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First buy genuine penegra on-line, the bone windows should be examined for fractures generic penegra 100mg with mastercard, beginning with the cranial vault itself order 50mg penegra amex, and then the skull base and the facial bones should be examined penegra 50 mg fast delivery. Next, the tissue windows should be examined for the presence of any of the fol- lowing: extraaxial hematomas (e. Next, the brain should be surveyed for any evidence of pneumocephalus, hydrocephalus, cere- bral edema, midline shift, or compression of the subarachnoid cisterns at the base of the brain. Finally, the subdural windows should be exam- ined for any hemorrhage that may not be visualized easily on the tissue windows. Computed tomography scans may be used for classification as well as for diagnostic purposes. Skull Fractures: Skull fractures are classified as either nondisplaced (linear) fractures or comminuted fractures. A comminuted frac- ture may be displaced inward, which is defined as a depressed skull fracture. Intracranial Hemorrhages: Intracranial hemorrhages are divided into two broad categories: extraaxial hematomas and intraaxial hema- tomas (Table 32. Intraaxial hematomas Extraaxial hematomas Intracerebral hematoma Epidural hematoma Subarachnoid hemorrhage Subdural hematoma Cerebral contusion Extraaxial hematomas include epidural and subdural hematomas. They typically are biconvex in shape because their outer border follows the inner table of the skull, and their inner border is limited by locations where the dura is firmly adherent to the skull (Fig. Epidural hematomas usually are caused by injury to a dural-based artery, although 10% of epidurals may be venous in origin. Their outer edge is convex, while their inner border usually is irregularly concave (Fig. Subdural hematomas are not limited by the intracranial suture lines, and this is an important feature that aids in their differentiation from epidural hematomas. Subdural hematomas usually are venous in origin, although some are due to arterial bleeding. Cere- bral contusions are posttraumatic lesions in the brain that appear as irregular, heterogeneous regions in which hyperintense changes (blood) and low-density changes (edema) are intermixed (Fig. Shepard Intraventricular hemorrhages are regions of high intensity within the ventricular system. Subarachnoid hemorrhages that occur as a result of trauma typically are located over gyri on the convexity of the brain. These are thin layers of high-intensity signal located on the surface of the cortex. They are distinct from the subarachnoid hemorrhages that occur as the result of a ruptured cerebral aneurysm, which usually are located in the arachnoid cisterns at the base of the brain. This is due to its long acquisition time and the difficulty of using it in the crit- ically ill. Diffuse axonal injury is defined as neuronal injury in the subcortical gray matter or the brainstem as a result of severe rotation or deceleration. Currently, angiography is used in acute head injury only when there is the sus- picion of a vascular injury. This concept is defined by the Monro-Kellie doctrine, which states that the total intracranial volume is fixed. Since the intracranial volume is fixed, unless there is some com- pensatory action, such as a decrease in the volume of one of the other intracranial components, the intracranial pressure will rise. This is related intimately to intracranial compliance, which is defined as the change in pressure due to changes in volume. The brain has very limited compliance and cannot tolerate significant increases in volume that can result from diffuse cerebral edema or significant mass lesions, such as a hematoma. Autoregulation also is impaired in the injured brain, and, as a result, there is pressure passive perfusion within and around injured regions of the brain. The intracranial compartment is divided into three compartments by two major dural structures, the falx cerebri and the tentorium cerebelli. As the brain slides over these dural edges, it compresses other regions of the brain (e. There are five types of herniation: transtentorial herniation, subfalcine herniation, central herniation, cerebellar herniation,andtonsillar herniation. Transtentorial herniation occurs when the medial aspect of the tempo- ral lobe (uncus) migrates across the free edge of the tentorium. This compresses the third cranial nerve, interrupting parasympathetic input to the eye and resulting in a dilated pupil. This unilateral dilated pupil is the classic sign of transtentorial herniation and usually (80%) occurs ipsilateral to the side of the transtentorial herniation. While there is significant overlap in the treatment of these two types of injury, there are some important differences that are discussed later in this chapter. Closed head injury treatment is divided further into the treatment of mild and moderate/severe head injuries. Herniation syndrome Mechanism Transtentorial herniation Medial temporal lobe is displaced across the tentorial edge Subfalcine herniation Medial frontal lobe is displaced under the falx Central (downward) herniation Cerebral hemisphere(s) is displaced down through the tentorial incisura Cerebellar (upward) herniation Cerebellum is displaced up through the tentorial incisura Tonsillar herniation Cerebellar tonsils are displaced through the foramen magnum 32. Brain Trauma Foundation, American Associa- tion of Neurological Surgeons, Joint Section on Neurotrauma and Critical Care. Shepard Closed Head Injury Mild Head Injury Treatment The majority of head injuries are mild head injuries. Most people pre- senting with mild head injuries do not have any progression of their head injury; however, up to 3% of mild head injuries progress to more serious injuries. Patients with mild to moderate headaches, dizziness, and nausea are considered to have a low-risk injury. Most of these patients require only observation after they have been assessed carefully, and many do not require radiographic evaluation. These patients may be discharged if there is a reliable individual to monitor them at home. A concussion is defined as physiologic injury to the brain without any evidence of structural alteration, as in the case presented. Loss of consciousness frequently occurs in concussions, but it is not part of the definition of concussion. Concussions may be graded on a scale of I to V based on criteria such as length of confusion, type of amnesia following the event, and length of loss of consciousness (Table 32. The initial resus- citation of a head-injured patient is of critical importance to prevent hypoxia and hypotension. Subdural/epidural hematoma resulting in midline shift >5mm Intracerebral hematoma >30cc Temporal or cerebellar hematoma with diameter >3cm Open skull fracture Skull fracture with displacement >1cm mortality rate of those patients who were normotensive on presenta- tion4. The combination of hypoxia and hypotension resulted in a mor- tality rate two-and-one-half times greater than if both of these factors were absent. If there is a surgical lesion present, then arrangements are made for immediate transport to the operating room. Although there are no strict guidelines for defining surgical lesions in head injury, most neurosurgeons consider any of the following to rep- resent indications for surgery in the head-injured patient: extraaxial hematoma with midline shift greater than 5mm, intraaxial hematoma with volume >30cc, an open skull fracture, or a depressed skull frac- ture with more than 1cm of inward displacement (Table 32. Also, any temporal or cerebellar hematoma that is greater than 3cm in diam- eter usually is evacuated prophylactically because these regions of the brain do not tolerate additional mass as well as other regions of the brain. After appropriate fluid resuscitation has been completed, intravenous fluids are administered to maintain the patient in a state of euvolemia or mild hypervolemia. If a patient is hypovolemic, elevation of the head may cause a drop in cardiac output and cerebral blood flow. Also, the head should not be elevated in patients in whom a spine injury is suspected or until an unstable spine has been stabilized. Also, patients with multisystem trauma often have painful systemic injuries that require analgesics, and most intubated patients require sedation. Short- acting sedatives and analgesics should be used to accomplish proper sedation without eliminating the ability to perform periodic neurologic assessments. This requires careful titration of medication doses and periodic weaning or withholding of sedation to allow for neurologic assessment. There is no evidence that the use of anticonvulsants decreases the incidence of late-onset seizures in patients with either closed head injury or trau- matic brain injury. Intracranial pres- sure monitoring consistently has been shown to improve outcome in head-injured patients.

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The initial diffusion of drug molecules leaves a drug- depleted polymeric zone with a length h purchase discount penegra on line, which increases with time cheap penegra 50mg overnight delivery. This event leads to an increase in diffusional distance over time System Release Mechanism Release Properties Release Kinetics Matrix Diffusion through a polymeric Drug release decreases with time Square root of time release “M t1/ matrix 2” 4 safe penegra 50mg. This particular design discount 100mg penegra free shipping, consisting of a thin layer of the drug-containing matrix and a relatively thick drug-free inert core, minimizes tailing in the drug release profile. When this implant is placed under the skin of an animal, estradiol is released and enters into systemic circulation. This stimulates the animal’s pituitary gland to produce more growth hormone and causes the animal to gain weight at a greater rate. At the end of the growing period, the implant can be easily removed to allow a withdrawal period before slaughter. The Compudose implant is available with a thick silicone rubber coating (Compudose-400) and releases estradiol over 400 days, whereas one with a thinner coating (Compudose-200) releases the drug for up to 200 days. Once implanted in the animal’s ear, the implant delivers estradiol valerate at the rate of 504 µg cm−2 day−1/2 over a period of 16 days. Such systems are designed in an attempt to improve the “M t1/2” release kinetics of a matrix system, so that release approximates the zero-order release rate of a reservoir device. The mixture is blended with a cross-linking agent, which results in the formation of millions of individually sealed microreservoirs. The mixture is then placed in a silicone polymer tube for in situ polymerization and molding. Drug molecules initially diffuse through the microreservoir membrane and then through the silicone polymer coating membrane. This implant provides zero-order release kinetics, rather than square root of time-release kinetics. The two open ends of the implant do not affect the observed zero-order release pattern because their surface area is insignificant compared to the implant’s total surface area. The drug permeation through the polymer membrane occurs at a rate that is 20 times slower than that through the polymer matrix, thus diffusion through the membrane is rate-limiting, which again improves the matrix-type square root of time-release kinetics, so that the release is like the zero-order release rate of a reservoir device. Following implantation in the upper arm, a single rod of Implanon releases 3-ketodesogestrel at the rate of > 30 µg/day for up to 3 years. However, some fundamental limitations of such implants include: • The implants must be surgically removed after they are depleted of drug. Degradation can take place via: • bioerosion—the gradual dissolution of a polymer matrix; • biodegradation—degradation of the polymer structure caused by chemical or enzymatic processes. For example, natural polymers such as albumin may be used; such proteins are not only water-soluble, but are readily degraded by specific enzymes. The terms degradation, dissolution and erosion are used interchangeably in this chapter, and the general process is referred to as polymer degradation. Thus polymers used in biodegradable implants must be water-soluble and/or degradable in water. In bulk erosion, the entire area of polymer matrix is subject to chemical or enzymatic reactions, thus erosion occurs homogeneously throughout the entire matrix Accordingly, the degradation pattern is sometimes termed homogeneous erosion. In surface erosion, polymer degradation is limited to the surface of an implant exposed to a reaction medium. Erosion therefore starts at the exposed surface and works downwards, layer by layer. If water is readily able to penetrate the polymer, the entire domain of polymer matrix is easily hydrated and the polymer undergoes bulk erosion. On the contrary, if water penetration into its center is limited, the erosion front is restricted to the surface of the polymer matrix and the implant undergoes surface erosion. In practice, the polymer degradation occurs through a combination of the two processes. As for non-degradable polymeric implants, biodegradable polymeric implants are divided into two main types: • reservoir devices in which the drug is surrounded by a rate-controlling polymer membrane (such devices are particularly used for oral-controlled release—see Section 6. The drug release for biodegradable polymeric implants is governed not by diffusion through a membrane, but by degradation of the polymer membrane or matrix. If the rate of polymer degradation is slow compared to the rate of drug diffusion, drug release mechanisms and kinetics obtained with a biodegradable implant are analogous to those provided by a nonbiodegradable implant (therefore a reservoir system gives a zero-order release profile and a matrix system gives a square root of time release profile). After drug depletion, the implant subsequently degrades at the site of implantation and eventually disappears. However, in many cases, drug release takes place in parallel with polymer degradation. In such cases the mechanism of drug release is complicated as drug release occurs by drug diffusion, polymer degradation and/or polymer dissolution. The permeability of the drug through the polymer increases with time as the polymer matrix is gradually opened up by enzymatic/chemical cleavage. The references cited at the end of this chapter deal with the relevant mathematical treatments of this topic. The polymers are prepared from lactide and glycolide, which are cyclic esters of lactic and glycolic acids. Low molecular weight polymers (< 20,000 g/mol) are directly synthesized from lactic and glycolic acid via polycondensation. High molecular polymers (> 20,000 g/mol) are prepared via ring-opening polymerization (Figure 4. Variations in lactic acid:gycolic acid ratios, as well as molecular weights, affect the degree of crystallinity, hydrophobicity/hydrophilicity, and water uptake. Lactic acid-rich copolymers are more stable against hydrolysis than glycolic acid-rich copolymers. Polymer degradation generally takes place in four major stages: • Polymer hydration causes disruption of primary and secondary structures. Zoladex implants are indicated for use in the palliative treatment of advanced breast cancer in pre- and peri- menopausal women, in the palliative treatment of advanced carcinoma of the prostate and in the management of endometriosis, including pain relief and the reduction of endometriotic lesions. The release profile of goserelin from the implants has been well characterized during product development. The initial release was then followed by a lag period up to 4 days, in which there was a rapid decline in the plasma concentration of the drug. As water penetrates the polymer matrix and hydrolyzes the ester linkages, the essentially hydrophobic polymer becomes more hydrophilic. Extensive polymer degradation is followed by the development of pores or microchannels in the polymer matrix, which are visible by scanning electron microscopy (Figure 4. After the initial induction period required to initiate polymer degradation, drug release is accelerated thereafter by polymer degradation. In the above study this maintained the mean goserelin concentrations in the range of about 0. Pores and channels produced by extensive polymer degradation are visualized in the micrograph. The release rate is determined by the polymer composition and molecular weight (Table 4. The Lupron Depot microspheres are indicated for the treatment of male patients with prostate cancer and female patients suffering from endometriosis and anemia due to fibroids. Just prior to intramuscular injection, the diluent is withdrawn by a syringe and injected into the single-dose vial to homogeneously disperse the microspheres. An initial burst release of leuprolide from the microsphere depot occurs in vivo, followed by quasi-linear release for the rest of the time period. The efficacy of leuprolide depot formulations was found to be the same as the efficacy achieved with daily subcutaneous injections of 1 mg leuprolide formulation. Polymer degradation occurs via hydrolysis, the biscarboxyphenoxypropane monomer is excreted in the urine and the sebacic acid monomer is metabolized by the liver and is expired as carbon dioxide via the lung (Figure 4. Sebacic acid-rich copolymers display much faster degradation rates than biscarboxyphenoxy propane-rich copolymers. Changes in the ratio of the monomers are reported to provide various degradation rates ranging from 1 day to 3 years. To fabricate the implant, the polyanhydride and the drug moiety are dissolved in dichloromethane.

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You probably worry most about either what’s going to happen or what has already happened buy penegra with a mastercard. What’s happening right now cheap penegra online mastercard, in this very instant penegra 50 mg visa, is likely considerably less stressful order generic penegra on line. Let’s try an experiment to see if you can bring those pesky, flitting little hummingbird-thoughts back into the present. Close your eyes tightly and bring all of your focus to the sensation of tension around your eyes. Squeeze your eyes even more tightly closed and feel which of your muscles are tightening in your face, between your eyes and in your forehead. Give this exercise a try right now and then return to the book when you’re through. H 16 • Mindfulness Medication Try it again and really focus on scrunching your eyes closed and feeling the tension in your eyes as well as around them. When you fix your concentration on doing something like this, I think you’ll find that it pushes any other thoughts of yesterday or tomorrow right out of your mind. Is it skiing, dancing, cooking, painting, gardening, photography or playing hockey? At those times when you’re deeply engrossed in a favourite activity does time stand still, or do other thoughts come into your consciousness? When you’re totally present in what you are doing, the only thoughts that exist tend to be about the activity you are engaged in. You already have the ability to quiet your mind and make it focus and that just happens to be a characteristic of the human mind that you can put to use for reducing your stress. I know what you’re saying is probably something like, “So scrunching my eyes reduces stress? As you’ve no doubt noticed during the preceding exercises, thoughts come and go very frequently. Most of us normally do not have the ability to consistently maintain concentration on one thought. Even if you’re generally feeling sad, angry, or happy, within a short time your mind will still drift from thought to thought. If each thought is that important and meaningful why don’t thoughts stay around longer than they do? The tricky thing about any thought is that while you find yourself immersed in it, it feels permanent. However, if you wait it out, often just a little longer, that thought will actually pass and then you’ll have, at least temporarily, a break from it. If you can think of your thoughts as clouds that form and change, vanish and reform, rather than as things that are true, absolute and permanent, it may help you to de-stress. A lot of what you’re thinking Meet Your Mind • 17 when you’re stressed is just a string of hypothetical ‘what-ifs’. When you bring some awareness to a particularly stressful moment, you can let the natural inclination of the mind to move on, work to your advantage. Now I’d like you to really consider how long a thought actually tends to last for you personally and whether or not it’s something that’s permanent and unchanging. Specifically, observe how long they last, how they change or jump around and how sometimes they just pass away and another thought comes up to take their place. Invisible chains Real as steel Full of form Thought is empty Thought has form Is thought empty form? When you start observing your thoughts, you might notice that they seem to arise spontaneously without an apparent thinker behind them. It may seem that your mind is working independently of you, or your conscious control. Bring your attention to your thoughts as they arise and keep in mind whether you’re consciously and intentionally producing these thoughts yourself, or whether they are just arising spontaneously. Close your eyes and this time notice if you’re H consciously and purposely producing your thoughts. If you were generating your thoughts why wouldn’t you know what your next thought was going to be? Your thoughts are like a game of dominos, one domino hitting another domino that then creates this train of thoughts. It’s as if the thoughts are being produced independently of any person behind them. What goes on in one thought, triggers a relationship to another thought that then presents itself. From your memory, the image triggers your history with and knowledge of, that type of bird. Something like the following internal conversation might take place: What a beautiful bird! It’s a real discovery to understand that, what’s on your mind is really just a flow of thoughts, each triggering the next, without any conscious activity, or sometimes even any real meaning, necessarily behind it. In response to an external or internal sensation, a thought arises, which triggers a memory of another event that then leads to a subsequent thought. Each thought is dependent on the preceding thought until a new sensation comes along. Thoughts are just reflections of a complex interplay between physiological and psychological activity and are based on your previous experiences and patterns. By recognizing that your thoughts actually occur independently, in a meandering and domino- like fashion, they should have less power over you. You can observe thought production as a process occurring outside of your conscious control, like your heartbeat, or your fingernail growth. Notice if there’s a connection between your thoughts and return to this chapter after H you’ve finished. We all have deeply embedded 20 • Mindfulness Medication memories of our experiences and there are multiple, unconscious, mental connections that occur between these memories. Practice In an attempt to train your mind to start becoming aware of the nature of your thoughts on a more regular basis, here are a few more exercises that I suggest you set some time aside to do every day. Whenever a thought arises and you’re consciously aware of it, simply note to yourself the word ‘thinking’. Take five to ten minutes in the morning before getting up, or in the evening before going to sleep, to observe your mind and its thoughts. Sometimes this exercise is harder to do if you’re tired but see what works best for you. Observe how your thoughts arise spontaneously, are often connected to the preceding thought and are impermanent in nature. Focus on the idea that ‘your thoughts are not you, they are just passing through’. Pick something that will serve as a cue for you that occurs during your average day and use it as a reminder to simply observe your thoughts for a moment before you act on them, just as you’ve been doing throughout this chapter. Your cue could be as simple as sitting down to eat a meal, getting ready to go for a walk, picking up your phone to make a call, going into the bathroom, sitting in your car for a moment before driving, whatever works for you. Stick a Post-it note up somewhere to remind you that it’s your intention to focus on your thoughts in that situation. In this Ichapter, I’m going to have you take a look at how these thoughts can link together habitually in what becomes your own personal belief system. A belief system is really just a pattern of stories that you have been taught or have learned since childhood, or that you have developed in response to your own experiences. It’s how you frame and understand the things that you encounter in the world around you. You have created a personal belief system about everything you have ever come across, every new discovery, every interaction and every activity, in order to fit things in with what you already know. You never just experience something without also experiencing the story that you then create about the event, based on your personal belief system. This is part of how one thought leads to another in patterns that tend to repeat themselves. It’s a normal part of your brain’s functioning to try to make sense of the world by relating new things to what you’re already familiar with. However, what’s helpful to you in providing meaning and context for novel experiences can also be harmful to you if you have developed a belief system that encourages a stress response. For example, when you look at another person, you project your belief system onto him or her.

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Overall discount penegra line, 70 percent (33 of 47 studies) of the articles were rated as 397 purchase penegra cheap,401 discount 100 mg penegra visa,402 penegra 100 mg cheap,407,412,437,461,472,473,477,505,515,516,527,528,537,541,554,555,608,610,612-623 positive studies. Eight of these studies targeted physicians along with other health care 518,519,526,537,541,555,612,621 473,477,516,614 professionals, four targeted pharmacists, and one targeted 608 nurses. The preponderance of studies (59 percent; 28 of 47) took place in the ambulatory care 472,505,511,515,516,518-520,526-528,534,537,541,543,553-555,609-613,616,617,619,620,624 setting. Eighteen of the studies 401,402,407,412,437,442,446,461,473,477,481,608,614,615,618,621-623 took place in the acute care, and one in the 397 nursing home setting. While three interventions focused on symptom-based 520,608,621 437,446,519,553,554,610,616-618,622 monitoring (patient reported symptoms), ten studies provided a combination of laboratory-, sign-, or symptom-based medication monitoring. This overlap was most often a result of the evaluation of clinical practice guidelines, order sets, or both that contain prescribing and monitoring elements. Sixteen studies addressed potentially nephrotoxic, hepatotoxic, or 473 442,461,555,618 cardiotoxic medications with a narrow therapeutic index, and certain laboratory 407,412,481,511,516,609,611,612 and medication combinations. Four provided guidance about potentially 401,477,614,622 inappropriate antibiotic management, and three provided information about pain 437,608,621 management. Twelve of the studies used interruptive alerts to display and prompt the clinician for an immediate response while providing 397,407,412,472,481,505,543,608,609,611,613,624 patient care. Outcomes As noted above, more than two-thirds (33 of 47) of the interventions were associated with a positive process outcome. A number of themes emerged from the variety of interventions that were conducted in various health care settings, using varying degrees of technological sophistication, and providing information to a number of health care professionals, as well as directly to patients. Two of the five studies (40 percent) that targeted sign-based medication monitoring showed that greater than 50 percent of the process endpoints improved. Ten 437,446,519,553,554,610,616-618,622 studies provided a combination of laboratory-, sign-, or symptom- 437,554,610,616-618,622 based monitoring, and seven or 70 percent showed statistically significant changes in at least half of their main process endpoints. One of the most frequently reported types of intervention (n = 12) provided decision support to improve chronic disease management (i. The type of chronic diseases varied based on patient population, but included the management of asthma, chronic obstructive pulmonary disease, depression, diabetes, hyperlipidemia, and hypertension. Overall, 67 percent of these interventions resulted in a statistically significant change in at least half of its major endpoints. Overall, 60 percent of these interventions resulted in statistically significant change in at least half of its main endpoints. Other common interventions (n = 8) included providing alerts and reminders to obtain 407,442,472,511,516,609,611,612 laboratory testing for newly prescribed or chronically used medications. Overall, 50 percent of these interventions showed a statistically significant change in at least half of their main endpoints. Overall, 86 percent of these interventions resulted in improvements in at least half of the major process changes reported as endpoints. Another metric commonly assessed was the response time to a variety of alerts (n = 7) including the management of narrow therapeutic index and potentially nephrotoxic medications, initiation of primary and secondary prevention, and time to pain assessment and 461,477,481,527,615,618,619 management. Overall, 71 percent of these interventions showed statistically significant improvements in at least half of its main endpoints. Finally, two interventions assessed pain management including error reassessment rate and 437,608 patient controlled analgesia order set use. Overall, both of these interventions showed statistically significant changes in at least half of its main endpoints. In our analysis, 70 percent (33 of 47 studies) of the included studies showed statistically significant changes in at least half of their main endpoints. When compared with sign- or symptom-based medication monitoring, laboratory-based medication monitoring studies were most likely (76 percent of the time) to be associated with a statistically significant change in at least half of its main endpoints. Moreover, these laboratory- based medication monitoring studies were conducted in a variety of health care settings including ambulatory, acute, and long-term care. The most successful types of studies focused on changing prescriber behavior, improving response time to generated alerts, and improving the diagnosis and management of chronic diseases. Reconciliation, Discharge Summaries, and Education Summary of the Findings for Process Changes Reconciliation. The problem of medication 35 reconciliation is especially acute for patients who receive care across settings: from hospitals, specialists, and primary care—most often the elderly and those with multiple health challenges. Four studies on medication reconciliation are included (Appendix C, Evidence Table 13,14,627,628 628 6). All were set in hospitals with the reconciliation done at discharge or transfer to another facility. One hospital 13 was a Statepsychiatric hospital and the others were general hospitals. All studies showed substantial improvement in agreement among records of medications provided by various clinicians involved in the care of the patients (Appendix C, Evidence Table 6). For example, one Dutch study showed improvements in agreement on prescriptions between the pharmacists and general practitioners with e-Prescribing compared with paper systems at discharge (31 percent vs. Poole and colleagues also showed improvements in prescribing (more therapeutic drug duplications were identified and resolved with an automated discharge medication worksheet for physicians). Most of the articles targeting educational aspects of medication management that measured changes in knowledge are covered in the section with intermediate outcomes. Combined Phases of Medication Management Summary of the Findings for Process Changes Although some studies in this report assessed systems that covered the whole medication management process (five phases plus reconciliation and education), only one provided cross- 438 phase study with changes in process. The studies often covered multiple medication management phases, such as prescribing (n = 7), order communication (n = 1), administering (n = 3), and monitoring phases (n = 6), as well as reconciliation (n = 1). Outcome measures focused on process and other intermediate measures, only two measured 630,631 patient outcomes (blood glucose levels in both cases). Most interventions targeted specific diseases such as 630,631 553,634 633 534 13 diabetes, asthma, cancer, high blood pressure, psychiatric patients, or the use of 514 563 certain classes of medications such as nonsteroidal anti-inflammatory drugs and antibiotics. Of the quantitative studies, five reported significant 13,563,630,631,634 improvements as a result of the intervention and four reported no significant 514,534,553,593 effects. Intermediate Outcomes Summary of the Findings Articles measuring intermediate outcomes as their main endpoint were selected. We focused on the intermediate outcomes of: use; measures which were correlated with use (such as ease of use of the system, perceptions of users of the system, computer experience, etc. Few hypothesis-driven studies with comparison groups assessed such intermediate outcomes as their main measure; 42 studies published in 44 articles were retrieved (Appendix C, Evidence Table 7). The study results tended to show positive levels of satisfaction and use and measured a number of correlates of both to determine driving factors barriers, or both. Studies of complex interventions often covered more than one phase of medication 540,644-647 management. Most of the studies were conducted in hospitals (n = 27) or primary care (n = 17), one in long-term care, and four in pharmacies, and assessed intermediate outcomes for health care staff. Prescribing was the most commonly studied phase of medication management, but each other phase was represented. Most studies did not report on the proprietary nature of their systems, 17 studied commercial systems and seven were home grown. Many studies looked to correlate use of medication management systems with other factors. Only nine studies assessed intermediate outcomes for patients (Table 633,637,639,641,642,648-651 13). Twenty-six studies looked at intermediate outcomes for interventions aimed at the prescribing phase (see Appendix C, Evidence Table 22). One study 653 focused on the use of standards for medical history, formulary, and benefits. Satisfaction and 636,637,644,645,654-659 correlates of satisfaction were measured in ten studies; use and measures 534,643,649,650,653,660-665 666 correlated with use were studied in 11 studies. Glassman and colleagues looked at the impact of drug-drug interaction alerts on physician knowledge over time. Participants were generally health care providers, located in either hospitals (16 540 studies), primary care (ten studies), or both, and one pharmacy. Four studies looked at the order communication phase; three 540,645,668 focussed on e-transfer of prescriptions, and all studied the perceptions of pharmacy staff 645 as well as other stakeholders. Rupp and Warholak administered a survey and followed up with interviews of American chain community pharmacy staff to assess their attitudes towards e- Prescribing and recruited a sample of 1094 pharmacists, technicians, and interns from 276 668 pharmacies.

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