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By A. Hamil. University of Colorado, Colorado Springs.
To forecast where these technologies are headed and how they will affect the major ac- tors in health system—hospitals cheap eurax 20 gm without a prescription acne 6 days after ovulation, physicians, consumers, and health plans—seemed like a worthy subject for a book. It then explores how emerging information technologies will affect hospitals, physicians, consumers, and health plans and how their relationships will change as they take up and use these new tools. All these actors crave a more satisfying role in the healthcare xii Preface process and yet will not, in some unqualified way, embrace impor- tant changes that they do not understand or do not believe will help them. The book also examines the growing absence of fit between our healthcare payment framework and other policies and the emerg- ing capacity to organize healthcare digitally. It discusses what poli- cymakers need to do to speed the transformation in the healthcare system and the leadership challenge involved in bringing about that transformation. The technologies discussed herein are real, and their potential for helping create a more respon- sive, safer, and more effective health system is enormous. Disciplining technology and those who create it to meet our needs is the ultimate task of leadership. To achieve the transformation in healthcare that society de- serves will require enlightened leadership—in the health professions and healthcare management and from government policymakers. It will also require a willingness on the part of healthcare practi- tioners and managers to understand and master the technologies themselves—to adapt them, play with them, and collaborate with those who create them—to make them easier to adopt and use. This book seeks to inspire a new generation of health- care professionals and managers to understand, master, and deploy these powerful new tools. Jeff Goldsmith May 2003 Preface xiii Acknowledgm ents Many people assisted in making this book possible. Neal Patterson, chairman and founder of Cerner Corporation, a pioneer- ing healthcare informatics firm, opened the door by inviting me to serve on Cerner’s board of directors. Gartner executives and analysts Jim Adams, Dave Garets (now of HealthLink), Janice Young, Thomas Handler, Wes Rishel, and Ken Kleinberg all contributed knowledge and ideas for this book. Christine Malcolm, formerly of Computer Sci- ences Corporation, now of Rush-Presybterian–St. On the hospital side, John Glaser, chief information officer at Partners HealthCare in Boston; David Blumenthal, director at the Institute for Health Policy and Physician at The Massachusetts Gen- eral Hospital/Partners HealthCare System; and Michael Koetting, vice president of planning at the University of Chicago Hospitals, were kind enough to read the manuscript and offer valuable advice on how to make it clearer, sharper, and more relevant. By happy coincidence, the University of Virginia is a hotbed of medical informatics activity and thought. Several Charlottesville colleagues helped early in the process to shape the book’s premise and focus on physicians. Robin Felder, professor of pathology and director of the University of Virginia’s Medical Automation Re- search Center, helped me understand the rapid advances in remote sensing technology and their future role in preventive health. On the scientific front, a fellow Cerner board member, William Neaves, president of the Stowers Institute; Paul Berg, professor emeritus of Stanford University; and George Poste, former chief scientific officer of Smith Kline Beecham, helped shed light on ad- vances in genetic diagnosis. Steven Burrill of Burrill and Company, a biotechnology investment bank, has produced superb analyses of the role of information technology in advancing genetic diagnosis and therapy. Finally, Anita Gupta ably assisted in the research on this book and the editing and preparation of this manuscript. Audrey Kaufman and Joyce Sherman of Health Administration Press provided valuable editorial comments and guidance. On his home page, in a special medical alert window, he found a reminder message from his physician, Dr. David, a 46-year-old computer software engineer, was in radiantly good health and had not seen his physician in 11 months. The reminder was part of a subscription agreement he had negotiated with her last year and was sent him automatically by Dr. Part of this agreement was a schedule of periodic monitoring of his health based on his genetic risk profile of potential health risks, including periodic blood tests. David did not need to leave his chair to have his blood analyzed; he simply placed his forefinger on a special touchpad attached to his office computer. A tiny laser beam in the touchpad scanned the blood particles passing through a capillary in his finger and digitally scanned his blood. The stream of digital information from David’s finger was in- stantly transmitted to the clinical laboratory in Dr. Kumar’s hos- pital, Springfield Memorial, through David’s broadband Internet connection. The identification and routing of his bloodwork was preset by the hospital’s computer system. This and all of David’s xvii other medical information was protected by an elaborate security system designed to shield both the sample and test results from scrutiny by anyone except David and his doctors.
Ask patient to blow nose and clear clots in order to visualize bleeding vessel better generic eurax 20 gm otc acne no more book. Attempt anterior nasal packing: Apply tetracycline ointment to tip of gauze before packing. Recommendations • Most cases of epistaxis are benign and resolve with good pressure to the nasal bridge. They can complain of pain in the jaw or have persistent pain on swallowing without fever. Ear, Nose Throat Foreign Body Definition: It is a foreign object inserted into the nose, ear, or throat. Causes • Typically self-inflicted by children putting foreign body into their nose or ear or swallowing foreign body. If a good light, otoscope/microscope, and tools like alligator forceps are available, it may be possible to try to remove a foreign body from the nose or the ear. Attempt to suction smooth objects like a bean or bead, but insects require alligator forceps under direct visualization • Foreign body in nose o If object can be visualized with light, can attempt the "Kissing Technique. It can be acute (occurring within the past few hours or days) or gradual (occurring within the past weeks or months). Drowsiness or lethargy is a minor change with slightly decreased wakefulness, but patient is aroused with verbal stimuli or light. Differential diagnosis: Several mnemonics can help to remember extensive differential diagnosis list. Acute Stroke Definition: A stroke is the acute loss of neurological function due to interruption of blood supply to the brain. Most strokes will present with a new focal neurologic deficit, such as unilateral weakness. However, both more severe presentations such as coma and more subtle presentations such as dizziness can be caused by a stroke. General management: Then general goal in management of all strokes includes consideration for airway protection, aspiration risk, blood pressure control, and immediate physiotherapy. However, the long- term prognosis in a patient in coma from severe stroke, whether ischemic or hemorrhagic, is quite low. Specific management • Ischemic stroke o Thrombolytics are not currently recommended in our setting for ischemic stroke for the following reasons: ■ In order to cause more good than harm, these drugs must be used early, generally within 3-5 hours of stroke onset, which in almost all cases will be impossible to achieve. Even within this accepted time window, the value of thrombolysis for acute stroke continues to be debated. Good agents that have been studied for this indication include hydrochlorothiazide and long acting Nifedipine. Recommendations • Stroke in Rwanda appears to have a different risk factor profile and likely a different pathophysiology from those in more industrialized countries. Stroke guidelines from these settings may therefore not be as appropriate for application in Rwanda. Therapeutics such as aspirin, statins, or thrombolytics (for ischemic strokes) or neurosurgery (for hemorrhagic strokes) are not likely to be very effective in these cases. Rather, focus on good early stroke care with prevention of aspiration, fever control and early physiotherapy. Young patients or those with an unclear presentations or history should be referred to referral center for advanced imaging and further workup. Non-traumatic Headache Definition: Pain in the head that can be classified as acute and singular (first headache), acute recurrent, or chronic in nature. If symptoms change or worsen, tell the patient to return to the hospital for evaluation. Seizure Definition: Uncontrolled shaking in the body from excessive and disorderly neuronal discharge in the cerebral cortex. Status epilepticus is defined as a seizure that lasts 5-10 minutes or two seizures without full recovery between them.
The mortality rate for gall bladder surgeries did not decline as a result of the lower risk because so many more were performed generic eurax 20gm line acne kit. When studies were finally done on completed cases, the results showed that laparoscopic cholecystectomy was associated with reduced inpatient duration, decreased pain, and a shorter period of restricted activity. But rates of bile duct and major vessel injury increased and it was suggested that these rates were worse for people with acute cholecystitis. Patient demand, fueled by substantial media attention, was a major force in promoting rapid adoption of these procedures. The major manufacturer of laparoscopic equipment produced the video that introduced the procedure in 1989. Doctors were given two-day training seminars before performing the surgery on patients. In 1992, the Canadian National Breast Cancer Study of 50,000 women showed that mammography had no effect on mortality for women aged 40-50. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. Patient, provider and hospital characteristics associated with inappropriate hospitalization. The cost of inappropriate admissions: a study of health benefits and resource utilization in a department of internal medicine. Fourth Decennial International Conference on Nosocomial and Healthcare-Associated Infections. Malnutrition and dehydration in nursing homes: key issues in prevention and treatment. Nationwide poll on patient safety: 100 million Americans see medical mistakes directly touching them [press release]. Characteristics of medical school faculty members serving on institutional review boards: results of a national survey. Peer reporting of coworker wrongdoing: A qualitative analysis of observer attitudes in the decision to report versus not report unethical behavior. The incident reporting system does not detect adverse drug events: a problem for quality improvement. Clinical pharmacy services, hospital pharmacy staffing, and medication errors in United States hospitals. The incidence and severity of adverse events affecting patients after discharge from the hospital. Antibiotic prescribing by primary care physicians for children with upper respiratory tract infections. Prescriptions of systemic antibiotics for children in Germany aged between 0 and 6 years. Antibiotic treatment of adults with sore throat by community primary care physicians: a national survey, 1989- 1999. Impact of antibiotics on conjugational resistance gene transfer in Staphylococcus aureus in sewage. Combined in situ and in vitro assessment of the estrogenic activity of sewage and surface water samples. Ozonation: a tool for removal of pharmaceuticals, contrast media and musk fragrances from wastewater? Determination of neutral pharmaceuticals in wastewater and rivers by liquid chromatography-electrospray tandem mass spectrometry. Trace determination of fluoroquinolone antibacterial agents in urban wastewater by solid-phase extraction and liquid chromatography with fluorescence detection. Determination of antibiotics in different water compartments via liquid chromatography-electrospray tandem mass spectrometry. Prescription of non-steroidal anti-inflammatory agents and risk of iatrogenic adverse effects: a survey of 1072 French general practitioners.
Bioavailability influences a nutrient’s beneficial effects at physi- ological levels of intake and also may affect the nature and severity of toxicity due to excessive intakes eurax 20gm mastercard acne yellow crust. The concentration and chemical form of the nutrient, the nutrition and health of the individual, and excretory losses all affect bioavailability. Bioavailability data for specific nutrients must be considered and incorporated into the risk assessment process. Some nutrients may be less readily absorbed when part of a meal than when consumed separately. Supplemental forms of some nutrients may require special consideration if they have higher bioavailability since they may present a greater risk of producing adverse effects than equivalent amounts from the natural form found in food. Nutrient–Nutrient Interactions A diverse array of adverse health effects can occur as a result of the interaction of nutrients. The potential risks of adverse nutrient–nutrient interactions increase when there is an imbalance in the intake of two or more nutrients. Excessive intake of one nutrient may interfere with absorp- tion, excretion, transport, storage, function, or metabolism of a second nutrient. With regard to the form of intake, fat-soluble vitamins, such as vitamin A, are more readily absorbed when they are part of a meal that is high in fat. Nutrient supplements that are taken separately from food require special consideration because they are likely to have different bioavailabilities and therefore may repre- sent a greater risk of producing adverse effects. The primary types of data used as background for identifying nutrient hazards in humans are: • Human studies. Human data provide the most relevant kind of infor- mation for hazard identification and, when they are of sufficient quality and extent, are given the greatest weight. However, the number of con- trolled human toxicity studies conducted in a clinical setting is very limited because of ethical reasons. Such studies are generally most useful for identifying very mild (and ordinarily reversible) adverse effects. Observa- tional studies that focus on well-defined populations with clear exposures to a range of nutrient intake levels are useful for establishing a relation- ship between exposure and effect. Observational data in the form of case reports or anecdotal evidence are used for developing hypotheses that can lead to knowledge of causal associations. Sometimes a series of case reports, if it shows a clear and distinct pattern of effects, may be reasonably con- vincing on the question of causality. Most of the available data used in regulatory risk assess- ments come from controlled laboratory experiments in animals, usually mammalian species other than humans (e. Such data are used in part because human data on nonessential chemicals are generally very limited. Moreover, there is a long-standing history of the use of animal studies to identify the toxic properties of chemical substances, and there is no inherent reason why animal data should not be relevant to the evalua- tion of nutrient toxicity. They can, for example, be readily controlled so that causal relationships can be recognized. The effects of chronic exposures can be identified in far less time than they can with the use of epidemio- logical methods. All these advantages of animal data, however, may not always overcome the fact that species differences in response to chemical substances can sometimes be profound, and any extrapolation of animal data to predict human response needs to take this possibility into account. Key issues that are addressed in the data evaluation of human and animal studies are described below (see Box 4-1). Evidence of Adverse Effects in Humans The hazard identification step involves the examination of human, animal, and in vitro published evidence that addresses the likelihood of a nutrient eliciting an adverse effect in humans. Decisions about which observed effects are adverse are based on scientific judgment. Although toxicologists generally regard any demonstrable structural or functional alteration as representing an adverse effect, some alterations may be con- sidered to be of little or self-limiting biological importance. As noted ear- lier, adverse nutrient–nutrient interactions are considered in the defini- tion of an adverse effect. As explained in Chapter 2, the criteria of Hill (1971) are considered in judging the causal significance of an exposure–effect association indicated by epidemiological studies. Relevance of Experimental Data Consideration of the following issues can be useful in assessing the relevance of experimental data. Some animal data may be of limited utility in judging the toxicity of nutrients because of highly variable interspecies differences in nutrient requirements.
