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Key challenges within such a process include effective communication within the organization and adoption of a graded approach towards radiation and safety purchase super avana uk. Dose assessment and national registries It is important to assess effective collective doses from diagnostic X ray and nuclear medicine examinations purchase discount super avana online. This can be best achieved by establishing national registration systems to monitor frequency and doses generic super avana 160mg with mastercard, with the aim of identifying long term trends. The results can be used to select priorities for clinical audit and optimization actions. Experience shows that it is beneficial to engage stakeholders (professionals, institutional representatives, users) in developing methodology for clinical audits focusing on processes and outcomes. Of equal importance is the cooperation between authorities and professionals when establishing clinical audits. Quality assurance, education and training, and the development of a radiation safety culture Radiation protection is embedded in everyday clinical practice and is part of overall standard procedures. Radiographers have an important role in medical radiation protection; it is important that their education and training meets high standards. There is a strong need for increased cooperation between education and training organizations and employers. Adherence to dose reduction should be rewarded through accreditation and communication. Education to achieve a culture of radiation protection should go hand in hand with promoting justified use of radiation based examination. Risk management measures reduce the potential or even prevent unintended exposures and they are, therefore, a critical component of radiation protection culture. There is a need to demonstrate, through standard health technology assessment, that radiation protection measures, such as technological development, meet clinical cost– benefit requirements. The establishment of a safety culture is a focus area within the efforts of the International Radiation Protection Association to develop and enhance a strong radiation protection culture. The implementation of the Basic Safety Standards in health care at the global level Access to high quality and safe radiotherapy is particularly essential for developing countries. Specific attention should be given to developing countries, where access to proper imaging should be improved and training in diagnostic imaging and radiation protection should be a high priority. Individual sensitivity One of the key future impacts on medical radiation protection from advances in radiobiology is the specific consideration of the individual sensitivity of patients to ionizing radiation. There is an increasing opportunity to take into account the variability of the individual sensitivity of patients in diagnostic applications of ionizing radiation. Specific emphasis is on the most sensitive patients, the most sensitive tissues, the examinations with the highest dose and the most frequent examinations. Repeated medical exposures of young patients that are hypersensitive to ionizing radiation are a major concern for radiation protection. If fully established, the system of radiation protection may need to be revised to take into account individual sensitivity to ionizing radiation. In order to improve our knowledge of this important question, individual sensitivity and hypersensitivity to low doses of medical imaging and consequences for radiation protection systems and practices have to be explored further by targeted research activities. Moreover, the technical development in diagnosis and therapy has increased the capabilities for more targeted and individual approaches. Radiation protection and safety issues are closely linked to patient safety issues, and management control systems must include radiation protection and safety. Consideration should be give to make maximum dose reduction techniques mandatory in new acquisition techniques. It is recommended to replicate the best practices that have been applied to the nuclear industry and adjust them to the medical sector. As the ultimate goal is to arrive at a situation where medical radiation protection is evidence based, there is a need to narrow the gap between evidence and practice. For this purpose, more emphasis has to be devoted to risk assessment, long term follow-up and risk management. Concern has been raised about the fact that there is little to no access to imaging techniques in developing countries. Access to high quality and safe radiotherapy is particularly essential for countries with low and medium income. Low and medium income countries represent 85% of the world’s population but only one third of radiotherapy treatment facilities are operated in these countries. Owing to improvements in hygiene and life expectancy, it is assumed that over the next decade the increase in cancer incidence in low and medium income countries will be about twice as high as in high income countries. There is an urgent need to develop and provide these countries with equipment for basic imaging and treatment. Training must go hand in hand with improvements in access to proper/ basic medical imaging. James’s Hospital, Dublin, Ireland f Expert Pro-Rad srl, Bucharest, Romania g French Nuclear Safety Authority, Paris, France Abstract The recently proposed revised Euratom Basic Safety Standards, while based on existing legislation in Europe, provide several important amendments in the area of radiation protection in medicine. These include, among others, strengthening the implementation of the justification principle and expanding it to medically exposed asymptomatic individuals, more attention to interventional radiology, new requirements for dose recording and reporting, an increased role of the medical physics expert in imaging and a whole new set of requirements for preventing and following up on accidents. The changes will bring further advances in radiation protection of patients across Europe but may pose some challenges to Member States, regulators and clinical professionals, who have to transpose them into national law and everyday practice. Those challenges are discussed in this paper and some suggestions for dealing with them are made, wherever allowed by the format of the relevant meeting. The need for further developments going beyond the revision of the Euratom (European Atomic Energy Community) legislation and requiring cooperation on national and European level has been clearly identified. The first Euratom legislation with respect to medical exposure was established in the 1980s [3] and further revised in the 1990s by the publication of Council Directive 97/43/Euratom: Medical Exposures Directive [4]. The radiology practitioner shall inform patients about the benefits and risks associated with the medical exposure, with special attention required in the case of asymptomatic individuals. In addition to patient exposure, staff exposure shall also be taken into account in justifying a type of medical procedure. Any other medical radiodiagnostic equipment shall have such a device/feature or equivalent means. The dose shall be part of the examination report, the intent being to raise awareness among prescribers and practitioners of the doses associated with an examination. Medical physics expert The proposed new definition and detailed description of the medical physics expert’s responsibilities aim to provide a link between their required competences and the assigned responsibilities. A greater level of medical physics expert involvement in imaging examinations is now required. Education and training The introduction of radiation protection in medical and dental schools was proposed as a mandatory requirement. A new legal provision requires mechanisms for timely dissemination of information on lessons learned from significant events involving unintended or accidental medical exposures.

Acknowledgements We would like to thank Dr David Robson for helpful discussions during the preparation of this paper purchase 160mg super avana with amex, and Professor D purchase super avana 160 mg amex. Appendix Covariance of two methods of measurement in the presence of measurement errors We have two methods A and B of measuring a true quantity T cheap super avana 160mg with amex. They are related T by A = T + εA and B =T+ εB, where εA and εB are experimental errors. Precision of test methods, part 1: guide for the determination of repeatability and reproducibility for a standard test method. Principal component analysis: an alternative to “referee” methods in method comparison studies. Measurement of left ventricular ejection fraction by mechanical cross-sectional echocardiography. Confirmation of gestational age by external physical characteristics (total maturity score). A multivariate approach for the biometric comparison of analytical methods in clinical chemistry. Measurement of the lecithin/sphingomyelin ratio and phosphatidylglycerol in amniotic fluid: an accurate method for the assessment of fetal lung maturity. Comparison of performance of various sphygmomanometers with intra-arterial blood-pressure readings. Comparison of clinic and home blood-pressure levels in essential hypertension and variables associated with clinic-home differences. Statistical comparison of multiple analytic procedures: application to clinical chemistry. Comparison of the new miniature Wright peak flow meter with the standard Wright peak flow meter. Guidelines for car- • One or more large prospective • Non-randomized or retrospec- • Generally lower or intermediate • Higher studies in progress diopulmonary resuscitation and studies are present (with rare tive studies: historic, cohort, or levels of evidence • Results inconsistent, contradic- emergency cardiac care. Ensur- tive and compelling Signifcantly modifed from: The Emergency Cardiovascular Care ing effectiveness of community- Committees of the American wide emergency cardiac care. This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care. Full issue available free for subscribers or for purchase for non-subscribers on our website. We’d love your feedback on this iPad download — please share your comments and questions in this survey. Ensuring • Generally higher levels of evidence • Consider decreasing the rate of insulin infusion research effectiveness of community-wide • Non-randomized or retrospective emergency cardiac care. Failure to comply with this pathway does • Consider decreasing the rate of insulin infusion not represent a breach of the standard of care. Full issue available free for subscribers or for purchase for non-subscribers on our website. We’d love your feedback on this iPad download — please share your comments and questions in this survey. B – Breathing - Ensure adequate ventilation • Non-invasive ventilatory support may be considered where appropriate. C – Circulation - Volume expansion should be provided when there is evidence of dehydration or volume depletion. We’d love your feedback on this iPad download — please share your comments and questions in this survey. Second symposium of the defnition and management of anaphylaxis: Summary report—Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. Full issue available free for subscribers or for purchase for non-subscribers on our website. We’d love your feedback on this iPad download — please share your comments and questions in this survey. If patient does not have risk factors for fatal or biphasic Consider inhaled B-agonists for persistent wheezing. Class Of Evidence Defnitions Each action in the clinical pathways section of Pediatric Emergency Medicine Practice receives a score based on the following defnitions. Guidelines for car- • One or more large prospective • Non-randomized or retrospec- • Generally lower or intermediate • Higher studies in progress diopulmonary resuscitation and studies are present (with rare tive studies: historic, cohort, or levels of evidence • Results inconsistent, contradic- emergency cardiac care. Ensur- tive and compelling Signifcantly modifed from: The Emergency Cardiovascular Care ing effectiveness of community- Committees of the American wide emergency cardiac care. This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care. Full issue available free for subscribers or for purchase for non-subscribers on our website. We’d love your feedback on this iPad download — please share your comments and questions in this survey. Guidelines for • Proven in both effcacy and • Results inconsistent, contradic- cardiopulmonary resuscitation effectiveness Class of Evidence: Class of Evidence: tory and emergency cardiac care. Failure to comply with this pathway does not represent a breach of the standard of care. Full issue available free for subscribers or for purchase for non-subscribers on our website. We’d love your feedback on this iPad download — please share your comments and questions in this survey. Guidelines for car- • One or more large prospective • Non-randomized or retrospec- • Generally lower or intermediate • Results inconsistent, contradic- diopulmonary resuscitation and studies are present (with rare tive studies: historic, cohort, or levels of evidence tory emergency cardiac care. Ensur- tive and compelling Emergency Cardiovascular Care ing effectiveness of community- Committees of the American wide emergency cardiac care. This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care. Full issue available free for subscribers or for purchase for non-subscribers on our website. We’d love your feedback on this iPad download — please share your comments and questions in this survey. Guidelines for car- • One or more large prospective • Non-randomized or retrospec- • Generally lower or intermediate • Higher studies in progress diopulmonary resuscitation and studies are present (with rare tive studies: historic, cohort, or levels of evidence • Results inconsistent, contradic- emergency cardiac care. Ensur- tive and compelling Signifcantly modifed from: The Emergency Cardiovascular Care ing effectiveness of community- Committees of the American wide emergency cardiac care.

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Echocardiography reveals prolapsing mitral valve in 5% r Echocardiography shows the mid-systolic bulging of of the normal population super avana 160 mg without a prescription; however generic 160mg super avana amex, not all are clinically significant purchase 160 mg super avana fast delivery, especially in the absence of any mitral in- the valve leaflets. There is an Definition opening snap after S2 caused by the stiff mitral valve, An abnormal narrowing of the mitral valve. If the Incidence patient is in sinus rhythm there is a pre-systolic increase Declining in the Western world due to the decline of in the volume of the murmur due to increased flow dur- rheumatic fever. Pulmonary hypertension may re- sult in pulmonary regurgitation with an early-diastolic Sex murmur (Graham–Steell murmur). The pathological process of rheumatic fever results in fibrous scarring and fusion of the valve cusps with cal- Investigations cium deposition. The valve becomes stiff, failing to open r Chest X-ray shows selective enlargement of the left fully. When the normal opening of 5 cm2 is reduced to1 atrium (bulge on the left heart border). The pressure within the within the mitral valve may be visible and there may left atrium rises and left atrial hypertrophy occurs. Signs of right ventricular hyper- falls with little increase possible on exertion. The condition is asymptomatic until the valve is nar- r Echocardiography is diagnostic showing the narrow- rowedbyaround 50%. Doppler studies can to pulmonary venous hypertension and the resultant assess the degree of stenosis and any concomitant mi- oedema, with dyspnoea, orthopnoea and paroxysmal tral regurgitation. A cough productive of r Cardiac catheterisation is used if Doppler is inconclu- frothy,blood-tingedsputummayoccur(frankhaemopt- sive and to assess for coronary artery disease if valve ysisisrare). On examination the patient may have mitral facies (bi- Management lateral, dusky cyanotic discoloration of the face). In se- The course of mitral stenosis is gradual with interven- vere mitral stenosis atrial fibrillation is very common. Associatedatrialfibrilla- The apex beat is tapping in nature due to a palpable first tion is treated with digoxin and anticoagulation. Prophylaxis against Chapter 2: Rheumatic fever and valve disease 45 infective endocarditis is required. Patients with refrac- On auscultation there is a high pitched early diastolic tory pulmonary venous congestion or pulmonary hy- murmur running from the aortic component of the sec- pertension are treated surgically by conservative surgery ond heart sound. This is a mid- diastolic rumbling murmur due to back flow of blood Aortic regurgitation during diastole causing a partial closure of the mitral valve. Definition Retrograde blood flow through the aortic valve from the aorta into the left ventricle during diastole. Investigations r Chest X-ray shows an enlarged left ventricle and pos- Aetiology/pathophysiology sibly dilation of the ascending aorta. This may result from: r Inability of the valve cusps to close properly due to mal valve movement. Doppler studies demonstrate thickening, shrinkage, perforation or a tear in the and quantify the regurgitation. Causes include rheumatic heart disease (now itor the clinical effect of the valve lesion is to measure rare in the United Kingdom), infective endocarditis the left ventricular dimension. An end systolic dimen- occurring on a previously damaged or bicuspid aor- sion of over 5 cm indicates decompensation. Causes include se- infective endocarditis should be administered when vere hypertension, dissecting aneurysm and Marfan’s appropriate. It is only when volume overload is heart size or diminishing left ventricular function are excessive and chronic that the left ventricle fails. The indications for surgical intervention usually by valve first sign of this decompensation is a reduction in the replacement. There is also reduced coronary artery perfusion with associated increased risk of myocardial ischaemia. Prognosis Mild or moderate aortic regurgitation has a relatively good prognosis and thus surgical intervention is not Clinical features required. However, it is important to perform surgical Aortic regurgitation is asymptomatic until left ventricu- correction before irreversible left ventricular failure lar failure develops. Onexamination there is a large volume pulse, which is collapsing in char- acter (see page 27). The blood pressure has a wide pulse Aortic stenosis pressure (high systolic and low diastolic pressure). Various signs of the high-velocity blood flow Aortic stenosis is a pathological narrowing of the aortic have been described but are rare. There is however turbulent r Echocardiography is diagnostic, often showing cusp flow across these valves, which become thickened and thickening and calcification. Severe stenosis may develop over a period of the degree of stenosis and can measure left ventricular 20–30 years. It may lead to thicken- r Treatment includes management of angina and car- ing and calcification of the aortic valve, which is often diac failure. This pres- r Severe stenosis (pressure gradient over 60 mmHg) or sure overload results in left ventricular hypertrophy and symptomatic stenosis are indications for surgery (see arelative ischaemia of the myocardium with associ- page 30). As the stenosis becomes more severe, re- but this is increased if coronary artery bypass is also duced coronary artery perfusion exacerbates myocardial required. Balloon valvuloplasty may be used in pa- ischaemia even if the coronary arteries are normal. Im- tients unfit for surgery or to improve cardiac function paired left ventricular emptying is most apparent dur- prior to surgery. Ischaemia and hypertrophy of the left ventricle may lead Prognosis to arrhythmias and left ventricular failure. Clinical features Patients are asymptomatic until there is severe steno- sis when they present with exercise-induced syncope, Pulmonary stenosis angina or dyspnoea. Narrowing of the pulmonary valve, resulting in pressure On examination the pulse is low volume and slow ris- overload of the right ventricle. On palpation there may be an aortic systolic thrill felt in the right second intercostal space. Aetiology The apex is slow and thrusting in nature but not dis- This is almost invariably a congenital lesion either as an placed. On auscultation there may be a systolic ejection isolated lesion or as part of the tetralogy of Fallot. Rarely click, followed by a mid-systolic ejection murmur heard itmaybeanacquiredlesionsecondarytorheumaticfever best in the right second intercostal space and radiating or the carcinoid syndrome. The murmur is best heard with the patient leaning forward with breath held in expiration. Pathophysiology The obstruction to right ventricular emptying results Investigations in right ventricular hypertrophy and hence decreased r Chest X-ray may show a post-stenotic dilation of the ventricular compliance, which leads to right atrial ascending aorta and left ventricular hypertrophy.

It is essential for the student to learn that the physician’s responsibility toward the patient does not stop at the end of the office visit or hospitalization but continues in collaboration with other professionals to ensure that the patient receives optimal care buy super avana 160 mg without prescription. Key personnel and programs in and out of the hospital that may be able to contribute to the ongoing care of an individual patient for whom the student has responsibility (e purchase super avana visa. The role of the primary care physician in coordinating the comprehensive and longitudinal patient care plan super avana 160 mg amex, including communicating with the patient and family (directly, telephone, or email) and evaluating patient well-being through home health and other care providers. The role of the primary care physician in the coordination of care during key transitions (e. The role of clinical nurse specialists, nurse practitioners, physicians assistants, and other allied health professionals in co-managing patients in the outpatient and inpatient setting. The importance of reconciliation of medications at all transition points of patient care. Discussing with the patient and their family ongoing health care needs; using appropriate language, avoiding jargon, and medical terminology. Participating in requesting a consultation and identifying the specific question to be addressed. Obtaining a social history that identifies potential limitations in the home setting which may require an alteration in the medical care plan to protect the patient’s welfare. Participate, whenever possible, in coordination of care and in the provision of continuity. Coordinating care across diseases, settings, and clinicians: a key role for the generalist in practice. Quality indicators of continuity and coordination of care for vulnerable elder persons. Management strategies need to take into account the effects of aging on multiple organ systems and socioeconomic factors faced by our elderly society. As the number of geriatrics patients steadily rises, the internist will devote more time to the care of these patients. Nutritional needs of the elderly and adaptations needed in the presence of chronic illness. Key illnesses in the elderly, focusing on their often atypical presentation, including: • Cardiovascular and cerebrovascular disease. Basic treatment plans for illness in the elderly, with an awareness of the pharmacokinetic and pharmacodynamic changes seen as we age. Principles of screening in the elderly, including immunizations, cardiovascular risk, cancer, substance abuse, mental illness, osteoporosis, and functional assessment. Principles of Medicare (including who and what services are covered) and prescription drug coverage (who and what drugs are covered). Taking a complete and focused history from a geriatric patient with attention to current symptoms, chronic illnesses, and physical and mental functioning. Always obtaining historical information from collateral source, whenever possible. Performing a mental status examination to evaluate confusion and/or memory loss in an elderly patient. Developing a diagnostic and management plan for patients with the with symptoms/conditions common in the geriatric population. Communicating the diagnosis, treatment plan, and subsequent follow-up to the patient and their family. Eliciting input and questions from the patient and their family about the diagnostic and management plan. With guidance and direct supervision, participating in discussing basic issues regarding advance directives with patients and their families. With guidance and direct supervision participating in discussing basic end-of- life issues with patients and their families. Participating in an interdisciplinary approach to management and rehabilitation of elderly patients. Accessing and using appropriate information systems and resources to help delineate issues related to the common geriatric syndromes. Respect the increased risk for iatrogenic complications among elderly patients by always taking into account risks and monitoring closely for complications. Demonstrate respect to older patients, particularly those with disabilities, by making efforts to preserve their dignity and modesty. Always treat cognitively impaired patients and patients at the end of their lives with utmost respect and dignity. Demonstrate commitment to using risk-benefit, cost-benefit, and evidence- based considerations in the selection of diagnostic and therapeutic interventions for the common geriatric syndromes. Recognize the importance of patient needs and preferences when selecting among diagnostic and therapeutic options for the common geriatric syndromes. Demonstrate ongoing commitment to self-directed learning regarding care of the geriatric patient. Appreciate the impact the common geriatric syndromes have on a patient’s quality of life, well-being, and the family. Recognize the importance of and demonstrate a commitment to the utilization of other health care professionals in the diagnosis and treatment of geriatric patients. Key indications, contraindications, risks to patients and health care providers, benefits, and techniques for each of the following basic procedures: • Venipuncture. Obtaining informed consent, when necessary, for basic procedures, including the explanation of the purpose, possible complications, alternative approaches, and conditions necessary to make the procedure as comfortable, safe, and interpretable as possible. Demonstrating step-by-step performance of basic procedures with technical proficiency. Appropriately documenting, when required, how the procedure was done, any complications, and results. Appreciate the fear and anxiety many patients have regarding even simple procedures. Regularly seek feedback regarding procedural skills and respond appropriately and productively. Internists, by virtue of their dedication to providing comprehensive care to their patients, must assess nutritional factors on a routine basis. Medical students should be prepared to provide patients with basic advice regarding ways to optimize their nutritional status. Students also need to have at least a basic working knowledge of the principles of nutritional assessment and intervention. Contributions of nutrition to medical problems such as obesity, hyperlipidemia, diabetes, and hypertension. How to perform a nutritional assessment and assist the patient in setting goals for dietary improvement. Daily caloric, fat, carbohydrate, protein, mineral, and vitamin requirements; adequacy of diets in providing such requirements; evidence of need for and potential risks of supplements (e. Common dietary supplements and their known adverse and beneficial effects on health. The consequences of poor nutrition on a critically ill patient, such as poor wound healing, increased risk of infection, and increased mortality.

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Before 1990 order super avana on line amex, the recovery rate for these cases was around 35 percent buy super avana toronto; it increased to about 90 percent in 2002 order generic super avana. Some take the “Just the facts, Ma’am” ap- proach and use the Internet to gather facts about their condition and what to do about it. Others are searching for referral information, answering questions such as, “Where is the best place for me to go to resolve my problem? However consumers may use it, the advent of the Internet has shifted power in medi- cine from one-on-one relationships controlled by professionals to spontaneous, geographically dispersed networks that may include as many as 100,000 participants. Still shell-shocked from his interaction, this Yale-trained internist related that he had diagnosed a long-time patient with a dread- ful rare, systemic, and fatal autoimmune disease that he had never encountered in his practice and had scheduled a treatment plan- ning session with the now-terrified patient to begin addressing her problem. The patient came to the meeting with a two-inch thick binder of articles she had downloaded via the Internet from national and international medical journals. It also contained a basic science section on the potential genetic and molecular basis of the illness. The patient placed the binder on the internist’s desk and said, “Why don’t we start here? When I related this story at one of my presentations, a physician posed the following rhetorical question about the exchange: “Why should I read it [the binder]? As I have subsequently learned, however, this response from physicians is not an unusual one. The “why should I read it” response reflects at least two kernels of truth wrapped in a thick layer of barely examined and ugly emotions. True enough, many physicians do not feel they have enough time to do their jobs properly; and certainly, a lot of the material in the binder may not have been directly relevant to the treatment 104 Digital Medicine planning task at hand. Remember, however, that the physician in Connecticut was deal- ing with a disease he had not treated before and thus needed to research the matter himself to participate meaningfully in the pro- cess. In business, this process is called “outsourcing to the customer,” which is what Federal Express did when it set up its web site to enable a customer to locate a package without going through its call center. By taking the initiative, the patient, not the doctor, took charge of defining medical reality. In the Connecticut example, the physi- cian did not explicitly delegate this task. Rather, the patient “vol- unteered,” in a desperate effort to begin immediately the task of defining her own medical reality and options. The binder repre- sented dozens of hours of tedious review of tens of thousands of page matches, reading, book marking, and downloading. What the angry physician responder also missed was that, how- ever well armed with information, the patient still engaged her physician and relied on his judgment. Rather, their dialog with a growing number of better-informed patients and family members will simply begin at a higher level of knowledge (or uncertainty) about the disease and its treatment options. The Internet is making the role of physician as teacher more explicit and eventually, as we will see in Chapter 8, more efficient. The emotional subtext of the physician’s anger is the feeling that their professional expertise is no longer respected. Whatever other pressures they may feel as members of one of the nation’s most successful and prestigious professions, many physicians feel marginalized by many of the changes that took place in our health- care system during the past 20 years. The diminution of professional authority brought about by the Internet is not exclusive to medicine. Michael Lewis’ recent book The Consumer 105 Next explored the jarring invasion of professional space in law, investing and other disciplines by uncredentialed teenage Inter- net buffs. All knowledge-based professions face the same Internet- spawned leveling of knowledge gradients as medicine. Accommodating these differences will be an important feature of tomorrow’s health system. Many consumers will continue to want the old-style physician-patient relationship and do not wish to be bothered by the rigors of custom-fabricating their own knowledge base. Consumer research has found that some people will want to delegate as much responsibility as possible to their physicians (and perhaps then sue them if things do not work out as they wish). These patients, who rely solely on their physicians for health information, are described as “accepting. They are really looking for wisdom—the thoughtful application of relevant medical knowl- edge to their unique situation. While Internet tools will certainly ac- celerate the flow of medical knowledge, converting that knowledge to wisdom will remain the physician’s burden and responsibility. Although their relationship sometimes contains adversarial ele- ments, physicians and their patients/consumers share two common goals. Both physi- cians and consumers are hungry for knowledge that will help lead to better care decisions. Second, and most important, they are both aligned in wanting to resolve the medical problem that brought them together. Moving from the present state of the medical Internet to a consumer-friendly knowledge re- source is going to take a lot of work and will involve the efforts of practitioners and healthcare executives, as well as consumers. The following is a look at the current situation; later, we will take a look at the future. Currently, the medical Internet is a bewildering mud slide of un- differentiated facts, opinions, pharmaceutical and health provider infomercials, personal web pages constructed by individual patients, bulletin boards and chat rooms hosted by volunteer physicians, sci- entific literature, press releases, and gossip. In addition to all of these sources, I even found articles about wolves (the species is Canus lupus). Of course, if I had just been diagnosed with lupus, which is incurable, my motivation to wade through this information would have more than matched the logistical challenge. The variable quality of medical information on the Internet is a widely acknowledged problem for anyone who uses it. One witty observer likened the current state of the medical Internet to a “virtual Haight/Ashbury. Besides being a site of colorful street theater, it was also an open-air drug bazaar, where one could buy pills of dubious provenance from complete strangers and take one’s chances. According to Harris Interactive, consumers are losing confidence in the In- ternet as a leverage point in their relationship to the medical care system (Figure 5. Despite the many millions invested in healthcare web sites, the medical Internet is daunting and difficult for many consumers to use. A free market economist would point out that the highly variable quality of medical information on the Internet can be attributed to the fact that the information is supposed to be “free. If it is true that “you get what you pay for,” the fact that people have been unwilling to pay for medical information on the Internet has diminished the incentives to create accessible and reliable content and for people with proprietary knowledge to post it. However, despite the logistical problems, when consumers con- front a life-changing illness, the Internet is the principal destination postdiagnosis. Clearly, consumers are going to need help, in addition to that of their physicians, in sorting through all of the potential knowledge domains about a given disease to find the “good stuff”—access to state-of-the-science knowledge and the treatment protocols that are testing that knowledge on the task of curing the disease. Ambitious “health reform” pro- posals, such as those of the early Clinton administration, sought to shift responsibility for deciding what medical care was needed from doctors and patients to health plans. Acting through their elected representatives and the news media, consumers told the health system that they wanted to be the architects of their own care and definers of their own needs and not delegate that responsibility to hospital systems, health plans, employers, or the government. If the first phase of the consumer movement in healthcare cul- minated in the rejection of external management of healthcare by health plans, the second phase will be the presentation of the bill.

Insertion of the needle more than lcm runs the risk of puncturing the internal carotid artery buy super avana 160mg otc. Internal carotid artery runs laterally and posterior to the posterior edge of the tonsil purchase cheap super avana online. Often present in a "tri-pod" position-sitting up and forward with obvious difficulty breathing or stridor proven super avana 160 mg. About 90% of bleeds come from a blood vessel in the anterior part of the nose and can be visualized. Ask patient to blow nose and clear clots in order to visualize bleeding vessel better. 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. If a seizure lasts more than 30 minutes, the body can no longer regulate homeostasis- blood pressure drops and acidosis builds, sometimes resulting in neuronal damage. Management: General goal is to stop the seizures as soon as possible to prevent permanent brain damage and aspiration. Once seizures are under control, patient should return to normal mental baseline between 1-8 hours. Once seizures are controlled for 24hr, wean off thiopental by decreasing the dose by lmg/kg every 12hr. The most common reaction, simple febrile reaction, is not life-threatening, but needs to be recognized early. Other reactions are more rare, but have a very high mortality rate (acute hemolysis and transfusion-related acute lung injury), and must be recognized and treated immediately. Ensure the patient really needs the transfusion and that the benefits outweigh the risks. Generally speaking, you can transfuse a unit of blood over 2hr (faster if it is a trauma patient or someone who is severely ill). If there is a transfer sheet from another facility, find out what antibiotic was given and how many doses • Exam o Obtain full set of vital signs, including saturation and temperature. If patient with fever on arrival and signs of sepsis, start antibiotics immediately. They require pumps for regular infusion and constant blood pressure monitoring (every five minutes). Treat aggressively with fluids and antibiotics, but if vital signs not improving or mentation stays low, call for transfer and further evaluation. Simple skin infections occasionally spread into deeper tissue layers and cause more serious local infection or systemic illness. If signs of systemic illness and pain out of proportion with exam findings, necrotizing fasciitis is likely. Recommendations • Simple cellulitis should be marked with a pen so patient or provider can monitor if redness extends beyond border despite antibiotics. They will often have vomiting, fast breathing, fruity breath, confusion, and vomiting. Medication is the key to treatment ■ Takingmediationasprescribedbutglycemiastillhigh • If on oral medications, start on insulin. These patient typically should be admitted overnight for glycemia monitoring to ensure correct insulin dose is started.

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Others respond to bullying with certifcation program offered by the Crisis Prevention Institute a strong reaction that may be experienced by the patient as (www order 160 mg super avana with amex. Clearly explain that you In general super avana 160 mg overnight delivery, the least experienced members of the team are the want to work collaboratively with the patient buy super avana 160mg visa, and offer the most at risk of being injured. Emphasize what you are, or are not, willing unless you have been appropriately trained. If appropriate, indicate that you can arrange for or family member represents a serious emergency; alert the the patient to be seen by another physician if he or she prefers. Finally, be mindful that any medi- member of the team to join you when you see the patient. Document your observations Critical incident debriefng and interventions and ensure that your supervisor is aware of Critical incidents can have a profound impact on everyone the situation. Critical incident debriefng is a voluntary process that allows individuals to discuss an incident from a personal Privacy issues or professional perspective. Facilitated by trained experts, such All of us leave a digital imprint wherever we go, and in some sessions are not about assigning blame or investigating errors. Rather, they allow for safe discussion of the incident and It is important to be aware of your imprint and the informa- normalization of the complex emotions they provoke. If highly personal information about you or are not included in a debriefng session that is relevant to you your loved ones is readily available on the web, it can be found and would like to have access to this service, make your wishes by others and used maliciously. Maximize your privacy by being cautious about the sort of personal information you put on the web, including social networking sites (e. Set your Case resolution privacy settings as high as possible and restrict access to The resident eventually reports the strained nature of the known friends or family members. Request that they do not relationship to their supervisor, who immediately arranges post information about you or your loved ones without explicit for a meeting between the patient, his family and the permission. With the patient’s permission, the hospital’s It is not uncommon for physicians to be surprised at the vol- Patient Representative is invited to attend. The meeting is ume of personal and professional information that can easily diffcult, but it reveals that the family had misunderstood be collected online. Depending on the site, you may be able to a critical component of the care offered to the patient request that information be removed or modifed; however, and had mistakenly blamed the resident for the outcome. The rap- port between the resident and the family continued to Finally, what might have been fun to post when you were an be guarded but was much more respectful. The resident undergraduate or medical student can be unhelpful as you seek also took an opportunity to review and modify their web academic appointments or fellowships. Increasingly, training presence and noted surprise at the volume of personal institutions and employers search social networking sites as information found online. The occurrence of either should be the • discuss the importance of boundaries in physician–patient cause of some potential concern. In fact, it is entirely possible that a boundary may be consciously crossed Case with the intention and actuality of assisting the treatment in A third-year family practice resident is following a 15-year- some way. In fact, boundary crossings may, at times, indicate old female patient for suspected depression and bulimia. However, at other times, ment and frustration with her body, noting “I’m as fat as boundary crossings may occur because of carelessness or a the Sahara desert. Boundary violations harm upset by this comment and complains to her parents, who the patient in some way. Introduction From the time of the Hippocratic oath, maintaining boundaries Boundaries, once established, ought not to be readily crossed. However, crossings do occur and often do not do harm to This is made clear in the Oath which requires that the physi- either the practitioner or the patient. Should harm come from cian will conduct himself or herself “In purity and holiness,” a boundary crossing, the action is then defned as a boundary will treat the sick, “will keep them from harm and injustice,” violation. For ex- ample, sexual behaviour with a patient is widely acknowledged Boundaries clarify the necessary distance between the doctor as harmful. Keeping healthy boundaries is often automatic triggering an angry and defensive reaction, is widely acknowl- and usually easy but can at times be diffcult for both patient and edged not to be harmful. It is important for the profession to have detailed guidelines and limits for appropriate boundary behaviour and Boundary crossings may, at times, simply be communication equally important to allow the for the doctor-patient relation- blunders. At other times, they indicate an innovative or an in- ship to be reasonably fexible—in keeping with any genuine tuitive departure from the common treatment protocol. Boundaries elucidate the roles and expectations addressing each other using frst names could be fne in many involved in the physician–patient relationship. Boundaries thus defne the limits of the therapeutic than simply as “Gertrude”, or worse yet: “Gertie”). Therapeutic frame Occasionally, physicians are required to negotiate diffcult and Boundaries between doctor and patient are particularly impor- sensitive boundaries. At times this is described as “dancing tant since they defne the therapeutic frame. These principles are as follows: here is that treatment must take place within a structural and 1. Physicians should remember that it is for the patients’ conceptual space defned by certain parameters. When physicians self-disclose they should always and “the norms” of the therapeutic encounter, which help de- consider the current stage the relationship is in (later fne a therapeutic milieu that is benefcial to the development in the doctor-patient relationship somewhat more of a therapeutic experience. Physicians should not disclose those things that are a successful, high-quality treatment. Physicians should think about how their self-disclosure zone” (or more optimistically a “pastel zone”) that is somewhat would sound to other people. Entering this gray or pastel zone may, at times, be Summary helpful, yet it is always risky and certainly could be detrimental. By Although most boundary transgressions are conceptualized setting, and then following reasonably clear and appropriate as being “over” the boundary (the doctor is intrusive or the boundaries, physicians make their life easier and simpler, and abusive), it is important to realize that sometimes the doctor increase their sense of joy in the practice of medicine. Case resolution The resident is an outstanding resident with no history of Guthiel and Gabbard’s article, The concept of boundaries in clinical boundary issues. The resident agrees that this particular practice: Theoretical and risk-management dimensions, is an excellent incident was a boundary crossing, and if not well managed overview of boundary issues. There are acknowledges that the wording of the comment was pertinent boundaries for the many various facets of the doctor awkward, inappropriate and clearly it was not helpful to patient relationship. In reviewing the principles of physician self- limited to disclosure, the resident realizes that what was disclosed did • social role, not sound appropriate to either the patient or her parents. The • money, meeting is tense but helpful; the family express that the • gifts and services, comments were seen as inappropriate and harmful but also • clothing, acknowledge that it was intended to support the patient and • language, normalize her self-image. The resident acknowledges that • self-disclosure, and the words were hurtful and demonstrates how to handle • physical contact. The complaint is dropped, Since self-disclosure is such an important boundary and since the resident is more mindful of their use of language in the case included an unwise self-disclosure it is worthwhile to discussing sensitive subjects, and the patient remains in the briefy cover this topic. Physician self-disclosure Most physicians would agree that sharing some personal details Key references with a patient is necessary and even helpful. The concept of bound- ing personal information may lead to disclosing increasingly aries in clinical practice: Theoretical and risk-management intimate and potentially sensitive information.