Sensitivity of the appetite control system in obese sub- jects to nutritional and serotoninergic challenges safe 2mg detrol. Some evidence for short-term caloric compensation in normal weight human subjects: The effects of high- and low- energy meals on hunger quality detrol 4 mg, food preference and food intake 4mg detrol free shipping. The early aortic lesions as seen in New Orleans in the middle of the 20th century 2 mg detrol overnight delivery. The effects of varying dietary fat on performance and metabolism in trained male and female runners. Polyunsaturated fatty acids result in greater cholesterol lowering and less triacylglycerol elevation than do monounsaturated fatty acids in a dose–response comparison in a multiracial study group. Dietary factors and risk of breast cancer: Combined analysis of 12 case-control studies. The relationship between dietary fat intake and risk of colorectal cancer: Evidence from the combined analysis of 13 case-control studies. The effects of preloads varying in physical state and fat content on satiety and energy intake. Conjugated linoleic acid and linoleic acid are distinctive modulators of mammary carcinogenesis. Induction of apoptosis by conjugated linoleic acid in cultured mammary tumor cells and premalignant lesions of the rat mammary gland. Conjugated linoleic acid inhibits proliferation and induces apoptosis of normal rat mam- mary epithelial cells in primary culture. Nutrient intakes and eating behavior scores of vegetarian and nonvegetarian women. Plasma lipid response to hypolipidemic diets in young healthy non-obese men varies with body mass index. Effect of dietary fat on absorption of β carotene from green leafy vegetables in children. Effects of low-fat, high-carbohydrate diets on risk factors for ischemic heart disease in postmenopausal women. Dietary supplementation with γ-linolenic acid alters fatty acid content and eicosanoid production in healthy humans. The association between noon beverage consumption and the diet quality of school-age children. Dietary fat and breast cancer in the National Health and Nutrition Examination Survey. Dietary and anthropometric determinants of plasma lipo- proteins during a long-term low-fat diet in healthy women. Effects of dietary fat restriction on particle size of plasma lipoproteins in postmenopausal women. Changes in plasma lipoproteins during low-fat, high-carbohydrate diets: Effects of energy intake. Prospective study of diet and female colorectal cancer: The New York Univer- sity Women’s Health Study. Weight loss on a low-fat diet: Consequence of the imprecision of the control of food intake in humans. Changes in bone turnover in young women consuming different levels of dietary protein. Impairment of hemolytic complement activation by both classical and alternative pathways in serum from patients with kwashiorkor. A longitudinal analysis of the impact of dietary intake and physical activity on weight change in adults. Long-term cholesterol-lowering effects of 4 fat-restricted diets in hypercholesterolemic and combined hyperlipidemic men.
By the time this transformation is completed discount 1 mg detrol with visa, our health system will be wired (as well as wireless) cheap 4mg detrol otc, more intelligent 2mg detrol mastercard, and much more responsive to both consumers and caregivers cheap detrol 4mg visa. Nevertheless, those who are interested in having such a system in the near future must be sobered by the difficulty for the health system to achieve real change. This is explained by a corollary proposition, first made by 171 Nathan Myrvold, the former chief technology officer for Microsoft, who once said, “Software is a gas. It has been easier for software firms to grow through acquisition and patch together interfaces than to fundamentally reexamine how their tools can be used to make healthcare better. Healthcare managers have been guilty, however, of assuming that simply purchasing and installing clinical software is enough to achieve real transformation. The reality is that transformation of care processes and relationships must be an explicit objective of the organization, with board, executive management, and clinical leadership all committed to making their contribution to achieving that transformation. Transformation is not a task that can be delegated to the vendor, because neither the vendor nor the chief information officer who manages the vendor relationship has enough power to change how care is actually ren- dered in healthcare organizations. Thus, their businesses have little leverage of scale and are thinly capitalized and vulnerable. Technologies need to solve problems, and if they do not, physicians literally have no time for them. However, physicians are exceptionally conservative as actors in the health system. Many have a small-business mentality and practice outside the sphere of the hospitals they use. Even in large groups and health systems, physicians tend to behave not as institutional citizens, but as free agents. They are often depressingly resistant both to leadership by their peers and to change itself. Although many profess to feel powerless, physicians tend to ex- ercise veto power over initiatives in hospitals and physician orga- nizations where they feel their personal interests are compromised, even if broader benefits can be achieved by cooperating. This is why physician leadership is a vital component of an effective digital transformation. Mobilizing a cadre of physician supporters is the es- sential ingredient in any successful clinical transformation. Toward this end, many healthcare organizations are appointing chief med- ical informatics officers or their equivalents to provide a focus and rallying point for physician involvement in healthcare transforma- tion. It is far easier for physicians to be convinced by colleagues than by lay managers of the need for change. Physicians are likely to be the most persuasive change agents among their own professional colleagues and can lead change with the rest of the clinical team. Unless physicians accept the need to change workflow and clini- cal processes and for improved communications within the clinical team, those changes simply will not occur. Moreover, physician skepticism about the need for change will infect the rest of the clinical team and engender resistance by nursing personnel and others on whom physicians depend for support. Physicians are also going to need to accept hospital help with digitizing their clinical operations in their offices and harmonizing them with the hospitals’ clinical systems. This is likely to be a tall Making an Effective Digital Transformation 173 order in many places, where an unfortunate legacy of the 1990s has been heightened mistrust between physicians and hospital man- agers. In the 1980s and early 1990s, physicians actively resisted any effort by the hospital to reach out to the physician’s office with connectivity strategies, such as remote order entry and retrieval of test results. Many physicians felt that hospitals would be tracking their clinical activities and using the information they generated to control physician behavior. Physicians feared information system linkages to the hospital would be used to profile physicians who practiced “expensive” medicine and enable the hospital to practice so-called “economic credentialing” (e. Rather than converting hospital records first, it encouraged all of the physicians in the community to stan- dardize their office clinical systems on a common platform. Then the hospital made it possible for physicians to connect to and edit their office records through dial-up connections inside the hospital, postponing the conversion of the hospital’s record systems until physicians had become “addicted” to a more convenient electronic practice styles. Suspicion of hospital motives linger, and these must be alleviated if a truly safe patient care environment is to be created. Just as hos- pitals must convince patients and their families that their electronic clinical records will be protected and used judiciously and only by those who need to be involved directly in the care process, so too must hospitals convince physicians that an integrated record plat- form will be used in a way that preserves the privacy and integrity of the physician’s practice. If physicians make it clear to hospitals that they need to make it easier for them to practice medicine, hospital managers and boards will respond.
Remember that these terms are entered into the database by hand and errors of classification will occur buy discount detrol 4mg line. The more that searches are limited discount detrol 2 mg with mastercard, the more likely they are to miss important citations 1mg detrol otc. In general 1 mg detrol mastercard, both the outcome and study design terms are options usually needed only when the search results are very large and unman- ageable. However, it may not be appropriate if you are looking for a quick answer to a clinical question since you will then have to hand-search more citations. Use of synonyms and wildcard symbol When the general structure of the question is developed and only a small num- ber of citations are recovered, it may be worthwhile to look for synonyms for each component of the search. For our question about mortality reduction in colorectal cancer due to fecal occult blood screening in adults, we can use sev- eral synonyms. Screening can be screen or early detection, colorectal cancer can be bowel cancer, and mortality can be death or survival. Since these terms are entered into the database by coders they may vary greatly from study to study for the same ultimate question. Truncation or the “wildcard” symbol can be used to find all the words with the same stem in order to increase the scope of successful searching. If you were searching for information about hearing problems and you used hear∗ as one of your search terms you would retrieve not only articles with the word “hear” and “hearing” but also all those articles with the word “heart. It is important to check the database’s help documentation to determine not only the correct symbol, but to also ensure that the database supports truncation. For instance, if a database automatically truncates then the use of a wildcard symbol could inadvertently result in a smaller retrieval rather than a broader one. The best way to get to know PubMed is to use it, explore its capabilities, and experiment with some searches. Remember that all databases are continually being updated and upgraded, so that it is important to consult the help documentation or your health sciences librarian for searching guidance. It uses a set of built- in search filters that are based on methodological search techniques developed by Haynes in 1994 and which search for the best evidence on clinical questions in four study categories: diagnosis, therapy, etiology, and prognosis. In turn each of these categories may be searched with an emphasis on specificity for which most of the articles retrieved will be relevant, but many articles may be missed or sensitivity for which, the proportion of relevant articles will decrease, but many more articles will be retrieved and fewer missed. It is also possible to limit the search to a systematic review of the search topic by clicking on the “systematic review” option. In order to continue searching in clinical queries, click on the “clinical queries” link in the left-hand side bar each time a search is conducted. Clicking on the “filter table” option within clinical queries shows how each filter is interpreted in PubMed query language. It is best to start with the specificity emphasis when initiating a new search and then add terms to the search if not enough articles are found. Once search terms are entered into the query box on PubMed and “go” is clicked, the search engine will display your search results. This search is then displayed with the search terms that were entered combined with the methodological filter terms that were applied by the search engine. Below the query box is the features bar, which provides access to additional search options. The PubMed query box and features bar are available from every screen except the Clinical Queries home page. Return to the Clinical Queries homepage each time a new Clinical Queries search is desired. The truncation or wildcard symbol (∗) tells PubMed to search for the first 600 variations of the truncated term. As a rule of thumb, it is better to use the wildcard symbol as a last resort in PubMed. Limits The features bar consists of limits, preview/index, history, clipboard,and details. To limit a search, click “limits” from the features bar, which opens the 40 Essential Evidence-Based Medicine Fig. This offers a number of useful ways of reduc- ing the number of retrieved articles.
Seek feedback regularly regarding therapeutic decision making and respond appropriately and productively discount 1mg detrol otc. Incorporate the patient in therapeutic decision making purchase detrol 1 mg fast delivery, explaining the risks and benefits of treatment discount detrol 1mg free shipping. Respect patients’ autonomy and informed choices buy detrol 1 mg fast delivery, including the right to refuse treatment. Demonstrate an understanding of the importance of close follow-up of patients under active care. Recognize the importance of and demonstrate a commitment to the utilization of other health care professionals in therapeutic decision making. During the internal medicine core clerkship, the student can put into practice some of the ethical principles learned in the preclinical years, especially by participating in discussions of informed consent and advance directives. Additionally, the student learns to recognize ethical dilemmas and respect different perceptions of health, illness, and health care held by patients of various religious and cultural backgrounds. Basic ethical principles (autonomy, beneficence, nonmaleficence, truth- telling, confidentiality, and autonomy). The role of the physician in making decisions about the use of expensive or controversial tests and treatments. Circumstances when it may be unavoidable or acceptable to breach the basic ethical principles. Participating in a preceptor’s discussion with a patient about a requested treatment that may not be considered appropriate (e. Participating in family and interdisciplinary team conferences discussing end- of-life care and incorporating the patient’s wishes in that discussion. Recognize the importance of patient preferences, perspectives, and perceptions regarding health and illness. Demonstrate a commitment to caring for all patients, regardless of the medical diagnosis, gender, race, socioeconomic status, intellect/level of education, religion, political affiliation, sexual orientation, ability to pay, or cultural background. Recognize the importance of allowing terminally ill patients to die with comfort and dignity when that is consistent with the wishes of the patient and/or the patient’s family. Recognize the potential conflicts between patient expectations and medically appropriate care. Therefore, they must master and practice self- directed life-long learning, including the ability to access and utilize information systems and resources efficiently. Key sources for obtaining updated information on issues relevant to the medical management of adult patients. Key questions to ask when critically appraising articles on diagnostic tests: • Was there an independent, blind comparison with a reference (“gold”) standard? Key questions to ask when critically appraising articles on medical therapeutics: • Was the assignment of patients to treatments randomized? Performing a computerized literature search to find articles pertinent to a focused clinical question. Summarizing and presenting to colleagues what was learned from consulting the medical literature. Recognize the value and limitations of other health care professionals when confronted with a knowledge gap. Appropriate care by internists includes not only recognition and treatment of disease but also the routine incorporation of the principles of preventive health care into clinical practice. All physicians should be familiar with the principles of preventive health care to ensure their patients receive appropriate preventive services. Criteria for determining whether or not a screening test should be incorporated into the periodic health assessment of adults. General types of preventive health care issues that should be addressed on a routine basis in adult patients (i. Methods for counseling patients about risk-factor modification, including the “stages of change” approach to helping patients change behavior. General categories of high-risk patients in whom routine preventative health care must be modified or enhanced (e. The potential roles and limitations of genetic testing in disease prevention/early detection. Obtaining a patient history, including a detailed family history, vaccination history, travel history, sexual history, and occupational exposures.