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Fildena

Fildena

By A. Muntasir. Sacred Heart University, Puerto Rico.

However discount 25 mg fildena with mastercard, if treatment has been started before the pregnancy cheap 100 mg fildena with amex, do not stop treatment and use the minimal effective dose buy fildena in united states online. Due to the risk of haemorrhagic disease of the newborn, administer vitamin K to the mother and the newborn infant. The administration of folic acid during the first trimester may reduce the risk of neural tube defects. Contra-indications, adverse effects, precautions – Do not administer in case of poisoning by caustic or foaming products, or hydrocarbons: risk of aggravation of lesions during vomiting (caustic products), aspiration pneumonia (foaming products, hydrocarbons), and airway obstruction due to foaming when vomiting (foaming products). Therapeutic action – Phenicol antibacterial Indications – Alternative to first-line treatments of bubonic plague – Alternative to first-line treatments of typhoid fever – Completion treatment following parenteral therapy with chloramphenicol Presentation – 250 mg capsule Dosage – Child from 1 year to less than 13 years: 50 mg/kg/day in 3 to 4 divided doses; 100 mg/kg/day in severe infection (max. In these events, stop treatment immediately; • gastrointestinal disturbances, peripheral and optic neuropathies. If used during the 3rd trimester, risk of grey syndrome in the newborn infant (vomiting, hypothermia, blue-grey skin colour and cardiovascular depression). In areas where resistance to chloroquine is high, chloroquine must be replaced by another effective antimalarial suitable for prophylactic use. Contra-indications, adverse effects, precautions – Do not administer to patients with retinopathy. Dosage – Child from 1 to 2 years: 1 mg 2 times daily – Child from 2 to 6 years: 1 mg 4 to 6 times daily (max. Contra-indications, adverse effects, precautions – Administer with caution and monitor use in patients with prostate disorders or closed-angle glaucoma, patients > 60 years and children (risk of agitation, excitability). Dosage – Acute or chronic psychosis Adult: initial dose of 75 mg/day in 3 divided doses; if necessary, the dose may be gradually increased up to 300 mg/day in 3 divided doses (max. Once the patient is stable, the maintenance dose is administered once daily in the evening. Duration – Acute psychosis: minimum 3 months; chronic psychosis: minimum one year. Contra-indications, adverse effects, precautions – Do not administer to patients with closed-angle glaucoma, prostate disorders; to elderly patients with dementia (e. Dosage and duration – Adult: 200 to 400 mg as a single dose if possible one hour before anaesthetic induction Contra-indications, adverse effects, precautions – May cause: diarrhoea, headache, dizziness, skin rash, fever. Remarks – Effervescent cimetidine can be replaced by effervescent ranitidine, another H2-receptor antagonist, as a single dose of 150 mg. The effervescent tablets containing sodium citrate have a more rapid onset of action, and can thus be used for emergency surgery. In the event of allergic reaction, severe neurological disorders, peripheral neuropathy or tendinitis, stop treatment immediately. Remarks – Capsules are not suitable for children under 6 years (risk of aspiration). Open the capsule and mix the content into a spoon with food or fruit juice to mask the unpleasant taste. Dosage – Adult: initial dose of 25 mg once daily at bedtime, then increase gradually over one week to 75 mg once daily at bedtime (max. Contra-indications, adverse effects, precautions – Do not administer to patients with recent myocardial infarction, arrhythmia, closed-angle glaucoma, prostate disorders. Treatment should be discontinued in the event of severe reactions (mental confusion, urinary retention, cardiac rhythm disorders); • psychic disorders: exacerbation of anxiety, possibility of a suicide attempt at the beginning of therapy, manic episode during treatment. Contra-indications, adverse effects, precautions – Do not administer to patients with acute respiratory depression or asthma attack. The newborn infant may develop withdrawal symptoms, respiratory depression and drowsiness in the event of prolonged administration of large doses at the end of the 3rd trimester. Monitor the mother and the infant: in the event of excessive drowsiness, stop treatment. In these cases, stop treatment immediately; • megaloblastic anaemia due to folinic acid deficiency in patients receiving prolonged treatment (in this event, administer calcium folinate). However, avoid using during the last month of pregnancy (risk of jaundice and haemolytic anaemia in the newborn infant). Remarks – Storage: below 5°C Once the bottle has been opened, the oral suspension keeps for 20 days at ambient temperature or 40 days refrigerated (between 2°C and 8°C). It is also possible to start at any moment of the cycle (if the woman is not pregnant). Contra-indications, adverse effects, precautions – Do not administer to women with breast cancer, severe or recent liver disease, unexplained vaginal bleeding, current thromboembolic disorders. However, if it is the only contraceptive method available or acceptable, it can be started 3 weeks after childbirth. Remarks – Desogestrel is a possible alternative when estroprogestogens are contra-indicated or poorly tolerated. It is preferred to levonorgestrel as its contraceptive efficacy is similar to that of estroprogestogens. It is therefore recommended to use an additional contraceptive method: condoms for 7 days and, if she has had sexual intercourse within 5 days before forgetting the tablet, emergency contraception. Dosage – Adult: 5 to 15 mg/day in 3 divided doses – Do not exceed indicated doses. Contra-indications, adverse effects, precautions – Do not administer to patients with severe respiratory insufficiency or severe hepatic impairment. At the end of treatment, reduce doses gradually to avoid withdrawal syndrome or rebound effect; • in the event of overdose: ataxia, muscular weakness, hypotension, confusion, lethargy, respiratory depression, coma. This regimen is only suitable for countries that are free from Onchocerca volvulus and/or Loa loa. Duration – According to clinical response Contra-indications, adverse effects, precautions – Do not administer to patients with bradycardia, ill defined arrhythmia, coronary artery disease. Contra-indications, adverse effects, precautions – Do not administer in the event of cardiac disorders (bradycardia, heart rhythm disorders, congestive heart failure). Contra-indications, adverse effects, precautions – Do not administer to patients with allergy to cyclines and to children under 8 years (may damage teeth) except for single dose treatment. Contra-indications, adverse effects, precautions – Do not administer to children under 3 years. Contra-indications, adverse effects, precautions – Do not administer to patients with hypercalcaemia, hypercalciuria, calcic lithiasis. When curative treatment is being administered to the mother, do not give vitamin D to the child. Contra-indications, adverse effects, precautions – Do not administer to patients with allergy to erythromycin or another macrolide. Patients should be warned that they must immediately stop treatment and seek medical attention in the event of visual disturbances such as blurred vision, reduced visual acuity, blind spot (scotoma), green-red colour blindness. It is also possible to start at any moment of the cycle (if the woman is not pregnant). Contra-indications, adverse effects, precautions – Do not administer to women with breast cancer, uncontrolled hypertension, uncontrolled or complicated diabetes, history of thromboembolic disorders, coronary insufficiency, valvular disease, stroke, severe or recent liver disease, unexplained vaginal bleeding, migraine with neurological signs, renal impairment, hyperlipidaemia, to women smokers over age 35. Other rare and severe adverse effects require discontinuation of treatment: hypertension, cardiovascular and thromboembolic disorders, jaundice, migraine, visual disturbances.

Clinicians should seek to use all 28 available evidence to guide decisions about the care of the individual patient buy fildena 150 mg amex. Evolving 30 evidence and treatment guidance should be made available to patients and prescribers to support them in their decision-making cheap 25mg fildena otc. Automatic substitution generic fildena 25mg with mastercard, defined here as the practice of dispensing one medicine instead of another equivalent and interchangeable medicine at the pharmacy level 31 without consulting the prescriber, is not appropriate for biological medicines, including biosimilar medicines and is not permitted at this time. Prescribers, of course, are always able to switch treatments for a given patient, provided it is safe to do so and there are appropriate monitoring arrangements in place. It is important to ensure that prescribers are aware of the different requirements associated with biological medicines, including biosimilar medicines (as well as some other products). Measures should be taken to ensure all those involved in the prescribing and dispensing of such medicines abide by these requirements, such as brand name prescribing. Q: Where can I find further Once placed on the market they continue to be information on safety of monitored by all relevant stakeholders to assure biological medicines? In different to the reference medicine addition, the companies marketing biosimilars have been identified for biosimilars. Medicines under additional monitoring have a black inverted triangle (▼) in their labelling. An inability to attribute any safety concerns to the correct product, manufacturer and 41 batch could prevent a root-cause determination and may put patients at risk. This variation is kept within strict acceptable limits, which is monitored by the manufacturer and approved by the regulator, known as ‘release specifications’. Some of them may be present in the human body and examples include proteins such as insulin and growth hormone. Active substances in biological medicines are larger and more complex than those of non- 44 biological medicines. A candidate molecule is designed, produced and compared with several batches of the reference (originator) medicine using advanced analytical techniques to assess its structure and function. It must be shown to match or be highly similar to the key characteristics of the molecular structure and biological activity, and will be expected to have similar function and clinical outcome. Any differences will be expected to have no meaningful clinical impact on the safety and efficacy of the medicine for patients. The manufacturer must ensure the process is controlled and the variability remains within release specifications approved by the regulatory authority. The assessment for any manufacturing change is done via a comparability exercise, informed by the historical manufacturing, non-clinical and clinical data available to the manufacturer. Depending on the scale of the change and the potential impact to the product, the regulator may ask for additional analytical data, non-clinical and clinical data, but the aim is to ask only for what is needed to make an assessment. If they contain more than one atom, the atoms can be the same (an oxygen molecule has two oxygen atoms) or different (a water molecule has two hydrogen atoms and one oxygen atom). Biological molecules, such 51 as proteins, can be made up of many thousands of atoms. Please refer to the European Medicine Agency’s website for the latest list of biosimilars authorised in Europe, as there are many other biosimilar products in development. The ability to make appropriate diagnostic and management decisions that have important consequences for patients will be assessed. The exam may require recognition of common as well as rare clinical problems for which patients may consult a certified internist. Exam content Exam content is determined by a pre‐established blueprint, or table of specifications. Trainees, training program directors, and certified practitioners in the discipline are surveyed periodically to provide feedback and inform the blueprinting process. The primary medical content categories of the blueprint are shown below, with the percentage assigned to each for a typical exam: Medical Content Category % of Exam Allergy and Immunology 2% Cardiovascular Disease 14% Dermatology 3% Endocrinology, Diabetes, and Metabolism 9% Gastroenterology 9% Geriatric Syndromes 3% Hematology 6% Infectious Disease 9% Nephrology and Urology 6% Neurology 4% Obstetrics and Gynecology 3% Medical Oncology 6% Ophthalmology 1% Otolaryngology and Dental Medicine 1% Psychiatry 4% Pulmonary Disease 9% Rheumatology and Orthopedics 9% Miscellaneous 2% Total 100% Every question in the exam will fall into one of the primary medical content categories shown above. There are also other important areas that are addressed in conjunction with this medical content, and these areas are called “cross content categories. Questions ask about the work done (that is, tasks performed) by physicians in the course of practice:  Making a diagnosis  Ordering and interpreting results of tests  Recommending treatment or other patient care  Assessing risk, determining prognosis, and applying principles from epidemiologic studies  Understanding the underlying pathophysiology of disease and basic science knowledge applicable to patient care Clinical information presented may include patient photographs, radiographs, electrocardiograms, recordings of heart or lung sounds, and other media to illustrate relevant patient findings. The primary medical categories can be expanded for additional detail to show topics that may be covered in the exam. Each primary medical content category is listed below, with the percentage of the exam assigned to this content area. Below each major category are subsection topics and their assigned percentages in the exam. Please note: The percentages below describe content of a typical exam and are approximate; actual exam content may vary. Investigations led to the knowledge how bacteria, fungi, and viruses are used to treat ailments ranging from colon cancer to malaria. The advanced methods which microbes are used lead one to believe that the ailments which currently harm the human population will one day be preventable. Microbes first came to human attention due to the work of the Dutch scientist Anton Van Leeuwenhoek. In 1676 using one of his homemade single-lens microscopes, Van Leeuwenhoek discovered what he called “animalcules,” and which are now what the science community currently refers to as bacteria (Dobell, 1960). It took around 200 years for the inclusion of microbes into preventative and palliative medicine. The advent of microorganisms in medicine, though seemingly a th modern day application, actually began in the mid-19 century with the work of Louis Pasteur. The same century which science saw the advent of braille, Freudian psychoanalytics, and the Doppler Effect, came the rising use of microbes in medicine. However, a majority of civilization believed that disease was spontaneously generated. So before microbes could be used to benefit mankind, mankind had to prove they existed. Pasteur, through experiments with nutrient broths, rejected the common thought that microbes appeared spontaneously and that they traveled through the air causing diseases in silkworms as well as spoiling beverages such as wine, beer, and milk. Though not the first to propose germ theory of disease, Pasteur accepted the hypothesis of germ theory scientifically and was able to persuade much of Europe of the validity of his findings (Tiner, 1991). This understanding began to explain many historical phenomena, notably instances in India and China where people were vaccinated against the smallpox disease using powdered scabs of patients infected with smallpox (Temple, 1986). Over time, the development of vaccinations was used to help protect against a wide array of diseases such as measles, mumps, and hepatitis. Microorganisms are widely used in modern medicine, and this is because microbes are an amazingly diverse population. Microbes consist of bacteria, fungi, archaea, protists, plants which are invisible to the naked eye, and plankton. Some scientists consider viruses to be microbes, though it is debatable due to the fact that viruses can’t reproduce independently of a live host.

Indices of protein metabolism in term infants fed human milk discount 50 mg fildena overnight delivery, whey-predominant formula generic 50mg fildena with visa, or cow’s milk formula buy 50 mg fildena overnight delivery. Indices of protein metabolism in term infants fed either human milk or formulas with reduced protein concentra- tion and various whey/casein ratios. Nutrient intakes and eating behavior scores of vegetarian and nonvegetarian women. The impact of alanyl-glutamine on clinical safety, nitrogen balance, intestinal permeability, and clinical outcome in postoperative patients: A randomized, double-blind, controlled study in 120 patients. Quantitative analysis of amino acid oxidation and related gluconeogenesis in humans. Relation between transamination of branched-chain amino acid and urea synthesis: Evidence from human pregnancy. A morphological study of the acute toxicity of L-cysteine on the retina of young rats. Susceptibility of the cysteine-rich N-terminal and C-terminal ends of rat intestinal mucin Muc 2 to proteolytic cleavage. Determination of amino acid requirements of young pigs using an indicator amino acid. Glutamine-enriched diets support muscle glutamine metabolism without stimulating tumor growth. The proportionality of glutaminase content to growth rate and morphology of rat neoplasms. Evidence that histidine is an essential amino acid in normal and chronically uremic men. The effects of sweat nitrogen losses in evaluating protein utilization by preadolescent children. Oral and intravenous tracer protocols of the indicator amino acid oxidation method provide the same estimate of the lysine requirement in healthy men. Transport of amino acids by the human placenta: Pre- dicted effects thereon of maternal hyperphenylalaninaemia. Lysine requirements of healthy adult Indian subjects, measured by an indicator amino acid balance technique. Lysine requirements of healthy adult Indian subjects receiving long-term feeding, measured with a 24-h indicator amino acid oxidation and balance technique. Threonine requirements of healthy Indian adults, measured by a 24-h indicator amino acid oxidation and balance technique. The effects of glutamine-supplemented parenteral nutrition in pre- mature infants. The effects of neonatally-administered monosodium glutamate on the reproductive system of adult hamsters. Further observations on the effects of neonatally admin- istered monosodium glutamate on the reproductive axis of hamsters. Tryptophan requirement in young adult women as determined by indicator amino acid oxidation with L-[13C]-phenylalanine. Effect of an oral tryptophan/carbohydrate load on tryptophan, large neutral amino acid, and serotonin and 5-hydroxyindoleacetic acid levels in monkey brain. Preliminary investigation of high-dose oral glycine on serum levels and negative symptoms in schizophrenia: An open-label trial. Is increased dietary protein necessary or beneficial for indi- viduals with a physically active lifestyle? Protein require- ments and muscle mass/strength changes during intensive training in novice bodybuilders. Differences in the composition of preterm and term human milk during early lactation. Serum glutamic acid levels and the occur- rence of nausea and vomiting after the intravenous administration of amino acid mixtures. The effects of aspar- tame on human mood, performance, and plasma amino acid levels. Effects of formula protein level and ration on infant growth, plasma amino acids and serum trace elements I: Cow’s milk formula. Total exchangeable sodium and potassium in non-pregnant women and in normal and pre-eclamptic pregnancy. Long-term oral branched-chain amino acid treatment in chronic hepatic encephalopathy. Nutritional value of [15N]-soy protein isolate assessed from ileal digest- ibility and postprandial protein utilization in humans. The risk of pronounced hyperkalaemia after arginine infusion in the diabetic subject. The effects of excess amino acids on maintenance of pregnancy and fetal growth in rats. Studies on reproduc- tive endocrine function in rats treated with monosodium L-glutamate early in life. The effects of oral administration of salts of aspartic acid on the metabolic response to prolonged exhausting exercise in man. Defective uptake of basic amino acids and L-cystine by intestinal mucosa of patients with cystinuria. Prolonged meat diets with a study of the metabolism of nitrogen, calcium and phospho- rus. Contribution of rat liver and gastrointestinal tract to whole-body protein synthesis in the rat. Salvage of exogenous urea nitrogen enhances nitrogen balance in normal men consuming marginally inadequate protein diets. Plasma tyrosine in normal humans: Effects of oral tyrosine and protein-containing meals. Glutamate as a neurotransmitter in the brain: Review of physi- ology and pathology. Dietary protein require- ments and body protein metabolism in endurance-trained men. Availability of intestinal microbial lysine for whole body lysine homeostasis in human subjects. Incorporation of urea and ammonia nitrogen into ileal and fecal microbial proteins and plasma free amino acids in normal men and ileostomates. Metabolic demands for amino acids and the human dietary requirement: Millward and Rivers (1988) revisited. The nutritional value of plant-based diets in relation to human amino acid and protein requirements. Lysine prophylaxis in recurrent herpes simplex labialis: A double-blind, controlled crossover study. Visual disturbances, serum glycine levels and transurethral resection of the prostate. Effects of methionine on the cytoplasmic distribution of actin and tubulin during neural tube closure in rat embryos. Studies on renal tubular protein reabsorption: Partial and near complete inhibition by certain amino acids.

In some regions buy 25mg fildena, the mean number of brachytherapy treatment patients per centre has increased by almost 50% [3] buy fildena overnight. As of 2007 cheap fildena 25 mg without a prescription, the average annual frequency of brachytherapy treatments in level I countries (0. Permanent seed implants continue to rise, for example in the United States of America, where approximately 220 000 new cases of prostate cancer are diagnosed each year, and more than 40 000 implantations for localized prostate neoplasms are performed annually [7]. In Europe, as in other locations, several thousand cases are already treated annually and this number continues to increase. These modalities differ considerably in the frequency with which they are performed, in patient radiation doses, in the way radiation is administered to the patient, and in radiation dose potentials to operators and staff. In addition to the principles of justification and optimization, the need for ongoing attention to overall radiation protection is essential for brachytherapy [6, 8–10]. Patients undergoing radiation therapy should have available to them the necessary facilities and staff to provide safe and effective treatment. There is a critical need for improved training in both the technical practice and radiation protection associated with brachytherapy. Clearly, national and regional studies on the patterns of use and radiation protection aspects of brachytherapy are an aspect of continuous improvement that could provide information where there has been a significant lack of specific data previously. Such studies serve to suggest areas for additional regional, national and international research and prioritization. In addition, brachytherapy is minimally invasive and may not require overnight hospitalization. The treatment often has little or no effect on the patient’s lifestyle, thereby allowing for a speedy return to normal activities [4]. Newer brachytherapy mechanisms now include intraoperative techniques and devices, electronic dose delivery, new plaques/films, microspheres, and seeds for imaging and localization. Remote afterloading equipment is typically the most complex equipment in brachytherapy [14]. While such applications serve to increase the usefulness and safety of brachytherapy treatments, it also suggests that ongoing expansion of both the equipment and training of staff [15] associated with such advanced treatments [16] will be necessary to ensure optimized treatments and safe applications. Brachytherapy may be performed manually using gamma-emitting 103 125 192 sealed sources, typically Pd or I for prostate, Ir for interstitial and 137 131 125 intravascular, Cs for intracavitary treatment, and occassionally Cs, I and 198 Au for other procedures. The goal should be the consistency of the administration of each individual treatment, the realization of the clinical intent of the radiation oncologist and the safe execution of the treatment [22–28]. They further point out that accidents and incidents should be reported and the lessons learned should be shared with other users to prevent similar mistakes. Accidents were caused by incorrect source strength, dose calculation errors, equipment failure, errors in quantities and units, badly implanted sources, removal of sources by patients or otherwise dislodged sources. As in all areas of radiation protection in medicine, brachytherapy requires a well staffed set of uniquely qualified individuals. However, there is a worldwide lack of qualified and trained [33] individuals for brachytherapy procedures and quality management programmes [15]. This is especially acute with regard to both the older brachytherapy techniques (still affordably practised in several countries) and newer highly technical methods requiring signficant equipment and human resources. There must be sufficient trained and knowledgeable staff with clinical and medical physics expertise to deliver a safe and effective radiation dose. Appropriate facilities and radiation protection infrastructure for monitoring and regulatory control with regard to brachytherapy are needed. The patient must be provided with specific recommendations concerning the previous points, subsequent pelvic or abdominal surgery, fathering of children and possible triggering of some security monitors. It is further suggested that all patients receive a wallet card with all relevant information about the implant. In an interesting twist on population management and overall globalization trends, the cremation of bodies, already common in some countries (e. This confluence of factors suggests that increased attention and care are needed to ensure that potential exposures of the public (and workers) are mitigated. If cremation is to be considered before that time, specific measures must be taken. In addition, they found that in the overwhelming majority of early death cases, the brachytherapy source was retrieved together with the prostate gland at autopsy (as suggested by international recommendations). Security provisions are required for brachytherapy sources to deter unauthorized access, and to detect unauthorized access and acquisition of the source in a timely manner. This may require locked and fixed devices, rooms, access control, continuous surveillance or other security provisions [19]. An emphasis on radiation safety principles is needed in the next decade as current methods mature and newer techniques are developed. Significant opportunities for improvement exist in the areas of quality management (and accident prevention) along with infrastructure needs, including equipment availability, sufficiently trained human resources and security safeguards. Still, most patient treatments are planned up to the tolerance level for normal organs and tissues such as kidneys and bone marrow. For an optimal treatment, an individual dose calculation — based on an individual biokinetics study for the substance to be used — needs to be performed in advance. It is necessary to have strict procedures to verify that the patient is not pregnant or breastfeeding. For the personnel, local skin doses to the fingers and hands from the β emitters used can reach high values if the staff members are not aware of the problem and do not take steps to reduce the dose. Individuals belonging to the ward nursing staff can easily reach effective doses of a few millisieverts per year. It is essential that information and education in radiation protection and the establishment of routines guarantee that doses to pregnant staff members are such that the dose to an embryo/foetus is kept under 1 mSv. Most therapeutic procedures are still for the 131 treatment of hyperthyroidism using I-iodide. The introduction of new radiopharmaceuticals for systemic cancer treatment in situations where surgery and external radiation therapy have failed is, however, progressing. Radiation protection in radionuclide therapy concerns patients, staff members, comforters and caregivers, other family members and the general public [2]. Cancer treatment with radioactive substances started at the same time with treatment 131 32 of thyroid cancer, also with I-iodide. There are a few antibodies available on the market, labelled with 131 90 90 I or Y, mainly for non-Hodgkin’s lymphoma ( Y-ibritumomab tiuxetan and 131 I-tositumomab) [3, 4]. In parallel to monoclonal antibodies and antibody fragments, very small molecular carriers such as peptides, have been found to offer advantages for certain targeting applications. Ongoing clinical and preclinical work involves their labelling 131 90 177 166 186 188 with a number of β emitters other than I, Y and Lu: Ho, Rh, Re, 87 149 199 105 Cu, Pr, Au and Rh [5, 6]. Phase I clinical trials have been performed with α emitting 213 211 Bi monoclonal antibodies on patients with leukaemia and At monoclonal antibodies on patients with brain tumours [5] and ovarian cancer [7]. Another 223 α emitter, Ra, is being evaluated in breast and prostate cancer patients with 77 111 123 125 bone metastases. Radiation synovectomy has, for a long time, been used as an alternative to surgery for the treatment of rheumatoid arthritis. As it is relatively simple, costs less than surgery and can be performed on an outpatient basis, its use is expected to increase [5].

Unbelievably generic fildena 150 mg online, large health systems with multiple hospitals may have as many as 500 legacy systems fildena 25mg on-line, pur- chased from different vendors generic fildena 25mg without prescription, written in different software lan- guages, and operating on different, often incompatible hardware. As a consequence of this tangle, slightly different versions of our clinical reality exist in as many as 15 different places inside the hospital. The fact that there is no unified picture of an individual’s health status is a hazard to that person’s health. Creating a unified repository of all information requires a common format for clinical information, a single patient identifier applied across departments, and an agreement by all those who provide care to contribute what they know to the digital record. Clinical Decision Support Clinical decision support played an increasingly prominent role in emerging clinical systems. In the mid-1980s, intensive care special- ists at George Washington University led by Dr. Altogether, these tools may be the most complex commercial software products ever built, considering that they are automating what may be the most complex process in the economy—health service. Clinical systems are becoming “context aware,” meaning that they will be wired to diagnostic devices and patient monitoring equipment. They can track real-time changes in the patient’s health and will follow patients as they move through different levels of care—from an ambulatory diagnosis through surgery, into recov- ery, or even into home healthcare. These new systems now alert care providers when the patient’s condition changes, prompting the clinical team to take specific actions to deal with an emerging problem. Most importantly, however, clinical systems are reaching a suf- ficient level of intelligence to bring up-to-date medical knowledge to the physician’s office, exam room, or hospital bed. As medical science better defines how to treat patients, that knowledge will flow through computer systems to the point of care. The clinical system will prompt physicians, nurses, and others involved in patient care to follow the care pathway that holds the most promise for improving the patient’s health. The Clinician’s Role These systems do not relieve physicians and the care team of their professional and moral obligation in making patient care decisions. Just as those who use a navigational system in an airplane have Digital Medicine 35 the ultimate responsibility for reaching the destination safely, the clinical team is going to remain accountable—to patients, family members, colleagues, the courts, and society—for making the right decisions. However, clinical decision support is transforming the electronic medical record into a powerful advocate for patient safety, as well as a research tool for recording and investigating what works in medicine (Figure 2. Physicians who want to understand the basis for the system’s rec- ommendations will be able to look behind the recommendations to the research studies and clinical drug trial results and even review the outcomes of care for the last several hundred patients who received a particular treatment in the hospital to see what clinical strategies have worked best. The traditional medical record documents a patient’s health his- tory and any treatments provided. The clinical information systems presented here will be more like navigational systems in an airliner. It will locate the patient in the sphere of medical risk, constantly update the clinical team on his or her condition, and indicate a trajectory based on the latest scientific knowledge to help the care team negotiate the patient through an episode of care. The system will present a clinical “dashboard” to the physician each morning, in whatever form and venue he or she chooses (home or office desktop, portable laptop or tablet computer, or personal digital assistant). Clinical systems will be intelligent enough to rec- ognize their users by their past inquiries and even their different cognitive styles. This latter capability is especially helpful, because physicians do not all think about a medical problem the same way. Most physicians will bridle against a rigid, prepackaged approach to making care decisions. As clinical systems evolve, they will be able to recognize those cognitive differences and enable physicians or other caregivers to acquire and process information in a way with which they are comfortable. Clinical software will enable physicians to stratify their pa- tients, active and inactive, into risk groups and will both orga- nize and maintain communication with them to ensure not only that their inquiries are answered, but also that they are comply- ing with treatment recommendations. It will “remember” prescrip- tions and communicate with patients or family members about whether the therapy is producing the desired results. Clinical soft- ware will automatically schedule follow-up appointments and send patients information electronically on their illness and treatment options. Information systems will also link them automatically to disease management programs, managed by voice-response tools such as Eliza, to interact with patients to ensure that they are taking their medications as prescribed and managing their own health effectively. The remote patient monitoring systems discussed earlier, whether they are wearable devices like the wireless cardiac monitor, passive sensors like those used in the smart house, or implantable devices like Medtronic’s intelligent pacemakers, will connect “pa- tients” to physicians or the care team through their clinical infor- mation systems. We need a new term for people at medical risk that does not imply that they are institu- tionalized or under active care. Until very recently, medical science has been remark- ably incurious about what treatments actually improve the patient’s health. Safety, not efficacy, has been the principal focus both of research and of regulation. With the advent of what is now known as the Agency for Health Research and Quality in the Department of Health and Human Services, the federal government in 1989 began funding research into clinical outcomes. Additionally, more than 180 organizations, including medical and surgical specialty societies, academic health centers, and commercial companies, are developing scientifically based clinical guidelines. Natural Language Processing Another important constraint is the interface with the clinician. Although moving from typing to pointing and clicking helped make clinical software more accessible, the ability of clinicians to enter new information and interact with the system still depends more than it ought to on a mouse or keypad. Physicians do not like to type; they are used to dictating (and correcting, and reviewing, and correcting again). Removing typing or pointing and clicking from the process of interacting with the clinical system will require advances not in speech recognition, which is surprisingly powerful today, but in something called “natural language processing. Prying common meanings loose from the stream of words recognized by a computer system is the technical challenge that stands between today’s clinical systems that rely on typing or point-and-click interfaces and a truly interactive voice- response capability. According to Gartner, a respected technology evaluation firm, this capability may still be a decade off. How to present clinical information and treatment options in a way that clinicians find accessible and easy to use is a less visible, but very significant, barrier to adoption by clinicians. The “desktop” may not be the best visual metaphor to use in organizing this information. David Gelernter, a brilliant computer scientist, has proposed a chronological stream or ordering of ideas or documents by the time they first connected to the user as an alternative to the more static idea of a desktop. Stabilizing and Strengthening Wireless Technology Many clinicians want to be able to practice medicine from any- where and not be chained to a computer terminal in their offices or the hospital. A surprisingly large percentage of physicians (26 percent as of 2001) and virtually all medical students and residents in training own personal digital assistants. As anyone who owns a cell phone knows, wireless technology is still a fragile, frustrating, and insecure medium. Hospital structures in particular are exceptionally hostile envi- ronments for wireless technology, with lead shielding, structural steel, elevators, and an almost lethal amount of radio frequency sig- nals from myriad devices and conduits. Nontechnical Issues Two nontechnical constraints will be more fully discussed in the chapters that follow. They are (1) high cost, a major challenge for hospitals, health plans, physicians, and everyone else in the health system, and (2) the need to rethink and reorganize the care pro- cess and culture of medical practice itself, which may be the most daunting challenge of all.

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