The Evidence-Based Medicine (EBM) is defined as " the conscientious, explicit and judicious use of current best facts to make decisions about the attention of specific patients. The practice of Evidence-Based Remedies means integrating specific clinical expertise with the best available exterior clinical proof from systemic research. By specific clinical expertise we suggest the effectiveness and judgment that each clinicians acquire through specialized medical experience and scientific practice ". (Sackett, 1996 cited in: http://www. ex. ac. uk/stloyes/extract. htm).
Other types of Evidence-Based Routines include the Evidence-Based HEALTHCARE, and Evidence -Based Nursing.
Evidence-Based Health Care is: "The conscientious use of current best information in making decisions about the attention of individual patients or the delivery of health services. Current best research is up-to-date information from relevant, valid research about the consequences of different types of health care, the prospect of harm from exposure to particular agencies, the correctness of diagnostic exams, and the predictive ability of prognostic factors"(http://www. ex. ac. uk/stloyes/extract. htm).
The Evidence-Based Nursing (EBN) is thought as "the process where the nurse makes scientific decision using the best available research information, their clinical know-how and patient personal preferences ". (Kathleen R. Steven, 1999).
History and need for Evidence-Based Practice
The EBP started its life in health care as EBM. This is based on the idea of shifting healthcare from basing decisions on opinion and past procedures. The earliest documented example of EBP was the development of aseptic strategy in the nineteenth centaury, pursuing observations of mix contamination. These issues made the doctors review their performance and ask questions regarding their software of the steps that should prevent pass on of infection. Since that time, it became clear that no areas of medical practice for health, whether in the community, home or clinic, should be "safe" from the idea of Evidence-Based Practice.
The importance of considering the EBP in the methodical field now became clear. Things are changing very fast in this time and the ongoing studies and researches lead to new results that ought to change a few of the old procedures. Obtaining the right facts and applying it into practice would help improving people's activities of disorder and health care and thus, a good nursing practice will be proven and patients will get better care services.
The Evidence-Based Practice is about making use of research use, professional view and knowledge together with individual patient characteristics and personal preferences in formulating scientific decisions (Dubouloz et al, 1999). It is, appropriately, about the interaction between the clinician and the client. Though it is expected that scientific practice depends upon the systemic application of rigorous methodical solutions to the evaluation of the effectiveness of health care interventions (booth, 1996).
In this research, we attempted to discover whether compressions applied to venous ulcers were truly effective or not.
During the whole amount of our working experience we found tons of situations in which patients will establish a type of lower leg venous ulcer ( wide open ulcers : like the heel bed sores in older patients, or interior, sealed ones such as varicose veins, phlebitis and DVT ). In all of these conditions, we used to advice our patients to use a compression bandage or a stocking over the site of the ulcer believing it is useful. But as we seen in the hospital environment, our elderly patients did not genuinely have their heel bed sores healed by using these compressions although we applied them to the sore sites for an extended time frame.
This made us ask our question: Whether these compression bandages are really beneficial or only we practice applying them anticipated to regimens and practices?!.
Is there any clinical, recent evidence that demonstrates this practice is dependant on?
We asked the question and continued searching.
Formulation of question
The concern or problem
"Venous lower leg ulcer is an open sore in your skin of the lower leg scheduled to high blood circulation pressure in the knee veins"(www. bad. org. uk ).
Epidemiology: Large-scale studies in both of UK and European countries claim that 1-2 % of the populace develops a calf ulcer. The trouble increases and reaches up to 4-5 % in older people (Tonbridge, 2004. pg. 610).
The underlying cause of the venous ulcer is a venous hypertension which results from where in fact the leg leg muscle does not pump the blood vessels to the heart and soul credited to incompetent valve in the deep, perforating or superficial vein.
Leg ulcer can decrease the patient's standard of living. Patients with venous leg ulcers will experience higher level of anxiety, melancholy and pain. Furthermore, their performance of activity of everyday living will be highly afflicted. In a report about the socio-economic aspect of chronic leg ulceration found that this condition inhibits work and leisure activities to a average or a severe level.
The venous ulcers require external compression bandages to apply controlled pressure to the knee venous system. This may improve venous return and improve the leg blood circulation and restoration.
Do applications of compression bandages fasten the treatment rates of venous calf ulcers in patients suffering from venous leg ulcers?
Population: Patients suffering from venous calf ulcers.
Intervention: Software compression bandages.
Comparison: Weighed against no program of compression bandages.
Out come: Fasten the recovery rates of venous knee ulcers.
Importance of formulating question:
We developed this question to direct our search and also to get a methodical answer that may confirm, or disprove our practice. Also, to have an opportunity to seek out scientifically based data regarding the success of using compression bandages for the patients suffering from venous lower leg ulcers. We will discuss the search studies with the ward supervisor and other nurses to apply the search effect studies on the patients. This may aid in better healing because of their venous calf ulcers to be able to reduce patients' sufferings and save the budget which is spent in dealing with venous knee ulcer, and which is known as of a comparatively high amount.
Searching the literature:
We have used different resources to find the related studies regarding our formulated question.
First, we began looking in Cochrane Data source.
Second, we looked in Proquest Repository.
Third, we looked in Pub-Med Repository.
Fourth, we searched through e-journal.
Fifth, we searched in Yahoo.
Sixth, hand publications search.
Key words found in searching strategies;
Venous lower leg ulcer and compression and healing
Venous leg ulcer and compression
Venous calf ulcer and bandage or bandages
Venous knee sore and compression and healing
Venous calf sore and bandage and healing
Venous leg sore and healing
Venous leg sore or venous calf ulcer and compression
Venous leg ulcer
From all the researches we've found, we came across a lot of new information with important details, statistically and medically. For instance, we understood that the heel bed sores is the next fast growing in the immobile patients who would - usually - be incontinent and also have dry skin and difficulty in turning in foundation. We also found an abstract stating that 41% of geriatrics' bed sores are the ones of heel. This significant percentage (research done in July 2004) lead us to further searching, especially that people know much is the introduction of sore is costly to treat and most important, reduces the grade of life of older patients.
As for the medical details and results, we found researches with varying assertions and conclusions. And in addition, with completely complete opposite outcomes. But most of them, of course, agreed on the scientific facts about venous ulcers (the two 2 types from it). Some of the researches discussed the sort and producer of the bandages used. Others mentioned the tiers of compression applied and more merely discussed the fact of the compression being of the good advantage or only a "harmless" one!.
However, a much better research in this matter is thought to discuss all other circumstances that may be playing a job in the treatment of the ulcer other than the applied compression. For example: patient's health and wellness and nutritional position, patient's era and the size and quantity of bed sores a patient is having additional to the degree of the sore. All of these factors were important relating to a study done about such highly, interrelated concern. Although, many studies didn't give it the deserved attention.
Other factual statements about the venous ulcers and which activated us more to research about any of it is the fact that in 45 to 60 percent60 % of circumstances the ulcerations of the low extremities would be a form of any venous source ( approx. 1% of adult population, including the orderly's " available sores " ). Furthermore, we have discovered that compression was the most widely used treatment for venous knee ulcers and it is being used for over than 300 years now although the setting of its action is not yet evidently understood. It's some how assumed that that application of external pressure reduces the superficial venous pressure and so, improves venous go back leading to a decrease in superficial venous hypertension and edema which, in turn, allow treatment of ulcers to occur.
Due to the adjustable outcomes and factors in each research we have found, we excluded a few of them:
Literature: 3 Level Paste Bandages Were FAR BETTER than 4 Coating Bandages for Treatment Venous lower leg Ulcer: Excluded since it discusses the power of pressure used as opposed to the principle of compression being useful or not.
Literature: Is Compression Bandaging Accurate? The Regime Use Of Software Pressure Measurements In Compression Bandaging Of Venous Lower leg Ulcers : That is also excluded because it is mainly speaking about a kind of low cost, lightweight and battery - driven pressure screen which is invented to be put under the pressure bandage.
Literature: Dressing For Healing Venous Leg Ulcers: This also reviewed and compared types of dressings applied under the compression (not the compression itself) so, it was excluded.
Critical Appraisal 1:
The researches we finally agreed to study are fastened behind as references, and mentioned in details in the next tables:
Efficacy and Tolerability of any Ulcer Compression Stocking for Therapy of Chronic Venous Ulcer weighed against a Below-Knee Compression Bandage posted in October 2004.
Author / Researcher
M. Junger, U Wollina, R Kohnen, E Rabe.
To investigate probability of improving treatment rates in ulcers cruris venosum by using an ulcer compression stocking (U stocking) when compared with compression bandages. The general concept aimed at showing non-inferior effectiveness of U-stocking weighed against bandages (the standard therapy in this problem).
Prospective, multicenter, open up labeled, randomized, dynamic controlled study with blinded analysis of most important endpoint.
Outcome Methods / Instruments
Therapy with the U stocking produced a substantial higher level of complete restoration of venous ulcers.
Result / Findings
Complete restoration rate uncovers U-stocking use is effective.
The U-stocking was more advanced than bandages in compression therapy for venous ulcer. It is also of relevance in respect with the long-term therapy, as well as the prevention of recurrence of the ulcer.
Study done in 2000-2002, variables considered, tolerability assessed, fell out patients were used, time of therapeutic considered and analyzed as well as the amount of ulcer treatment ( evaluated by planimetry )
Some patients dropped out of the analysis for other reasons than complete healing so final test size was going to be prematurely terminated. (Recalculation of the scale saved it). Other factors which impact healing rate weren't considered.
This result may not be that correct as a compression remedy was being put on patients before the study implemented.
A Systemic Overview of Compression Treatment for Venous Leg Ulcers released in September 1997.
Alison Fletcher, Nicky Cullum, Trevor A Sheldon.
To estimate the specialized medical &cost effectiveness of compression system for treating venous leg ulcers.
Systemic review of research.
Rate of curing &percentage of ulcers healed with in a period period.
Results / Findings
24 randomized managed trials were contained in the review. 5 mentioned in details and most of them arranged that compression systems improve the curing of venous leg ulcers.
Compression system boosts the healing of venous knee ulcers &should be utilized routinely in easy venous ulcers. Insufficient reliable proof exists to indicate which system is the very best.
The level of the studies evaluated in this systemic review provides results a couple pounds and trustworthiness. Also the selection of the studies without restrictions regarding the date of their magazines or the terminology enhances the reliability on the results reported.
The research information was quite fragile: Many trials had inadequate test size &generally, poor strategy. The same system applied by different staff under different circumstances may result in the attainment of greatly differing pressures, making interpretation difficult.
The quality research in this area is generally poor: Trials tend to be too small, follow up is short, recurrence of ulcers is hardly ever considered, &sometimes multiple ulcers are incorrectly regarded as unbiased ulcers. Several paperwork do not record the technique of bandage software, the knowledge of staff, and other aspects of bandaging, &patient's range of motion, which all affect treatment. Exactly the same system applied by different personnel under different circumstances may bring about the attainment of greatly differing stresses; making interpretation difficult. This problem rarely makes the intellects of researchers.
A Systemic Overview of Compression Remedy for Venous Leg Ulcers published in1998.
Simon. J Palfreyman, Rona Lochiel &Jonathan A Michaels.
To determine the comparative performance of compression treatments used in the treatment of venous lower leg ulcers.
Systemic review of randomized controlled studies (RCT).
Quality of trials was driven using proforma based on CONSORT declaration and Cochrane collaboration checklists.
Result / Findings
Results fluctuate in each study in line with the compared compressions. Most studies take for granted that compression is effective in curing venous knee ulcers and base their studies upon this information.
More high - quality trials are essential &more emphasis should be located on economical &quality of life data to try to ascertain the cost- effectiveness &power of the procedure options available.
Gives very specific &thorough prescriptions about the chosen examples &the way of randomizing &blinding them. Time and year of the included studies weren't limited. Also no restrictions on the united states of origin of the tests.
Included very in depth literatures and pays off focus on every small depth which is very necessary for judgment of the quality of the studies.
Search was limited to English words articles or articles that provided sufficient details in English. Quality of the studies were very mixed with majority of tests being of relatively brief duration &small test size. Omission of a particular description of the technique of randomization or blinding made the research's reality doubtful (They only explained that the participants were randomized but not offered convincing information regarding "how "did they randomize them! ).
Short durations ( between 4 weeks &18 months ) is doubtful as it isn't an adequate long enough period to detect the amount of ulcers healed, nor it might prospect or determine the recurrence rates for any of the interventions.
A analysis that assessed compression versus non-compression was found but it got the same (methodological) problem. In addition, the generalizability than it to UK is also questionable, since the use of the mentioned kind of bandage there (in UK) is limited!
Compression therapy is trusted in the treating venous lower leg ulcers but this isn't necessarily predicated on the quantity of evidence open to justify the practice.
There's a clear need for greater, high quality tests to verify the benefits of compression remedy.
Higher Compression Elastic Bandages show no Significant Edge in the treating Venous Knee Ulcers printed in 2002.
To compare time for you to total treatment using two compression bandage regimens.
Complete healing of ulcers
Result / Findings
There was no statistically significant difference between the restorative healing times of the two groups with different kinds of bandages (elastic and inelastic bandages). Healing was significantly slower for large ulcers than it is good for the small ulcers.
There's no appreciable gain in adding higher compression to accelerate ulcer therapeutic.
Exactly describes the way bandages were applied to be able to prevent variations &inaccuracy of the results.
Some patients were excluded &some withdrawn but luckily for us, range of patients from the 2 2 communities was equivalent and so, results were unaffected.
Critical Appraisal 2:
Efficacy and Tolerability of Ulcer Compression Stocking for Remedy of Chronic Venous Ulcer, Weighed against a Below-Knee Bandage
Prospective, multicenter, open up labeled, randomized, active controlled research with blinded diagnosis of major endpoint.
Population / test:
Patients with long-term venous ulcers in the knee (121 patients)
Inclusion / exclusion conditions:
134 patients with venous ulcers were first chosen, patients with afflicted ulcers or fatness were excluded down the road.
Finally, 121 patients were entitled.
Time structure of review:
From October 2000 to October 2002
Time body of interventions:
Applying U-Stocking for 12 weeks for at least 8 hours daily
Outcomes steps / interventions:
U-Stocking or bandages requested at least 8 hours per day and up to 12 weeks. Main endpoint was curing rate after 12 weeks assessed by planimetric procedures. Secondary outcome factors were: A chance to healing, changes in ulcer size (planimetry), connection with use and patient's conformity.
General concept targeted at showing non-inferior effectiveness of U-Stocking compared to bandages (the typical therapy). Most important desired final result is complete ulcer recovery after 12 weeks.
(The non-inferiority margin was placed as 15% of the recovering rate).
Secondary target parameters:
Comparison of time to complete therapeutic: analyzed with long-rank test.
Planimetry: defined degree of ulcer healing showing it as a percentage remission of ulcer surface and assessed with Mann-Whitney U-tests.
Experience of use (partly of patient).
Satisfaction of nursing personnel.
Time had a need to apply the U-stocking or compression bandage.
Comparisons performed with the two sample testing and interpreted in an exploratory manner.
Results / conclusions:
Primary endpoint analysis: Complete ulcer curing which unveils that U-Stocking is more significant and superior to bandages with restorative healing rate of 47. 5% against 31. 7%.
Other factors that have a direct effect on patients' therapeutic rates (e. g. : high health proteins diet) were not considered. Also long pre-treatment period (using compression therapy for continuous period before the study) had not been given any attention.
Conclusion of analysis:
U-Stocking might be effective. But the ex - compression therapy is still considered the best remedy. This study effect is not totally the result of the U-Stocking since the prior use of the compression remedy by the patients may have interfered with it.
We think this review has covered tons of important details and considered other factors that are not - in most of the days - put in to attention while researching about the ulcers' restoration. However, it is principally focusing on a one type of pressure device (and this is the U-Stocking) and presuming right from the start that the compression therapy is - for awarded - useful. It eventually and clearly says that "some research are available in the literature of the effectiveness of compression bandages in venous calf ulcers " nevertheless they only wished to prove the effectiveness of the U-Stocking in comparison to it.
A Systemic Overview of Compression Treatment for Venous Knee Ulcers
This study done by the researcher Alison Fletcher and his group ( we found their names quite a lot inside our searching for this issue ), done to calculate the scientific and cost efficiency of compression system for treating calf ulcers.
Systemic review of research.
Varies in each included study.
24 randomized managed trials included. Research workers say that that the studies' facts was weak due to the inadequate test size and the poor methodology.
Inclusion / exclusion criteria:
(Systemic reviews do not perform studies but only analyze the found literatures and assess the related studies to a chosen issue).
Time framework of the study:
Used magazines that are published anytime with out limitations.
Time shape of treatment:
Comparisons of past researches in the same concern with participation of different and specific details.
Structured guidelines were used: digital search of 19 specialist databases including Medline, CINAHL, and EMBASE. Side searching also used scrutiny of citation and contact with relevant manufacturers and original creators. Data collected with no restrictions on publications status, dates (as previously mentioned) or dialects.
24 relevant randomized handled trials were recognized. Five were discussed and they are:
Compression Versus No Compression :
3 trials: 2 confirmed higher proportion of healed ulcers when compression used, the remaining one proved a non- significant therapeutic rate with "Unna's Boot "specifically.
Another 3 studies likened different forms of compression (brief stretch, 2 covering and 4 layer bandages) with treatments using no compression and this, showed that restoration advanced with compression.
Elastic Multilayer Higher Compression Bandages Versus Inelastic Compression :
This study exhibited an overall significant increase in healing by using the higher compression bandages.
Comparisons between different medium and high compression systems: This reported no factor in benefits of both compared types.
Compression Hosiery Versus Compression Bandages :
This research reported complete therapeutic of those patients whose ulcers were
Treated with brief stretch out bandages in an interval of three months.
Intermittent Pneumatic Compression Treatment :
This is a small review, reported the good thing about adding an intermittent pneumatic compression to the compression stockings every once in awhile. It, also, unveils an increase in treatment rates by using this intermittently added compression.
Results / results:
Results of all examined literatures almost agreed that healing rate of venous leg ulcers is improved by the utilization of bandages and thus, suggest possible greater results with higher tiers compressions. However, the various types of compression systems themselves when compared collectively in a trial (for example: multilayer and short stretch out bandages, Unn's Shoe, etc ) show no difference in performance.
Intermittent pneumatic compression, on the other hand, seemed to report a significant benefit when added, every once in awhile, to these compression systems.
Conclusion of studies:
The review concluded that compression systems enhance the restoration of venous knee ulcers and suggested the utilization of of them routinely, so long as arterial diseases are proved to be absent.
The review accepted the poor methodology of the included studies. Their small sample sizes and the short term of follow-up. Also, the recurrence of the ulcers had not been considered and some patients with multiple ulcers were improperly regarded as 3rd party ulcers which was misleading the results.
Other restrictions already shown in the table, in this research's first critical appraisal.
According to us, we found it's a little difficult to agree with all this since the review which is based on poor and poor studies make us wonder how strong would be the evidences they provided us with, and if indeed they were only an advertisal studies that market segments for specific manufacturers !!?.
Also, we thought that if the basic principle of application of pressure is, in essence, the concept, then a increase in pressure should, definitely, be of relevance in treatment, which is the actual included studies acquired varied to state it !.
A Systemic overview of Compression Remedy for Venous Knee Ulcers
A systemic overview of randomized controlled trials (RCT).
Population / test:
Each included research varies.
Inclusion / exclusion requirements:
Suitability to be one of them systemic review was made the decision upon a crucial appraisal of key determinants of the grade of the tests.
Trials that included patients with combined ulcer etiologies were excluded.
Time structure of analysis:
Included studies were not restricted regarding the date and 12 months.
Time structure of involvement:
After excluding the other studies, staying trials which experienced met the inclusion criteria underwent a critical appraisal (a performa based on CONSORT affirmation and Cochrane cooperation checklists). This motivated the quality of the trials and graded them by assessing: approach to randomization and blinding, research of results, completeness of follow up, blinding and objectivity of final results, appropriateness of statistical examination of the results.
Other studies with significantly less than 50 individuals were included after specifically considering these final results : complete ulcer recovery ( which is considered as an absolute, measurable endpoint ), period to complete ulcer therapeutic, recurrence rates with in a year, complications and morbidity, compliance with treatment, patient's satisfaction and quality of life, economic analysis.
Eight electronic data source were searched (including Medline, Embase and CINHAL), discussion proceedings and hand searching key publications, citations within papers.
Extracted data were synthesized quantitatively and qualitatively.
Some excellent trials (8 of these) were regarded as high-quality trials at the time of data extraction but while looking at, sadly, were fount to lack an essential detail about the blinding of final result assessment and ways of randomization. Likewise, other trials possessed no opportunity of pooling the results for the meta-analysis therefore, these, and the previous mentioned trials, all were excluded presenting a chance for only 4 studies. Research was carried out using DerSimonian and Larid arbitrary effects methods.
Researches examined and their outcomes are brought up in the next point.
Results / studies:
Research 1: Unna's Shoe versus Other Therapies
Analysis confirmed no statistically significant variations between Unna's Boot
Compared with other remedies.
Research 2: Pneumatic Compression:
More patients healed in treatment with pneumatic compression. But result is not
that accurate because the sample size was insufficient to make wisdom.
Research 3: Compression versus No Compression:
Only 1 trial found were compression was weighed against no compression whatsoever.
With in this trial there was no clear gain statistically detected!.
Research 4: Multilayer versus Single covering Compression Bandages:
This is only one review and it demonstrated that multilayer compression bandages were
Associated with a greater number of ulcers healed than one part bandages.
Research 5: Elastic versus Non-Elastic Bandages:
A trial demonstrated that probability of healing were higher with stretchy bandages when
Compared with non-elastic bandages.
Conclusion of the studies:
Compression therapy seems to be used generally in the treatment of venous knee ulcers not as a result of strong evidences available in its regard, but, because of its prolonged amount of practice that managed to get as a "schedule " work! (Used since more than 300 years).
Quality of the analysis was very merged. Most the tests were of relatively short durations (4 weeks - 18 months) and small sample size. Other, high-graded researches were excluded because they missed a little and an essential detail (approach to randomization and blinding of allocation and assessment).
Only 2 studies gave the exact method of randomization and the rest just "stated" that their participants were "randomized"!
Only 1 analysis assessed compression versus no compression, but it possessed a methodological problem as the unit of randomization was the ulcer, not the individual. Besides, generalizability of research to U. K made the analysis doubtful as the compression of Unna's Shoe (found in the analysis) is not trusted for the reason that country.
Another point of limitation is the fact some studies mentioned a complete therapeutic of ulcers with in mere 4 - 6 weeks which is unbelievable as such an interval is not sufficient enough to detect the amount of ulcers healed. Plus, it does not consider the rate of recurrence of the ulcers.
Higher Compression Elastic Bandages show No Significant Benefits in the Treatment of Venous Knee Ulcers
Population / sample:
112 patients with venous leg ulcers
Inclusion / exclusion standards:
Not pointed out.
Time framework of the analysis:
Time body of treatment:
All patients treated with a zinc-impregnated paste bandage applied right to ulcer. Paste was covered with Tensopress in 57 patients and with elastocrepe in 55 of them. Tubular bandage was applied then at the top of the bandages and ulcers grouped as small, medium and large, the randomized within 3 size groups.
Ulcer study analysis forms were filled. Photographs taken at monthly
Healing took place in 33 patients treated with Tensopress and in 34 patients treated with Elastocrepe.
Results / studies:
Difference was not statistically significant.
Conclusion of the analysis:
There is not a appreciable gain in adding compression to increase ulcer curing.
Some patients were excluded plus some withdrawn from the study, but fortunately, quantity in each group was comparative and therefore, results weren't affected.
This review compares mainly 2 types of bandages used as compression treatments put on treat venous calf ulcers. It concludes that adding more compression to ulcers will not really accelerate its recovery. This supports the previous research's final result; however, the study did not consider other factors that help curing while exploring about effects and real usefulness of the 2 types of bandages.
Conclusion and suggestions:
As we've seen, every research assorted from the other's final results, and perhaps, when 2 concluded the same result they'll be varying in the facts!.
In simple fact, it was very hard to get articles that targets investigating the truth about effectiveness of the compression systems. A 300 years time frame is very sufficient to make the behavior of practice as strong as a technological fact!. On the contrary hand, enormous studies are found contrasting one type of compression system to another and one new invention ( like the pneumatic pressure system ) to another device. These studies benefits are, also, different.
The level of researches available some how provides practice of applying bandages to the venous knee ulcers some weight and trust on trustworthiness. But the quality which was poor in almost all of them weakens this trust and limits it.
We think that the nature of the topic is the primary things that surround it with the difficulties. Since it isn't just the ulcer and the therapeutic of it that are involved, however the patient's health and wellness condition, the knowledge of the personnel making use of the pressure and the technique of putting it on!. The elevation of the extremity, the amount of mobility of the patient, the number of sores he has ( in case there is multiple sores ) and the amount of each of them. Etc. Each one of these variations make every individual patient highly unique, some times to the level that you cannot count on grouping him with others (who appear to be similar cases to him) in a study.
We hope that these specific measurable details could be more focused on by the analysts and be assessed more accurately to be able to get proper technological evidences which will lead our practice to an improved health care delivery to the patients and in turn, better effects and improvement in patient's health.