, herbalism, etc. ... clinical ecology
Initially driven by anxiety about the possibility of medical negligence cases, clinical risk management has evolved into the study of IATROGENIC DISEASE. The ?rst priority of risk managers is to ensure that all therapies in medicine are as safe as possible. Allied to this is a recognition that errors may occur even when error-prevention strategies are in place. Lastly, any accidents that occur are analysed, allowing a broader understanding of their cause. Risk management is generally centred on single adverse events. The threat of litigation is taken as an opportunity to expose unsafe conditions of practice and to put pressure on those with the authority to implement change. These might include senior clinicians, hospital management, the purchasing authorities, and even the Secretary of State for Health. Attention is focused on organisational factors rather than on the individuals involved in a speci?c case.... clinical risk management
A test on human volunteers of the effectiveness and safety of a drug. A trial can also involve systematic comparison of alternative forms of medical or surgical treatment for a particular disorder. Patients involved in clinical trials have to give their consent, and the trials are approved and supervised by an ethics committee.... trial, clinical
ultrasound features of the *Arnold–Chiari malformation in fetuses with spina bifida. The banana sign refers to the shape of the cerebellum owing to caudal displacement; the lemon sign refers to the lemon-shaped head resulting from scalloping of the frontal bones. See illustration.... banana and lemon signs
(CCGs) self-governing bodies set up by the Health and Social Care Act 2012, following the abolition of *primary care trusts and *strategic health authorities, to commission most NHS services in England. CCGs are formed of all GP practices within a given geographical area, and all GP practices must belong to a clinical commissioning group. All CCGs have their own constitution and governing body, which (in addition to GPs) must include at least one registered nurse and at least one secondary care specialist doctor. There are currently 195 CCGs in England.... clinical commissioning groups
consideration of the moral issues attendant upon, and questions arising from, clinical practice, as distinct from research. In North America, it is common for hospitals to employ a clinical ethicist or provide a formal clinical ethics consultation service. In the UK, clinical *ethics committees are increasingly common in the NHS.... clinical ethics
see community health.... clinical medical officer
the branch of medicine dealing with the study of actual patients and the diagnosis and treatment of disease at the bedside, as opposed to the study of disease by *pathology or other laboratory work.... clinical medicine
(See EVIDENCE-BASED MEDICINE.) Clinical trials aim to evaluate the relative effects of di?erent health-care interventions. They are based on the idea that there must a fair comparison of the alternatives in order to know which is better. Threats to a fair comparison include the play of chance and bias, both of which can cause people to draw the wrong conclusions about how e?ective a treatment or procedure is.
An appreciation of the need to account for chance and bias has led to development of methods where new treatments are compared to either a PLACEBO or to the standard treatment (or both) in a controlled, randomised clinical trial. ‘Controlled’ means that there is a comparison group of patients not receiving the test intervention, and ‘randomised’ implies that patients have been assigned to one or other treatment group entirely by chance and not because of their doctor’s preference. If possible, trials are ‘double-blind’ – that is, neither the patient nor the investigator knows who is receiving which intervention until after the trial is over. All such trials must follow proper ethical standards with the procedure fully explained to patients and their consent obtained.
The conduct, e?ectiveness and duplication of clinical trials have long been subjects of debate. Apart from occasional discoveries of deliberately fraudulent research (see RESEARCH FRAUD AND MISCONDUCT), the structure of some trials are unsatisfactory, statistical analyses are sometimes disputed and major problems have been the – usually unwitting – duplication of trials and non-publication of some trials, restricting access to their ?ndings. Duplication occurs because no formal international mechanism exists to enable research workers to discover whether a clinical trial they are planning is already underway elsewhere or has been completed but never published, perhaps because the results were negative, or no journal was willing to publish it, or the authors or funding authorities decided not to submit it for publication.
In the mid 1980s a proposal was made for an international register of clinical trials. In 1991 the NHS launched a research and development initiative and, liaising with the COCHRANE COLLABORATION, set out to collect systematically data from published randomised clinical trials. In 1994 the NHS set up a Centre for Reviews and Dissemination which, among other responsibilities, maintains a database of research reviews to provide NHS sta? with relevant information.
These e?orts are hampered by availability of information about trials in progress and unpublished completed trials. With a view to improving accessibility of relevant information, the publishers of Current Science, in 1998, launched an online metaregister of ongoing randomised controlled trials.
Subsequently, in October 1999, the editors of the British Medical Journal and the Lancet argued that the case for an international register of all clinical trials prior to their launch was unanswerable. ‘The public’, they said, ‘has the right to know what research is being funded. Researchers and research funders don’t want to waste resources repeating trials already underway.’ Given the widening recognition of the importance to patients and doctors of the practice of EVIDENCE-BASED MEDICINE, the easy availability of information on planned, ongoing and completed clinical trials is vital. The register was ?nally set up in 2005.... clinical trials
(CGI) rating scales commonly used by clinicians to measure symptom severity and treatment response in treatment studies of patients with psychiatric illnesses. Many researchers consider them to be a good tool to measure the clinical utility or relevance of a given treatment. The Clinical Global Impression–Severity scale (CGI-S) is used to rate the severity of the patient’s symptoms relative to the clinician’s past experience with patients who have the same diagnosis. Scores range from 1 (normal) to 7 (extremely ill). The Clinical Global Impression–Improvement scale (CGI-I) measures change in the patient’s presentation from baseline. Scores range from 1 (very much improved) to 7 (very much worse). A score of 4 indicates no change.... clinical global impression
(NCAS) see Practitioner Performance Advice.... national clinical assessment service
(OSCE) a type of examination used increasingly in the health sciences (medicine, dentistry, nursing, physiotherapy, pharmacy) to assess clinical skills in examination, communication, medical procedures, and interpretation of results. The examination usually takes the form of a circuit of stations around which each candidate moves after a specified time interval (5–10 minutes) at each station. Stations are a mixture of interactive and noninteractive tasks. Some have an examiner and a simulated patient, either an actor for assessment of communication or history-taking skills or a manikin of a specific part of the body (e.g. to demonstrate how to use an auriscope). Other stations have investigation results with a list of questions that are to be completed on computer-marked examination papers. Each station has a different examiner and the stations are standardized with specific marking criteria, thus enabling fairer comparison with peers.... objective structured clinical examination
There are some minor signs, such as: relaxation of the facial muscles (which produces the staring eye and gaping mouth of the ‘Hippocratic countenance’), as well as a loss of the curves of the back, which becomes ?at by contact with the bed or table; discoloration of the skin, which takes on a wax-yellow hue and loses its pink transparency at the ?nger-webs; absence of blistering and redness if the skin is burned (Christison’s sign); and failure of a ligature tied round the ?nger to produce, after its removal, the usual change of a white ring, which, after a few seconds, becomes redder than the surrounding skin in a living person.
The only certain sign of death, however, is that the heart has stopped beating. To ensure that this is permanent, it is necessary to listen over the heart with a stethoscope, or directly with the ear, for at least ?ve minutes. Permanent stoppage of breathing should also be con?rmed by observing that a mirror held before the mouth shows no haze, or that a feather placed on the upper lip does not ?utter.
In the vast majority of cases there is no dif?culty in ensuring that death has occurred. The introduction of organ transplantation, however, and of more e?ective mechanical means of resuscitation, such as ventilators, whereby an individual’s heart can be kept beating almost inde?nitely, has raised diffculties in a minority of cases. To solve the problem in these cases the concept of ‘brain death’ has been introduced. In this context it has to be borne in mind that there is no legal de?nition of death. Death has traditionally been diagnosed by the irreversible cessation of respiration and heartbeat. In the Code of Practice drawn up in 1983 by a Working Party of the Health Departments of Great Britain and Northern Ireland, however, it is stated that ‘death can also be diagnosed by the irreversible cessation of brain-stem function’. This is described as ‘brain death’. The brain stem consists of the mid-brain, pons and medulla oblongata which contain the centres controlling the vital processes of the body such as consciousness, breathing and the beating of the heart (see BRAIN). This new concept of death, which has been widely accepted in medical and legal circles throughout the world, means that it is now legitimate to equate brain death with death; that the essential component of brain death is death of the brain stem; and that a dead brain stem can be reliably diagnosed at the bedside. (See GLASGOW COMA SCALE.)
Four points are important in determining the time that has elapsed since death. HYPOSTASIS, or congestion, begins to appear as livid spots on the back, often mistaken for bruises, three hours or more after death. This is due to the blood running into the vessels in the lowest parts. Loss of heat begins at once after death, and the body has become as cold as the surrounding air after 12 hours – although this is delayed by hot weather, death from ASPHYXIA, and some other causes. Rigidity, or rigor mortis, begins in six hours, takes another six to become fully established, remains for 12 hours and passes o? during the succeeding 12 hours. It comes on quickly when extreme exertion has been indulged in immediately before death; conversely it is slow in onset and slight in death from wasting diseases, and slight or absent in children. It begins in the small muscles of the eyelid and jaw and then spreads over the body. PUTREFACTION is variable in time of onset, but usually begins in 2–3 days, as a greenish tint over the abdomen.... death, signs of
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