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By U. Derek. Lycoming College.

We need more research to identify why these injuries occur and find ways to prevent them from happening cheap asacol 400mg with visa. In those days buy discount asacol 400 mg, it was common practice to x-ray pregnant women to measure their pelvises and make a diagnosis of twins discount asacol 400mg online. Finally generic asacol 400mg overnight delivery, a study of 700,000 children born between 1947 and 1964 in 37 major maternity hospitals compared the children of mothers who had received pelvic x-rays during pregnancy to those of mothers who did not. It found that cancer mortality was 40% higher among children whose mothers had been x-rayed. To obtain useful information, X-rays are taken almost continuously, with minimum dosages ranging from 460 to 1,580 mrem. X-ray radiation accumulates in the body, and ionizing radiation used in X-ray procedures has been shown to cause gene mutation. The health impact of this high level of radiation is unknown, and often obscured in statistical jargon such as, “The risk for lifetime fatal cancer due to radiation exposure is estimated to be 4 in one million per 1,000 mrem. A medical doctor with a PhD in nuclear and physical chemistry, Gofman worked on the Manhattan Project, discovered uranium-233, and was the first person to isolate plutonium. In a nearly 700-page report updated in 2000, “Radiation from Medical Procedures in the Pathogenesis of Cancer and Ischemic Heart Disease: Dose-Response Studies with Physicians per 100,000 Population,”(90) Gofman shows that as the number of physicians increases in a geographical area along with an increase in the number of x-ray diagnostic tests performed, the rate of cancer and ischemic heart disease also increases. Gofman elaborates that it is not x-rays alone that cause the damage but a combination of health risk factors that include poor diet, smoking, abortions, and the use of birth control pills. Gofman predicts that ionizing radiation will be responsible for 100 million premature deaths over the next decade. Gofman notes that breast cancer is the leading cause of death among American women between the ages of 44 and 55. Because breast tissue is highly sensitive to radiation, mammograms can cause cancer. Sarno, a well-known New York orthopedic surgeon, found that there is not necessarily any association between back pain and spinal x-ray abnormality. He cites studies of normal people without a trace of back pain whose x-rays indicate spinal abnormalities and of people with back pain whose spines appear to be normal on x-ray. Moreover, doctors often order x-rays as protection against malpractice claims, to give the impression of leaving no stone unturned. It appears that doctors are putting their own fears before the interests of their patients. They concluded that 23% of all admissions were inappropriate and an additional 17% could have been handled in outpatient clinics. Thirty-four percent of all hospital days were deemed inappropriate and could have been avoided. Martin Charcot (1825-1893) was world-renowned, the most celebrated doctor of his time. He became an expert in hysteria, diagnosing an average of 10 hysterical women each day, transforming them into “iatrogenic monsters” and turning simple “neurosis” into hysteria. Only 100 years ago, male doctors believed that female psychological imbalance originated in the uterus. When surgery to remove the uterus was perfected, it became the “cure” for mental instability, effecting a physical and psychological castration. Women are given potent drugs for disease prevention, which results in disease substitution due to side effects. Approximately 4 million births occur annually, with 24% (960,000) delivered by cesarean section. Sakala contends that an “uncontrolled pandemic of medically unnecessary cesarean births is occurring. They also used this argument for tobacco, claiming that more studies were needed before they could be certain that tobacco really caused lung cancer. State journals such as the New York State Journal of Medicine also began to run advertisements for Chesterfield cigarettes that claimed cigarettes are "Just as pure as the water you drink… and practically untouched by human hands. The authors estimated that 106,000 deaths occur annually due to adverse drug reactions. The safety of new agents cannot be known with certainty until a drug has been on the market for many years. The mortality rate in hospitals for patients with bedsores is between 23% and 37%. Critics will say that it was the disease or advanced age that killed the patient, not the bedsore, but our argument is that an early death, by denying proper care, deserves to be counted. It is only after counting these unnecessary deaths that we can then turn our attention to fixing the problem. The report calls for adequate nursing staff to help feed patients who are not able to manage a food tray by themselves. The Coalition report states that malnourished residents, compared with well-nourished hospitalized nursing home residents, have a fivefold increase in mortality when they are admitted to a hospital. Nosocomial Infections The rate of nosocomial infections per 1,000 patient days rose from 7. Due to progressively shorter inpatient stays and the increasing number of admissions, however, the number of infections increased. Morbidity and Mortality Report found that nosocomial infections cost $5 billion annually in 1999,(10) representing a $0. At this rate of increase, the current cost of nosocomial infections would be around $5. Barbara Starfield presents well-documented facts that are both shocking and unassailable. Starfield warns that one cause of medical mistakes is overuse of technology, which may create a "cascade effect" leading to still more treatment. Starfield notes that many deaths attributable to medical error today are likely to be coded to indicate some other cause of death. She concludes that against the backdrop of our poor health report card compared to other Westernized countries, we should recognize that the harmful effects of health care interventions account for a substantial proportion of our excess deaths. When doctors bill for services they do not render, advise unnecessary tests, or screen everyone for a rare condition, they are committing insurance fraud. In some cultures, elderly people lives out their lives in extended family settings that enable them to continue participating in family and community affairs. American nursing homes, where millions of our elders go to live out their final days, represent the pinnacle of social isolation and medical abuse. Over 40% (3,800) of the abuse violations followed the filing of a formal complaint, usually by concerned family members. Incidents of physical abuse causing numerous injuries such as fractured femur, hip, elbow, wrist, and other injuries. Dangerously understaffed nursing homes lead to neglect, abuse, overuse of medications, and physical restraints. In 1990, Congress mandated an exhaustive study of nurse-to-patient ratios in nursing homes. Yet it took the Department of Health and Human Services and Secretary Tommy Thompson only four months to dismiss the report as ‘insufficient. Because many nursing home patients suffer from chronic debilitating conditions, their assumed cause of death often is unquestioned by physicians. Some studies show that as many as 50% of deaths due to restraints, falls, suicide, homicide, and choking in nursing homes may be covered up. In fact, researchers have found that heart disease may be over-represented in the general population as a cause of death on death certificates by 8-24%. In the elderly, the overreporting of heart disease as a cause of death is as much as twofold. The study found only 8% of the patients were well nourished, while 29% were malnourished and 63% were at risk of malnutrition. As a result, 25% of the malnourished patients required readmission to an acute-care hospital, compared to 11% of the well- nourished patients. The authors concluded that malnutrition reached epidemic proportions in patients admitted to this subacute-care facility. Studies show that compared to no restraints, the use of restraints carries a higher mortality rate and economic burden. Several studies reveal that nearly half of the listed causes of death on death certificates for elderly people with chronic or multi-system disease are inaccurate. Medco oversees drug-benefit plans for more than 60 million Americans, including 6.

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There is as yet no clear evidence that monly (approximately 10% of the population) is supplements should be given to all those with ischaemic avariant of methylene tetrahydrofolate reductase order asacol 400mg on-line, heart disease buy 400 mg asacol overnight delivery, although several trials are in progress buy 400 mg asacol free shipping. G enetic syndrom es 1 Patterns of inheritance cheap asacol 400mg free shipping, 516 Incidence Patterns of inheritance Rises with increasing maternal age (1 in 3000 when mother is less than 30 years to 1 in 300 when mother Autosomal dominant:Mendelian pattern of inheritance is 35–40 years and 1 in 30 in women above 45 years). Be- where the presence of a single abnormal allele is able cause of the high birth rate in mothers below 35, half to produce the disease. There may be reduced expres- of all Down syndrome children are born to mothers sion of the condition if the condition does not have full below 35. Autosomal recessive: Mendelian pattern in which Age both genes must be defective to produce the clinical phe- Congenital. M = F There is no male-to-male transmission, daughters of an affected male will be obligate carriers. In X linked domi- Geography nant conditions, females may also demonstrate the clin- All ethnic communities. The additional chromosome 21 is usually follow normal Mendelian patterns of inheritance. In this (94% of cases) the result of non-disjunction of chromo- set of conditions males and females may be affected, but some 21 during the formation of the maternal ovum. In about 3% of cases there is mosaicism with some cells demonstrating a normal Down syndrome karyotype. Definition Pathophysiology Down syndrome is the clinical condition usually result- The Alzheimer’s disease seen with Down syndrome is ing from a trisomy of chromosome 21 first described by thought to be due to the presence of three copies of the Langdon Down in 1865. Chronic granulomatous Recessive Cytochrome Neutrophils can phagocytose material, but are unable disease b245 to generate respiratory burst and hence kill bacteria. Duchenne muscular dystrophy Recessive Dystrophin Progressive proximal muscle weakness with calf psuedohypertrophy. Causes progressive intellectual deterioration, loss of purposeful use of hands and jerky truncal ataxia. Leber optic atrophy Multiple loci Sudden onset adult blindness, cardiomyopathy, cardiac conduction defects. Short into adult life, but by 40 almost all have Alzheimer’s middle phalynx of little finger, single horizontal pal- disease. Klinefelter syndrome r Congenitalheartdiseasein30%,mostcommonlyatri- Definition oventricular septal defects. Tracheo-oesophageal fistula, duodenal atresia, annu- lar pancreas, Hirschsprung’s disease. Definitive diagnosis is made by chori- more X chromosomes the more severe the phenotype. All appear normal until puberty when hypogo- tions for testing include maternal age and a Down nadism becomes prominent. Most Tall, with long arms and legs, hypogonadism, female pu- cases of Turner syndrome spontaneously abort during bic hair profile, high-pitched voice, reduced facial and pregnancy. As there is nor- mally only one copy of the X chromosome, females Incidence suffer from X linked recessive conditions such as 1in5000 live births. O verdose, poisoning 1 and addiction Alcohol and drugs of abuse, 521 Overdose and poisoning, 526 r Alcohol dependence is defined as a maladaptive pat- Alcohol and drugs of abuse tern of use associated with tolerance and withdrawal syndrome despite significant physical and psycholog- Alcohol abuse and dependence ical problems. Patients often exhibit a stereotyped drinking pattern with alcohol consumption taking Definition preference over other activities. Regular or binge consumption of alcohol sufficient to A history of alcohol consumption should be taken from cause physical, neuropsychiatric or social damage. In addi- Incidence/prevalence tion signs of chronic liver disease and other complica- 3–4%ofthepopulationreportalcohol-relatedproblems. Sex Complications 2M : 1F r Medical complications include gastritis, peptic ulcer Aetiology disease, pancreatitis, hepatitis, cirrhosis, portal hy- Various factors have been implicated: pertensionwithoesophagealvarices,cardiomyopathy, r Genetic factors: Evidence includes variation across hypertension. Health care professionals Blood alcohol levels are of limited value, a persistently with access to opiates may abuse drugs like fentanyl. Incidence/prevalence Heroin abuse fell during the late 1990s, but rose again Management rapidly in 2000 and 2001. A fall in use since then has 1 Identification and advice at an early stage may be been attributed to the fall in supply after the Taliban enough to avert serious medical, neuropsychiatric banned production in Afghanistan. Precipitating fac- numbers of users, the number of heroin-induced deaths tors should be identified and psychological sup- has remained static. Abusers and diazepam or lorazepam in the treatment of repeatedly take the drug to achieve the euphoric effect; seizures. Withdrawal in acetaldehyde accumulation resulting in flushing, symptoms also occur, and so further doses are taken to headache, anxiety and nausea. Heroincanbesmoked(‘chasingthedragon’),snorted, or injected into a vein (‘shooting up’ or ‘mainlining’), or subcutaneously (‘skin popping’) or intramuscularly. Prognosis It acts rapidly, within 10–20 seconds, if injected, and 15% die by suicide, 30% continue to have life-long within 20–30 seconds, if snorted. Opiate abuse and dependence Clinical features Definition Following use of heroin, side effects include nausea and Opiate dependence or addiction is defined as the con- vomiting (usually only on first few uses), drowsiness, tinued use of opiates, despite these causing significant sedation, constricted pupils and dry, itchy skin. Opium contains morphine and A history should be taken of recent and previous codeine. Natural and synthetic derivatives of these drugs heroin use, including methods of administration, use of are useful, effective analgesics, but opiates also have the otherdrugssuchasbenzodiazepines,alcoholintake,pre- potential to become drugs of abuse. A close social history should be taken, ofabuse,butotherdrugsincludingmorphine,pethidine, as well as a medical history and examination. In its pure form, heroin is a white powder, but on the Complications streets it is bought as an off-white or brown powder, and r The most serious complications are associated with isknownbymanystreetnamesincluding‘H,gear,smack, intravenous use. Use of non-sterile equipment and Chapter 15: Alcohol and drugs of abuse 523 water used to mix the powder lead to cellulitis, throm- Cocaine abuse and dependence bophlebitis, skin and organ (e. Itisnormallyboughtasawhitepowder, Withexcessivedoses,comaanddeathfromrespiratory which is usually snorted or smoked. This combusts more readily making the when tolerance is reduced, or if other drugs or alcohol cocaine more potent. Social problems include loss of job, deterioration in The street term ‘freebasing’ means smoking cocaine, ei- relationships and criminal activities to obtain money ther as the salt or base. Cocaine and crack can also be to buydrugs,includingstealing,prostitutionanddrug injected, although this is far less common. Incidence/prevalence Investigations 7% of 20–24 year olds have tried cocaine, mainly snort- These depend on the presentation of the individual. About 10–15% of those who try snorting cocaine vestigations may be needed for possible complications become abusers. Crack is linked with areas of social depending on the history and clinical diagnosis. Heroin intoxication is treated by ensuring airway pro- tection, and giving the opiate antagonist naloxone. Tolerance does seem to occur to some not cause euphoria, is used as a method of programmed extent. Baseformsofcocaine, Supportive therapy is needed to prevent the patient from including crack, have a more rapid onset but a much seeking increased doses (either of heroin, other drugs or shorter duration of action. In alcohol, its effects are increased by an active metabolite, some cases, patients stay on long-term methadone at which only forms in the presence of alcohol. Physical side effects include dilated pupils, dry mouth, 524 Chapter 15: Overdose, poisoning and addiction sweating, tachycardia and loss of appetite. Within half an 2 Agitation and hypertension often respond to di- hour of the last dose of a binge, there is a ‘crash’ when the azepam. Haloperidol and phenothiazines should be user feels intense cravings, depression and anxiety. Long-term users coronary vasoconstriction due to unopposed alpha may become persistently restless, with anorexia, weight effects). Smok- physical effects from withdrawal so sedatives or a re- ing can cause granulomas and pulmonary oedema. Other medical tension or myocardial ischaemia) and antidepressants complications include hypertension, myocardial in- may be indicated.

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The the operation not occupied by shift of other struc- patient may feel short of breath generic asacol 400 mg line, wheezy and complain tures fills with blood and serum which organises and of chest tightness and retrosternal discomfort discount asacol 400mg free shipping. Thecoughthenbecomeswet Thoracoscopy is used for diagnosis of pleural disease discount 400 mg asacol overnight delivery, and productive of yellow or green sputum discount 400 mg asacol with mastercard. Discoloured mediastinoscopy to sample upper mediastinal lymph sputum signifies infection, which may be of bacterial or nodes and mediastinotomy to sample lower mediasti- viralorigin. Single lung ventilation is used to allow the collapse of the lung being operated on, e. The airway mucosa becomes red and oedematous, there Specific complications following thoracic surgery in- is often an overlying mucopurulent exudate. Respiratory infections Investigations Acute bronchitis These are usually not required, there may be a mild neu- trophil leucocytosis even in viral infections. Patients presenting with acute bronchitis during an influenza epidemic may ben- Incidence efit from treatment with a neuraminidase inhibitor if Very common. Only if secondary bacterial infection is suspected should a course of antibiotics be Age prescribed. Any Prognosis Sex The illness usually lasts up to a week in healthy adults, M = F prolonged symptoms may occur. Changes in the course 98 Chapter 3: Respiratory system of the illness or presence of bronchopneumonia suggest Table3. Conditions impairing Defence mechanism defence mechanism Pneumonia Cough Coma/anaesthesia Respiratory depression Definition Neuromuscular weakness Pneumonia is an infective, inflammatory disease of the Ciliary function Smoking, influenza, colds lung parenchyma. Bronchiectasis (including cystic fibrosis and Kartagener’s syndrome) Aetiology Ciliary function can also be It is useful to classify pneumonia according to the impaired mechanically by causative organism or the clinical setting, e. This helps to determine the choice of carcinoma Phagocytosis Smoking antibiotics for treatment. Alcohol Pneumonia most often occurs in children and the el- Hypoxia derly, but may also affect young, fit adults. Viralpneumonia is less common, but bacterial pneumo- r Atypical pneumonias cause predominantly interstitial nia may be a secondary complication. Causes include the atypi- Pathophysiology cal bacteria Chlamydia, Coxiella, Mycoplasma and Le- The infection may be as a result of impairment of one or gionella. Pathologically pneumonia Symptoms may include fever, dyspnoea, pleuritic pain can be divided into broncho-, lobar or atypical pneumo- and cough often productive of green sputum; however, nia depending on the pattern of inflammation. It is predisposed to by immobility and dation (such as dullness to percussion, increased vocal viral infections which lead to retention of secretions resonance, bronchial breathing) but even if frank con- especially in the lower lobes. The infection is centred solidation is not present, most patients have tachypnoea on the bronchi and bronchioles and spreads to involve (>20 breaths/minute) and crackles. In atypical pneu- adjacent alveoli, which become consolidated with an monia the signs of consolidation in the lung are often acute inflammatory exudate. Red hepatisation Organisation of the fluid into a fibrin mesh containing red cells, neutrophils and bacteria. Grey hepatisation Clearance of the red blood cells and neutrophils and predomination of macrophages in an attempt to clear the remaining bacteria. Resolution The fibrin meshwork is broken down, neutrophil debris is ingested by macrophages which are cleared through the lymphatics. The air spaces are filled with an acute 6weeks to ensure resolution, and to exclude any un- inflammatory exudate causing the lung to be firm and derlyinglesionsuchascarcinomacausingobstruction. Several identifiable secretions,analgesiaforpleuriticpainwherenecessary stages are seen in a pneumococcal lobar pneumonia andoxygenifthereishypoxia(guidedbyarterialblood (see Table 3. Outcome depends greatly on the age of the patient and r The white cell count will normally demonstrate a neu- concurrent disease (including diabetes mellitus, chronic trophilia. If patients require admission, sputum and renal failure, congestive heart failure and underlying res- blood cultures should be taken and specific serologi- piratory disease such as chronic obstructive pulmonary cal tests are available for Legionella and other atypical disease). If severe sepsis or in a neutropenic patient combination Pseudomonas, Proteus) 60% piperacillin/ tazobactam and gentamicin may be used Strep. Intermediate coexisting chronic disease, hypoxia (PaO2 < 8kPaor ratesoftuberculosisoccurinCentralandSouthAmerica, oxygen saturation < 92%), bilateral or multilobe in- Eastern Europe and Northern Africa. Ascoreof2ormorecorefeaturessuggestaseverepneu- Aetiology monia with indication for initial combined antibiotic M. It is spread by coughing up of live bacilli after invasion of the disease into a main bronchus (open tu- berculosis), which are then inhaled. Approximately 7000 new cases a year in the United r Theemergenceofmultipledrugresistanceduetonon- Kingdom and rising throughout Europe and the United States. Groups particularly at risk include the elderly, the very Age young, alcoholics, immunosuppressed, e. The macrophages Asian sub-continent have a 40 times greater incidence of can phagocytose the organisms, but mycobacterial cell Chapter 3: Respiratory infections 103 wall components interfere with the fusion of the lyso- Secondary tuberculosis somes with the phagocytic vacuole, so that the bacteria r Secondary tuberculosis is a reactivation of infection can survive intracellularly. It may occur at any time from weeks just below the pleura in the apex of the upper lobe or up to years after the original infection. It matory process forms the ‘Ghon focus’ usually just differs from primary infection in its immunopathol- beneath the pleura. The lymph nodes are rarely involved, and there is lymph nodes at the lung hilum, and excite an immune reactivation of the immune response in the tissues. This pattern forms the primary r Inthelung,thebacteriahaveapreferencefortheapices complex with infection at the periphery of the lung (higher pO2), and form an apical lung lesion known and enlarged peribronchial lymph nodes. It begins as a small caseating r The outcome of the primary infection depends on the tuberculous granuloma, histologically similar to the balance between the virulence of the organism and Ghon focus, with destruction of lung tissue and cavi- the strength of the host response (see Table 3. T cells are re-induced by the secondary infec- the host can mount an active cell mediated immune tion, with activation of macrophages, and exactly as response the infection may be completely cleared. Collagen is healing of the apical region with collagen de- is deposited around these, often becoming calcified. This is called a ‘progres- tissue, thinning of the collagen wall and increasing sive primary infection’. Coughing disperses these bacilli into the at- Poor immune system eg Good immune response, e. Without malnutrition, extremes of healthy immunised treatment, extensive caseating lesions develop rapidly, age, intercurrent disease individual leading to a high mortality. This disease is sometimes Use of appropriate antibiotics called ‘galloping consumption’. By that time there may be no evidence of tu- comesinfectedbymiliarydisseminationwithmultiple berculosis elsewhere. If a lesion erodes a pulmonary vein, there may be systemic miliary dissemination, for ex- Clinical features ample to the meninges, spleen, liver, the choroid and 1 Primary tuberculosis is usually asymptomatic, occa- the bone marrow. The hypersensitivity reaction may produce patient mounts a good immune response, organisms atransient pleural effusion or erythema nodosum. The outstanding Chapter 3: Respiratory infections 105 features are fever (drenching night sweats are rare) be normal, as tubercles are not visible until they are and cough productive of mucoid, purulent or blood 1–2 mm. Microscopy Formal culture of material is the only way of accu- The characteristic lesion, the tubercle (granuloma) con- rately determining virulence and antibiotic sensitivity sists of a central area of caseous tissue necrosis within and should be attempted in every case, results may which are viable mycobacteria. It relies on the hypersensitivity reaction, usually heals spontaneously but occasionally may per- and is rarely helpful in the diagnosis of tuberculosis: sist giving rise to bronchiectasis particularly of the i The Tine test and Heaf test are for screening: 4/6 middle lobe (Brock’s Syndrome). If the spots are confluent, logicalfractures,particularlyofthespinetogetherwith the test is positive, indicating exposure. The reaction is read at Investigations 48–72 hours and is said to be positive if the indura- r An abnormal chest X-ray is often found incidentally tion is 10 mm or more in diameter, negative if less in the absence of symptoms, but it is very rare for a than 5 mm. The X-ray shows purified protein derivative this can indicate active patchy or nodular shadowing in the upper zone with infection requiring treatment. In an immunocom- fibrosis and loss of volume; calcification and cavita- promised host (such as chronic renal failure, lym- tion may also be present. Human immunity depends largely on the haemag- niazid, ethambutol and pyrazinamide, and a further glutinin (H) antigen and the neuraminidase (N) antigen 4months of rifampicin and isoniazid alone. Major shifts in these antigenic re- taken 30 minutes before breakfast to aid absorption. Thesecancauseapandemic,whereasantigenicdrift organism is sensitive for a full 6 months to avoid de- causes the milder annual epidemics.

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In order to address and resolve these hurdles buy asacol 400 mg online, the Committee envisions the design of several targeted pilot studies discount asacol 400 mg without a prescription. These studies would probe key aspects of this new research paradigm and demonstrate to health-care providers the value of a molecularly informed taxonomy of disease generic asacol 400mg mastercard. By demonstrating value for patients buy generic asacol 400mg on-line, the pilot studies will seek to lay the groundwork for a sustainable discovery model in which relevant clinically validated molecular data are routinely generated at the “point of care” because they meet the commonly accepted risk-benefit criteria that apply to all clinical test results. Pilot Studies should draw upon observational studies As emphasized above, the Committee believes that much of the initial work necessary to develop the Information Commons should take the form of observational studies. In this context, what we mean by observational studies is that, although molecular and other patient-specific data would be collected from individuals in the normal course of health care, no changes in the treatment of the individuals would be contingent on the data collected. This approach to discovery is already in use today, although most current initiatives draw in a very limited range of clinical data. For example, genome-wide association studies comparing individuals with and without a diagnosis of Crohn’s disease securely identified a number of gene variants that implicate autophagy in the pathophysiology of Crohn’s disease while similar comparisons for Age Related Macular Degeneration implicated complement factor H (McCarthy et al. In other instances, clinically relevant genotype-phenotype correlations have been discovered in the course of observational studies performed during randomized clinical trials. For example, a randomized clinical trial was performed to compare the efficacy of different formulations of interferon alpha in the treatment of chronic infection with hepatitis C. The enrollment of individuals in these studies had no bearing on their diagnoses, treatments, or in most cases, anything else in their lives. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease 54 was simply to ask the question “Are there gene variants in the general population that are associated with who ends up with a particular diagnosis or experiences a particular treatment response? For example, there are likely to be a great many ways to classify patients based on molecular data, and only some will have clinical utility. In general, clinical utility will need to be evaluated using randomized clinical trials. Observational studies will also need to be followed by functional studies that seek to determine the mechanistic basis of observed molecular associations with clinical outcomes. We anticipate that laboratory based research of this sort will be essential to elucidate the underlying reasons for observed associations between molecular data and clinical outcomes and that these mechanistic insights will play an essential part in establishing the Knowledge Network and guiding its use. Be of a sufficient size, as well as scientific and organizational complexity, to reveal on the basis of actual experience the most significant barriers to the development of point- of-care discovery efforts. Address one or more unmet medical needs for which deeper biological understanding of a disorder would likely lead to near-term changes in treatment paradigms and health outcomes. Include the generation and analysis of a range of molecular-data types potentially including, but not limited to genomic data (sequence and expression), metabolomic data, proteomic data, and/or microbiome data. Be led by an organization charged with delivering healthcare with strong partnerships with researchers. Involve partnerships with a broad array of stakeholders, both public and private, including health-care providers, patients, payers, and scientists with expertise in genomics, epidemiology, social science, and molecular biology. Seek to remove barriers to data sharing and provide an ethical and legal framework for protecting and respecting individual rights. Draw on laboratory research to assess the biological underpinnings of associations between molecular data and clinical outcomes. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease 55 Below, we outline two example pilot studies; the first, “The Million American Genomes Initiative”, is selected to pilot the use of one of the key layers of ‘omic information that is "ready to go". This pilot project would help to populate the Information Commons with relevant data and facilitate learning how to establish connections with other layers. By focusing on healthcare recipients in diverse states of health and disease, this project would also help evaluate the new discovery paradigm by allowing correlations to be made between germline sequences and a vast range of phenotypes. The second “Metabolomic profiles in Type 2 Diabetes” is disease specific and is designed to ensure the early introduction of a different ‘omic layer (metabolomics) into the Information Commons and to pilot evaluation of more targeted questions in the new discovery paradigm. In focusing on a pilot study involving complete sequence data, we do not intend to elevate sequence data above other data in their importance to the Knowledge Network. Instead, this proposal recognizes that sequencing methods are “ready to go,” or nearly so, for very-large-scale implementation and the acquisition of such data in a point-of-care setting would, of necessity, require addressing key challenges related to informed consent, protection of data, data storage, and data analysis that will be common to all types of data. This proposal also recognizes that sequencing on this scale will inevitably be undertaken in the near future in an effort to make connections between human-genome-sequence data and common diseases. We view it as important to the development of the Knowledge Network that this effort be grounded in the new discovery model, which would make possible systematic comparisons of the molecular data with electronic medical records, now and into the future: that is, the study design should allow correlations between genotypes determined now and health outcomes that occur years or decades later. The sequencing of one million genomes would include a sufficient range of individuals with different health outcomes and sufficient statistical power to detect associations. For example, amoxicillin-clavulanic acid is a widely used antibiotic that causes severe liver injury in one out of approximately 15,000 exposures. In a one-million-patient sample we would expect to include many individuals with this—and other similarly rare—adverse drug reactions and other medical conditions. It is also essential that the sample size be large enough to build a concrete picture of the distribution of gene variants in individuals free of specific diagnoses. Example Pilot Study 2: Metabolomic profiles in Type 2 Diabetes Recent metabolomic profiling of blood samples from individuals who subsequently developed type 2 diabetes showed marked differences in the characteristics of branched-chain amino acids sampled from blood draws (Wang et al. These early analyses suggest the potential of metabolomic analyses to help identify those individuals at most risk of developing diabetes, and in particular, may help to elucidate the physiological steps involved in the transition between insulin resistant pre-diabetes and full-blown diabetes. We therefore envision a pilot project focused on understanding this transition using metabolomic profiles in blood. This work would begin with targeted quantitative metabolomic studies transitioning towards more comprehensive metabolomic profiles over time. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease 56 gained from Pilot 1 and research from other layers of the Information Commons (such as the microbiome and exposome) could contribute substantially to strategies to delay or prevent the development of type 2 diabetes. Anticipated outcomes of the pilot studies The pilot studies are intended to lead to new connections between genetic or metabolomic variation and disease sub-classifications, often with implications for disease management and prevention. More importantly, they will provide the lessons necessary to facilitate a more rapid transition in the way molecular data are used. For example, pilot projects of sufficient scope and scale could lead to the development of new discovery models, including those in which patient groups self-organize in recognition of shared clinical features and then pursue efforts to generate relevant molecular data. Such an initiative also would permit many logistical, ethical, and bioinformatic challenges to be addressed in ways that would benefit future efforts and lead toward the sustainable implementation of point-of-care discovery efforts. A research model based on open data sharing requires changes to data access, consent and sharing policies Research to develop a Knowledge Network of Disease will need to resolve complex ethical and policy challenges including consent, confidentiality, return of individual results to patients, and oversight (Cambon-Thomsen et al. The Committee’s vision of a Knowledge Network of Disease and its associated benefits for future patients will become a reality only if the public supports a new balance between research access to materials and clinical data and respect for the values and preferences of donors. Ultimately, there should be no dichotomy between “patient data or materials” and “those who benefit from this research. How might these ethical and policy challenges be resolved so that the pilot studies described previously might be carried out? The Committee recommends that an appropriate federal agency initiate a process to assess the privacy issues associated with the research required to create the Knowledge Network and Information Commons. Because these issues have been studied extensively, this process need not start from scratch. However, in practical terms, investigators who wish to participate in the pilot studies discussed above—and the Institutional Review Boards who must approve their human-subjects protocols— will need specific guidance on the range of informed-consent processes appropriate for these projects. Subject to the constraints of current law and prevailing ethical standards, the Committee encourages as much flexibility as possible in the guidance provided. As much as possible, on-the-ground experience in pilot projects carried out in diverse health-care settings, rather than top-down dictates, should govern the emergence of best practices in this sensitive area, whose handling will have a make- or-break influence on the entire information-commons/knowledge-network/new-taxonomy initiative. Inclusion of health-care providers and other stakeholders outside the academic community will be essential. Intensive dialog about the benefits of an Information Commons containing individual-centric data about health and disease. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease 57 patient representatives, and disease advocacy groups. Reaching out to communities that have been suspicious of research because of historical abuses would strengthen trust. At the workshop the Committee convened, we heard patient advocates and public representatives argue forcefully that more transparency regarding research and more collaboration among researchers, research institutions, and the public would facilitate research. For example, when constructively engaged, advocacy groups have advanced biomedical research by helping to design studies that are attractive to patients, publicized the projects, helped to recruit participants, and raised money to help pay for the research.

It has been found to correlate with infection status and is an effective mechanism for identifying candidates for testing (Armstrong et al discount 400 mg asacol amex. Researchers who were evaluating hepatitis C incidence along the Texas–Mexico bor- der found tattooing to be an independent risk factor for infection in their majority-Hispanic population (Hand and Vasquez discount asacol 400mg online, 2005) cheap asacol 400mg free shipping. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www order asacol 400mg with mastercard. As effective antiretroviral therapies emerged, recommendations for screening and testing were expanded (Myers et al. TheThe availability of rapid tests in theavailability of rapid tests in the Copyright © National Academy of Sciences. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Table 5-2 provides guidance on the interpreta- tion of hepatitis B serologic test results. Cost-effectiveness data on the use of laboratory testing in particular at- risk populations are available. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Reactivations have also been reported to occur with other types of immunosuppressives, notably anti–tumor- necrosis factor therapy for rheumatoid arthritis and infammatory bowel disease (Esteve et al. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Research to develop a vaccine for hepatitis C continues although it is unlikely that a vaccine will be developed and licensed in the near future. Given the com- plexity of the issues surrounding vaccination of children and adults, this report devotes a separate chapter (Chapter 4) to immunization. Support for abstinence is an element of harm reduction but is not a requirement for participation in harm-reduction programs. Harm reduction focuses on providing information about safer practices (for ex- ample, how to inject without exposing oneself to contaminated blood), providing materials for engaging in safer practices (such as needle syringes and condoms), and offering hepatitis B vaccination. Because harm reduc- tion does not condemn illicit-drug use and instead seeks practical solutions to mitigate its harmful consequences, these programs can be controversial (Des Jarlais et al. The guidelines are updated regularly to refect advances in care and should be referred to as the basis of appropri- ate medical management. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. In addition, any pa- tient who has stigmata of liver disease—ascites, enlarged spleen, jaundice, or encephalopathy—or a platelet count below 100,000 (which is a sign of possible splenomegaly) should be referred immediately to a specialist. The primary care provider should take a his- tory and perform a physical examination with emphasis on symptoms and signs of liver disease. Patients found to have signs or symptoms of liver disease or a low platelet count (below 100,000) should be referred to a specialist who has experience in managing persons with advanced hepatitis C. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. For genotype 1 patients, it may be preferable frst to do a liver biopsy to determine the degree of liver involvement and scarring before making a decision about whether treatment should be considered sooner rather than later. Finally, primary care providers should counsel patients to abstain from, or at least limit, alcohol consumption be- cause heavy alcohol use is the greatest contributor to the rate of progressive liver fbrosis. Because patient characteristics that are associated with not responding to treatment generally are associated with not receiving treatment, it is diffcult to ascertain from available research fndings the degree to which lower up- take into treatment represents discrimination against minority populations or appropriate implementation of treatment guidelines. For example, in another study of veterans, less treatment was received by minority-groups members and by persons who were older, who had a history of drug and alcohol use, or who had comorbid illnesses (Butt et al. However, researchers found that in a large national cohort of veterans less than one-fourth of the patients who began treatment for chronic hepatitis C completed a 48-week course. The major predictors of treatment noncompletion were pretreatment anemia and depression (Butt et al. For example, a study found that Hispanic patients were more likely to be candidates for treatment but were Copyright © National Academy of Sciences. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Another study found that blacks and Hispanics were 24–27% less likely than whites to receive surgi- cal therapy (Sonnenday et al. Once researchers controlled for receipt of treatment, the difference in mortality in black patients was no longer signifcant (Davila and El-Serag, 2006). Those data on racial and ethnic disparities in the outcomes of and treatments for chronic hepatitis underscore the need for additional research to understand the biologic and societal basis of the disparities. They also indicate the urgency of new policies that ensure that optimal medical care is given to all without regard to race or ethnicity. Although treatment costs are high, some studies have found that treat- ment can be cost-effective. In particular, several studies compared the costs Copyright © National Academy of Sciences. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. There is evidence that people’s ability to pay affects whether they seek and receive appropriate medical care for chronic hepatitis B and hepatitis C. The committee recognizes that uncertainties in funding and health-care reform may make implementation of such a pro- gram challenging. General Population Various factors can lead to diffculties in accessing screening, preven- tion, testing, and care related to viral hepatitis. Obstacles to obtaining such services may be limitations in private or public insurance coverage and cost- sharing, lack of access to public health insurance, lack of public funding to support implementation of state viral hepatitis plans, lack of hepatitis awareness and health literacy, inadequacy of sites or practice settings where health-care services are received, transportation needs, social stigmas, fear of legal prosecution related to drug use and immigration, and such cultural factors as religious beliefs, beliefs about biologic products, health percep- tions, and language. Among those, however, the most important barriers to receipt of existing services are inadequacy of health-insurance coverage and lack of money to pay for services. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. As discussed in Chapter 4, health insurance must provide strong coverage for immunization, counseling services, medical treatment, and prescription drugs, or the insurance’s cost-sharing features will prevent use of services. High deductibles (amounts to be paid out of pocket before coverage begins) or beneft limits are common in insurance policies that are provided by medium and small employers or in-network plans (which provide different coverage in network from out of network). The current fragmentation of viral hepatitis services involving vaccina- tion, risk-factor screening, laboratory testing, and medical management is a major obstacle to the effective delivery of needed services and makes com- pliance more diffcult. The lack of coordination between services can inhibit use by requiring people to travel to multiple sites to obtain care, impairs the development of trusting relationships among multiple providers, and taxes a health system’s ability to transfer information where and when it is needed for good clinical care. One important consequence of the fragmentation of viral-hepatitis ser- vices is inconsistency in referral of people who have chronic viral hepatitis for appropriate medical care. That gap refects defciencies primary-care providers’ knowledge, and it can be substantial when there are barriers, such as physical barriers (that is, screening and testing services in a different location from medical-management services), economic barriers, and cultu- ral barriers. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. In addition, it traced the outcome of therapy and continued to follow those who did not respond. A relatively large percentage of patients (45%) were evaluated in the clinic and underwent liver biopsy. On the basis of the extent of fbrosis on biopsy, 124 patients received anti- viral therapy—32% of the patients referred to the clinic and 24% of those who had viremia. The federal government is the largest purchaser of health insurance nationally, with about 8 million people covered through the Federal Em- ployees Health Benefts Program and those covered through Medicare, Medicaid, and the Children’s Health Insurance Program.

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The Exercise Prescription Health Series consists of 45 customized exercise prescriptions specifically developed for individuals with a variety of health conditions such as diabetes asacol 400mg visa, cardiovascular disease discount asacol 400 mg line, osteoarthritis 400mg asacol for sale, and lower back pain purchase asacol 400 mg with visa. Your patients can then implement these prescriptions individually or take them to a certified exercise professional who can guide them in filling their customized exercise prescription. The 2008 Physical Activity Guidelines recommend a minimum of 150 minutes of moderate, or 75 minutes of vigorous, physical activity a week (for example, 30 minutes per day, five days a week) and muscle- strengthening activities on two or more days a week. Moderate physical activity means working hard enough to raise your heart rate and break a sweat, yet still being able to carry on a conversation. Your guidance in linking them to community resources and, more specifically to exercise professionals, is a key strategy. In fact, several studies have suggested that efforts made by healthcare systems to increase the physical activity habits of their patients are best accomplished by transforming their “patients” into “participants”. This is best done by providing your patients with information on local resources and support systems. When prescribing physical activity, it is necessary not just to counsel your patients, but to provide them with information on how and where they can ‘fill’ their prescription. The referral to an exercise professional can be an extremely useful tool for you as a healthcare provider. A qualified exercise professional can help your patient safely start and maintain an effective exercise program. They will understand the “fitness goals” you and your patient have discussed and work with them to create a plan of action to achieve them. They can help your patients adapt these goals to their individual situations, such as fitting physical activity into their busy schedule and addressing other barriers to exercise that they may face. An exercise professional can also be great source of motivation and encouragement, as well as a resource for the latest objective health and fitness information. A referral to a qualified exercise professional can give your patient all the information and support they need to start and maintain an exercise program and save you time in the office. Consulting the American College of Sports Medicine The first step that you can take is to consult with the American College of Sports Medicine (www. Once you have found one or a few individuals you believe may be a good match, it is important to ask questions about their background, certifications and client practices. For more details on what to look for in an exercise professional, please keep reading through the end of the document. Finding Qualified Exercise Professionals As with any specialist, it is important to find one or more fitness professionals to whom you are comfortable referring your patients. A health fitness professional will understand the fitness goals you and your patient have discussed, help them refine those goals, and design a carefully structured plan to help your patient achieve them. A referral to qualified health fitness professional can give your patient all the information and support they need to start and maintain an exercise program and save you time in the office. Below we offer several suggestions on how you can develop a trusted exercise referral network as part of your clinic practice. Questions that you could ask exercise professionals in helping you make this decision include:  Do they hold a 4-year degree from an accredited university in Exercise Science, Kinesiology, Exercise Physiology, or a related health and fitness field? Do they have additional training and a certification by a nationally-recognized organization? These questions should help you begin to gauge if an exercise professional would be a good addition to your referral network. Our communities often offer a wealth of untapped programs that go largely unknown to the general public. Furthermore, many of these facilities will also have in-house fitness professionals that qualify for your network. By including qualified programs in your community, you will be ensuring that your patients have convenient access to the support and guidance that they need. Developing an Exercise Referral Network As you begin identifying local professionals, programs, and facilities, it will be helpful to formally develop a referral network to have this information readily available for your patients when they are in the clinic. We understand that you are likely too busy to develop an extensive referral network yourself. While this may seem imposing, the rapid changes in our health system also bring with them great opportunity. Educating them on the benefits of prescribing physical activity for their patients is an essential first step that you can take. The next step is to approach and gain the support of your healthcare administrative team. Again, we are happy to support your efforts through joint conference calls or directly communicating with your leadership. Once you have gained the support of your colleagues and administration, one of the next steps includes integrating the Physical Activity Vital Sign (see the “Assessing Physical Activity” section of this guide) in your healthcare system’s electronic medical records. These are examples of just some of the initial steps that can be taken in making physical activity a standard part of your disease prevention and treatment paradigm! On average, how many days per week do you engage in moderate to strenuous exercise (like a brisk walk)? Has your healthcare provider ever said that you have a heart  Yes  No condition and that you should only do physical activity recommended by a healthcare provider? In the past month, have you had chest pain when you were  Yes  No not doing physical activity? Do you lose your balance because of dizziness or do you  Yes  No ever lose consciousness? Do you have a bone or joint problem (for example, back,  Yes  No knee or hip) that could be made worse by a change in your physical activity? References to Good medical practice updated in March 2013 Good practice in prescribing and managing medicines and devices 1 In Good medical practice (2013)1 we say: n 18 You must make good use of the resources available to you. You should n 14 You must recognise and work within the make records at the same time as the limits of your competence. You must relevant to your practice and alert you to safety be prepared to explain and justify your decisions information about medicines you prescribe. It may also be used to Compendium lists Summaries of Product describe written information provided for Characteristics and Patient Information Leafets. While some of this guidance is particularly 8 If you are unsure about interactions or relevant to prescription only medicines, you other aspects of prescribing and medicines should follow it in relation to the other activities management you should seek advice from you undertake, so far as it is relevant and experienced colleagues, including pharmacists, applicable. This guidance applies to medical prescribing advisers and clinical pharmacologists. You must prescriptions and orders are clear, in accordance maintain and develop the knowledge and skills with the relevant statutory requirements and include your name legibly. In England prescriptions can be sent electronically to a pharmacy; in Wales and Scotland, information is held in a barcode on a paper prescription. If, after discussion, the doctor still c Department for Health, Social Services and considers that the treatment would not Public Safety (Northern Ireland) be of overall beneft to the patient, they do not have to provide the treatment. Advice on training for or social care professionals (for example, those caring for patients with dementia in care homes6). Prescribing for yourself or those close to you 13 You should make sure that anyone to whom 17 Wherever possible you must avoid prescribing you delegate responsibility for administering for yourself or anyone with whom you have medicines is competent to do what you ask of a close personal relationship. You must not 14 You should prescribe medicines only if you prescribe a controlled medicine for yourself have adequate knowledge of the patient’s or someone close to you unless: health and you are satisfed that they serve a no other person with the legal right to the patient’s needs. Each person has a role to play in making decisions about e arrangements for monitoring, follow-up and treatment or care. You must have or take an condition, the potential risks and side effects and adequate history, including: the patient’s needs and wishes. You should check that the patient has understood the information, and encourage them to ask questions to clarify 7 or, where appropriate, parents or carers with authority to make decision on behalf of patients. Medicines may be prescribed without consent if it is likely to be of overall beneft to adults who lack capacity, or in accordance with mental health legislation. Good practice in prescribing and managing medicines and devices any concerns or uncertainty. You should consider Sharing information with colleagues the benefts of written information, information 30 You must contribute to the safe transfer of in other languages and other aids for patients patients between healthcare providers and with disabilities to help them understand and between health and social care providers. This consider information at their own speed and to means you must share all relevant information retain the information you give them. To help with this, you should consider the role that other members 31 It is essential for safe care that information of the healthcare team, including pharmacists, about medicines accompanies patients (or might play.

The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes generic 400 mg asacol mastercard. Has not Achieved Level 1 Level 2 Level 3 Level 4 Level 5 Level 1 Discusses with the patient Knows the indications purchase asacol 400 mg mastercard, Knows the indications buy 400 mg asacol visa, Performs procedural Develops pain indications purchase asacol 400 mg with amex, contraindications contraindications, contraindications, potential sedation providing management and possible complications of potential complications complications and appropriate doses effective sedation protocols/care plans local anesthesia and appropriate doses of of medications used for procedural with the least risk of analgesic/sedative sedation complications and Performs local anesthesia using medications minimal recovery time appropriate doses of local Performs patient assessment and through selective anesthetic and appropriate Knows the anatomic discusses with the patient the most dosing, route and technique to provide skin to landmarks, indications, appropriate analgesic/sedative choice of medications sub-dermal anesthesia for contraindications, medication and administers in the procedures potential complications most appropriate dose and route and appropriate doses of local anesthetics used for Performs pre-sedation assessment, regional anesthesia obtains informed consent and orders appropriate choice and dose of medications for procedural sedation Obtains informed consent and correctly performs regional anesthesia Ensures appropriate monitoring of patients during procedural sedation Comments: Suggested Evaluation Methods: Procedural competency forms, checklist assessment of procedure and simulation lab performance, global ratings, patient survey, chart review Copyright (c) 2012 The Accreditation Council for Graduate Medical Education and The American Board of Emergency Medicine. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. Has not Achieved Level 1 Level 2 Level 3 Level 4 Level 5 Level 1 Prepares a simple wound for Uses medical terminology Performs complex wound Achieves hemostasis in a Performs advanced wound suturing (identify appropriate to clearly describe/classify repairs (deep sutures, bleeding wound using repairs, such as tendon suture material, anesthetize a wound (e. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. Has not Achieved Level 1 Level 2 Level 3 Level 4 Level 5 Level 1 Performs a venipuncture Describes the indications, Inserts a central venous Successfully performs 20 Teaches advanced vascular contraindications, anticipated catheter without central venous lines access techniques Places a peripheral undesirable outcomes and ultrasound when intravenous line complications for the various appropriate Routinely gains venous vascular access modalities access in patients with Performs an arterial Places an ultrasound difficult vascular access puncture Inserts an arterial catheter guided deep vein catheter (e. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. Has not Achieved Level 1 Level 2 Level 3 Level 4 Level 5 Level 1 Adheres to standards for Routinely uses basic patient Describes patient safety Participates in an Uses analytical tools to maintenance of a safe safety practices, such as time- concepts institutional process assess healthcare quality working environment outs and ‘calls for help’ improvement plan to and safety and reassess Employs processes (e. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. Demonstrates an awareness of and responsiveness to the larger context and system of health care. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. The copyright owners grant third parties the right to use the Emergency Medicine Milestones on a non-exclusive basis for educational purposes. The Subspecialty Milestones are arranged in columns of progressive stages of competence that do not correspond with post-graduate year of education. For each reporting period, programs will need to review the Milestones, identify those that best describe a fellow’s current performance, and ultimately select a box that best represents the summary performance for that sub-competency (see the figure on page v). Selecting a response box in the middle of a column implies that the fellow has substantially demonstrated those milestones, as well as those in previous columns. Selecting a response box on a line in between columns indicates that milestones in the lower columns have been substantially demonstrated, as well as some milestones in the higher column. A general interpretation of each column for subspecialty medicine is as follows: Not Yet Assessable: This option should be used only when a fellow has not yet had a learning experience in the sub-competency. Critical Deficiencies: These learner behaviors are not within the spectrum of developing competence. Column 3: Describes behaviors of a fellow who is advancing and demonstrating improvement in performance related to milestones. Ready for Unsupervised Practice: Describes behaviors of a fellow who substantially demonstrates the milestones identified for a physician who is ready for unsupervised practice. This column is designed as the graduation target, but the fellow may display these milestones at any point during fellowship. Aspirational: Describes behaviors of a fellow who has advanced beyond those milestones that describe unsupervised practice. These milestones reflect the competence of an expert or role model and can be used by programs to facilitate further professional growth. It is expected that only a few exceptional fellows will demonstrate these milestones behaviors. Answers to Frequently Asked Questions about Milestones are available on the Milestones web page: http://www. For each reporting period, a fellow’s performance on the milestones for each sub-competency will be indicated by:  selecting the column of milestones that best describes that fellow’s performance or,  selecting the “Critical Deficiencies” response box Selecting a response box on the line inbetween columns indicates that milestones in lower levels have Selecting a response box in the middle of a been substantially demonstrated as well as some column implies milestones in that column as milestones in the higher columns(s). Gathers and synthesizes essential and accurate information to define each patient’s clinical problem(s). Demonstrates skill in performing and interpreting non-invasive procedures and/or testing. He or she is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that includes the delivery of safe, effective, patient-centered, timely, efficient, and equitable care. He or she is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that includes the delivery of safe, effective, patient-centered, timely, efficient, and equitable care. Identifies forces that impact the cost of health care, and advocates for and practices cost-effective care. He or she is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that includes the delivery of safe, effective, patient-centered, timely, efficient, and equitable care. He or she is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that includes the delivery of safe, effective, patient-centered, timely, efficient, and equitable care. Has professional and respectful interactions with patients, caregivers, and members of the interprofessional team (e. He or she is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that includes the delivery of safe, effective, patient-centered, timely, efficient, and equitable care. He or she is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice that includes the delivery of safe, effective, patient-centered, timely, efficient, and equitable care. An improvement plan is in place to facilitate achievement of competence appropriate to the level of training. The Milestones are a product of the Internal Medicine Subspecialty Project, a Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Internal Medicine. Subject to statutory exception and to the provisions of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press. First published 2010 Printed in the United Kingdom at the University Press, Cambridge A catalog record for this publication is available from the British Library Library of Congress Cataloging in Publication data Mayer, Dan. To the extent permitted by applicable law, Cambridge University Press is not liable for direct damages or loss of any kind resulting from the use of this product or from errors or faults contained in it, and in every case Cambridge University Press’s liability shall be limited to the amount actually paid by the customer for the product. Every effort has been made in preparing this publication to provide accurate and up-to-date information which is in accord with accepted standards and practice at the time of publication. Although case histories are drawn from actual cases, every effort has been made to disguise the identities of the individuals involved. Nevertheless, the authors, editors, and publishers can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation. The authors, editors, and publishers therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this publication. Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use. However, the publisher has no responsibility for the websites and can make no guarantee that a site will remain live or that the content is or will remain appropriate. Kaplan v vi Contents 17 Applicability and strength of evidence 187 18 Communicating evidence to patients 199 Laura J. Henry Pohl, then Associate Dean for Aca- demic Affairs, asked me to develop a course to teach students how to become lifelong learners and how the health-care system works. The first syllabus was based on a course in critical appraisal of the medical literature intended for inter- nal medicine residents at Michigan State University. The basis for the orga- nization of the book lies in the concept of the educational prescription proposed by W. The goal of the text is to allow the reader, whether medical student, resident, allied health-care provider, or practicing physician, to become a critical con- sumer of the medical literature. This textbook will teach you to read between the lines in a research study and apply that information to your patients.

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