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By G. Dawson. Chicago School of Professional Psychology. 2018.

The Internal Revenue Code and state laws forbid not-for-profit hospitals (recall that 85 percent of all community hospitals are not-for-profit) from giving physicians (or anyone else) anything of value trusted kamagra polo 100mg. Competitive advantage for specific providers could be eliminated by regulation that requires clinical information systems developed by different vendors to interoper- ate (that is buy 100mg kamagra polo overnight delivery, to use common record formats, coding conventions, messaging standards, etc. This would mean that, once installed, physicians could use their clinical software in conjunction with any of the available local hospitals or retrieve information about their patients from any of them. The fact that software and services could be provided on a dial- in basis without significant capital expenditures by hospitals on the physicians’ behalf could help change some of the equation as well. The most expensive part of a physician office’s digital conversion is transferring all of its existing patient records to digital form so they can be used by the information system. If these costs can be surmounted and physicians can obtain password-protected access to computerized patient records and clinical decision support from their offices, it would be a major boost to overall computerization. Hospitals and Physicians Digitizing Patient Records Together Ideally, hospitals and physicians should move together to digitize patient records. Technical opportunities exist for hospitals to create Physicians 87 virtual private networks that segregate the physician’s clinical records from those of the hospital (as well as the rest of the Internet), protect the physician’s business autonomy and privacy, and still provide the transparency of information flow that is needed for optimal patient care. Physicians have to be willing to wade into the battle over how digital medicine is organized and be assured that their concerns about autonomy and privacy are recognized. When you sum the potential impact of various information tech- nologies across the physician’s world, the aggregate impact is im- pressive. Speed the flow of new knowledge to physicians and store it efficiently so physicians don’t have to rely on their memories 2. Guide and assist in patient care itself, wherever the physician or patient may be at the moment 3. Free physicians from paper records and bills, reducing their prac- tice expenses 4. Facilitate collaboration between physicians both in consultation and in learning As with hospitals, this progress will not come easily, quickly, or cheaply. Moreover, not all physicians will be able to realize all of these benefits at the same time. Physicians practicing in larger groups and clinic settings will find these tools become available to them sooner simply because their organizations have the financial resources and personnel to make them happen and the capability 88 Digital Medicine of experimenting with these tools before adopting them wholesale. Physicians in private practice will have to overcome mistrust of their hospitals and each other and work with their colleagues to build data systems they can use from the office or from home. However, what ails physicians stretches far beyond the curable logistical difficulties of medical practice itself. At the root of medicine’s midlife crisis is the nagging feeling on physicians’ part that patients and society no longer trust them. Consumers are sending physicians a message: be more available to us when we need your help, do not patronize us, and give us the information we need to help us manage our own health. The physicians who hear these messages develop new relationships with consumers and may find their practices acquire more meaning. Physicians who grasp this capability effectively will also find that they can grow their practices and, by making more efficient use of their own time, still devote more time to the patients who need the personal contact. Information technology can extend the power of the physician’s mind, a most valuable and fragile tool, and can help strengthen the doctor-patient relationship. As this relationship is improved, it may help lay the groundwork for a newer, more confident medicine. Although they may not believe it, physicians retain extraordinary power in our health system. All too often, they have used that power to retard needed changes in health policy and management. With information technology, however, physicians have a marvelous op- portunity to lead the transformation. Because they remain strategic actors, not only in health systems, but also in the lives of patients, physicians hold the key to “birthing” the digital transformation of the health system. For further, in-depth readings on the benefits of digitization on physicians, I recommend Digital Doctors by Marshall de Graffenried Ruffin, Jr. Trails Other English Speaking Countries in Use of Electronic Medical Records and Electronic Prescribing. Measured against this end point, the contem- porary health system in the United States has become increasingly user-unfriendly. The institutions of medical practice—hospitals, health plans, and physician organizations—have grown so large and become so intimidating that many of them dwarf those who give and receive care. As mechanisms for transmitting knowledge, healthcare organizations have become riddled with bureaucracy and institutional processes that impede the free flow of communication between patients and caregivers. Moreover, as discussed in Chapter 1, healthcare institutions have become prisons of vital medical knowledge.

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One example could be feasibility studies on health data cooperatives with an assessment of ethical buy kamagra polo 100 mg free shipping, legal and soci- 2 buy 100 mg kamagra polo with amex. Develop and promote models for individual al implications comparing diferent European healthcare responsibility, ownership and sharing of per- system settings. An appropriate data ownership framework for ment pathways and track the safety and efec- patients will therefore be needed, especially given that tiveness of these interventions. For this reason, issues relating interfaces is needed to enable the use of smartphones, to data ownership, storage, handling, editing, sharing, tablets, other mobile services, ‘smart home’ and tele-he- controlling and access regulations have to be addressed. The implementation of this recommen- ethical basis for integrating data generated about and by dation 2 and 3 will strengthen the fnality for the patients’ users into health information collected by medical profes- beneft. Additionally, a framework for the management and communication of predictive information derived 4. For this rea- data silos of national healthcare systems and so improve son fexible and adaptable guidelines will be needed to interoperability. Personal and economic benefts evolve and incorporate lessons from experiences of the 13 various stakeholders; so for example the efect in terms tient advocacy organisations; 3) supporting lifelong lear- of justice and fairness in healthcare is difcult to predict ning and skills to promote good health. Improve communication and education stra- althcare system and increase the patient’s role tegies to increase patient health literacy. Develop common principles and legal frame- lic and private sector organisations deliver information works that enable sharing of patient-level in ways that make it difcult to understand and act on, data for research in a way that is ethical and or that are even incomplete and inaccurate. This stratifcation will the skill and competence of health professionals, patient greatly reduce the number of patients within any such advocacy organisations, media and government and subgroups. In view of this, international co-operation will private sector agencies to provide health information in become increasingly important in order to recruit suf- a manner appropriate to their audiences are as equally cient numbers of patients for the generation of statisti- important as an individual’s skills. Data everyone with access to accurate and actionable health protection regulation, invented mainly to protect consu- information; 2) delivering person-centred, lay-friendly mers against the misuse of personal data, for example on health information resources and services involving pa- the internet, needs to be reviewed critically in the context 14 of its detrimental impact on medical research, in order not Examples of on-going activities to stife data collection for research purposes, registries or cross-border sharing of research data. Europe involve a strong voice from patient advocacy groups to adequately balance the interests of the individual patients In May 2011 the Health Directorate of the European and society as a whole. Commission‘s Directorate General for Research and In- novation organised the conference ‘European Perspec- tives in Personalised Medicine’, which aimed to take Key Enablers for Challenge 1 stock of recent achievements in health-related research Europe: e. Ministries of health, fnance, re- ritise future actions needed at the European level. The work- cieties, foundations, patient organisations, healthcare shops (http://ec. Recently members king Groups develop positions on key topics and of these societies have published an opinion paper make proposals and recommendations to the Forum. Patient recruit- In Canada, the Canadian Institutes for Health Research ment – consents and ethics; 4. Increasing the impact of research jects in various diseases areas were funded through and development investment. Develop- comprehensive cataloguing of high quality biobank speci- ment of prospective surveillance and monitoring systems mens and biomarkers, and their use in all large-scale studies for personal health data will also contribute to the accu- on patient and population cohorts (‘top-down approach’) mulation of data on individuals across their life course. Thus it is not only omics or imaging technologies misinformation on diseases, their symptoms and potential that will generate vast amounts of data. Aspects include: (1) how health records data from diferent types of registries and to store and provide access to huge amounts of human emerging fows of unstructured data coming from, for ex- health-related sensitive data under a secure and common ample, connected objects or social media. Even though of huge datasets taking into account the fact that storage the launch of translational projects as a main driver for pro- may be either centralised or decentralised; (3) how to in- ducts and services development is key, market successes terrogate such data; and (4) how to link such data to ex- 18 perimental data. Furthermore it needs to be determined • Create a framework for data usage and connect it to who fnances such activities and who will reap the bene- a digital environment to facilitate and improve medi- fts. New solutions, such as cloud computing and secure cal data sharing while ensuring transparency and data user authentication, have been developed to cope with protection. Yet most of these still have to • Support an appropriate infrastructure to collect and demonstrate their applicability, especially in the health store the huge amount of information generated. Some public–priva- • Involve big data organisations in research, motivate te partnership projects of the Innovative Medicines Initiati- and stimulate them to invest in research. For these databases the citizen’s and patient’s lifecycle should be considered not only when an episode of severe Targeted achievements until 2020 and beyond – Re- or acute disease occurs. This recommendation also inclu- commendation des a laboratory quality control nationwide and if possible Europe-wide. Support translational research infrastructures plied and propagated so as to become standard practice in and enforce data harmonisation fostered by health. Develop and encourage the fast uptake of tech- • Give access to data from silos by encouraging and faci- nologies for data capture, storage, manage- litating data sharing. Support analytical methods and modelling way that data are stored, secured and shared, respec- approaches to develop new disease models, e. This requires the following another patient who has the same fngerprint (‘electronic actions: twin’), whose electronic medical record of natural history of disease and treatment outcome will help medical de- • Harmonise the format in which big data are collected cision-making through modelling and prediction. The introduction of genomic (sequence) and molecular • Decide which data will be needed (e.

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These same principles of physiology kamagra polo 100mg on-line, pathology cheap 100mg kamagra polo fast delivery, and appro- priate therapeutic intervention guide the rest of the text. Aside from a brief discussion of excessive heat in the womb (¶), the next group of chapters —swellings or tumors (apostemes) from various humoral causes (¶¶–), wounds of the womb and vagina (¶¶–), and itching of the vagina (¶¶– )—derive their substance from the Viaticum. The man’s seed, in turn, may itself be too thin and liquidy, or his testicles may be so cold that he cannot generate seed. A test is then offered to determine whether the cause lies with the man or the woman (¶). Inter- estingly, infertility in either partner is considered incurable; it is only if neither partner is found to be sterile that medical aids are deemed to be in order. Five recipes are then provided, sometimes for the woman alone, sometimes for the man and woman together. Neither here nor in the vast majority of medieval medical texts are there any explicit instructions on how to conceive females. Those that this author advocates, interestingly, all rely on amulets or sympa- thetic magic (¶¶–), which derive from the author’s alternate source, the Book on Womanly Matters. It is notable that there is no reference here to any of the many herbs of presumed contraceptive or abortifacient properties de- scribed in a variety of readily available pharmacological texts. From the Viati- cum the author draws discussions of the causes of miscarriage (¶), care of the pregnant woman (¶a; ¶ in the present edition), common disorders of pregnancy (¶¶b and c; in the present edition, ¶¶ and , respectively), followed by a brief statement on the process of birth itself (¶), then aids for difficult birth (¶¶–). Then, perhaps referring to Muscio’s Gynecology,the author adds the specific instruction that ‘‘the women who assist her ought not look her in the face, for many women are ashamed to be looked upon dur- ing birth’’ (¶). These, in turn, are followed by twelve remedies for ex- tracting the fetus that has died in utero (¶¶–). Recipes for removing the afterbirth (¶¶– and –) and treating postpartum pain (¶) follow, while a test to determine the sex of the fetus closes the text (¶¶–). Some of these obstetrical remedies derive from the Viaticum, though many of the rest reflect traditional practices, some of them magical, some strictly herbal. These consisted of both prenatal procedures and instruc- tions for attendance at the birth itself. Sneezing is to be induced; potions are to be prepared; a magnet is to be held in the hand; coral is to be suspended from the neck; the white substance found in the dung of a hawk is to be drunk, as are the washings from the nest and a stone found in the belly of a swallow. Here, too, we find the explicit statement that ‘‘the womb follows sweet smells and flees foul ones. The Book on the Conditions of Women is very much the offspring of Greco- Roman and Arabic medicine. Although by no means slavish in its adherence to the Viaticum or its other sources, the points on which it diverges from its textual models are for the most part themselves reflections of the survival of certain ancient medical notions (the concept of uterine movement being the most prominent) through a probable combination of oral and literate trans- mission. The only distinctive indication that Conditions of Women is the prod- uct of a Christian culture is the prologue (¶¶–). A recasting of the creation story of Genesis (:– and :) into Galenic physiological terms, the pro- logue explains how woman’s subjugation to man allows reproduction to take place, which in turn is the chief cause of illness in the female body. The au- thor recasts Galen’s original view of man as the perfect standard (from which women then deviate) into a case of equal divergence of both men and women from a temperate mean. Lest the man tend too strongly toward his natural state of hotness and dryness,God desired that the male’s excess be restrained by the opposite qualities of the female, coldness and wetness. The author nevertheless leaves no doubt that this mutual ‘‘tempering’’ is not really a balancing out of equal oppo- sites: the man is ‘‘the more worthy person’’; heat and dryness are ‘‘the stronger qualities. A  charm from a fifteenth-century medical amulet (bottom row, left of center). The text in the circle surrounding the square reads: ‘‘Show this figure to a woman giving birth and she will be delivered’’ (Hanc figuram mostra mulierem in partu et peperit). Introduction  sowing seed in a field—a metaphor that, on the one hand, contradicts the text’s own assumption that women, too, have seed, yet on the other firmly reifies the original Genesis dictum that the female is indeed subject to the male. It is because women are in fact weaker than men that they suffer so greatly in childbirth and that they are more frequently afflicted by illness, ‘‘especially around the organs assigned to the work of Nature. It was out of pity for their plight—and, it seems, because of the influence of one woman in particular— that the author, laboring ‘‘with no small effort,’’ was induced to ‘‘gather the more worthy things from the books of Hippocrates, Galen and Constantine, so that I might be able to explain both the causes of [women’s] diseases and their cures. Conditions of Women, probably one of the first attempts to synthesize the Galenic frame- work of the new Arabic medicine with older Hippocratic traditions, offers, in effect, what will become the foundation for later medieval Latin views of female physiology and pathology. Treatments for Women That Treatments for Women could have come out of the same general social milieu as Conditions of Women is an indication of how diverse twelfth-century southern Italian medical culture was. Despite their shared general subject mat- ter of women’s medicine, Treatments for Women and Conditions of Women are surprisingly different in their theoretical outlook, their organizational struc- ture, and their social-intellectual origins. There are onlya few vaguely Galenic elements of theory, and its use of the com- pound medicines that were apparently introduced into Italy by Constantine the African is likewise limited. This is not to say that it has no medical theory that gives struc- ture to its therapeutic precepts; on the contrary, there are several consistent principles of female physiology and disease that underlie this seemingly ran- dom string of remedies.

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Psychosocial factors Issue Are there specific psychosocial interventions that can reduce cardiovascular risk? Evidence Observational studies have indicated that some psychosocial factors cheap 100mg kamagra polo mastercard, such as depression and anxiety purchase kamagra polo 100 mg on line, lack of social support, social isolation, and stressful conditions at work, independently 38 Prevention of cardiovascular disease influence the occurrence of major risk factors and the course of coronary heart disease, even after adjusting for confounding factors (246–248). Other psychosocial factors, such as hostility and type A behaviour patterns, and anxiety or panic disorders, show an inconsistent association (249, 250). Rugulies (246), in a meta-analysis of studies of depression as a predictor for coronary heart disease, reported an overall relative risk for the development of coronary heart disease in depressed subjects of 1. This finding was consistent across regions, in different ethnic groups, and in men and women (247). In a large randomized trial of psychological intervention after myocardial infarction, no impact on recurrence or mortality was found (253). Another large trial that provided social support and treatment for depression also found no impact (254). Depression has a negative impact on quality of life (255, 256), and antidepressant therapy has been shown to significantly improve quality of life and functioning in patients with recurrent depression who are hospitalized with acute coronary syndromes (257, 258). The association has been demonstrated in subjects in different countries, and in various age groups (250, 259–262). While these findings provide some support for a causal interpretation of the associations, it is quite possible that they represent confounding or a form of reporting bias, as illustrated in a large Scottish cohort (263). Well planned trials of interventions to reduce work stress and social isolation are required to elucidate whether there is a true cause–effect relationship and, more importantly, whether inter- vention reduces cardiovascular risk. In the meantime, physicians and health care providers should consider the whole patient. Early detection, treatment and referral of patients with depression and other emotional and behavioural problems are, in any case, important for reducing suffering and improving the quality of life, independent of any effect on cardiovascular disease. Mobilizing social support to avoid or solve social and work concerns is also a legitimate response to a patient’s difficulties (258). Multiple risk factor interventions Issue Are multiple risk factor interventions effective in reducing cardiovascular risk? Evidence A Cochrane systematic review has evaluated the effectiveness of multiple risk factor interven- tions for the primary prevention of cardiovascular disease in adults from general populations, occupational groups and high-risk groups (106). Eighteen randomized controlled trials involving counselling and/or health education, with or without pharmacological treatment, which aimed to affect more than one cardiovascular risk factor (smoking, diet, physical activity, blood pressure and blood cholesterol) were included. Overall, modest reductions in smoking prevalence, systolic blood pressure, diastolic blood pressure, and blood cholesterol were observed. The studies with the highest baseline levels of smoking prevalence, diastolic blood pressure or cholesterol levels demonstrated greater intervention-related reductions in these risk factors. The pooled effects of the ten trials with clinical event endpoints showed no significant effect on total or cardiovascular disease mortality; this is consistent with the extent of changes in risk factors. However, trials that focused on participants with elevated blood pressure, and those that used drug treatment, demon- strated significant reductions in coronary heart disease mortality and total mortality. Interventions using personal or family counselling and education, with or without drug treatment, were more effective in modifying risk factors and reducing mortality in people at high risk because of raised blood pressure. These results argue in favour of multiple risk factor interventions for prevention of cardiovascular disease in multifactorial high-risk groups. For the general low-risk population, policy measures that create a conducive environment which facilitates behavioural change may have a greater impact at lower cost than individual counselling and therapeutic approaches. Blood pressure lowering Issue Does lowering blood pressure reduce cardiovascular risk? Evidence Raised blood pressure is estimated to cause about 7 million premature deaths throughout the world, and 4. It is a major risk factor for cerebrovascular disease, coronary heart disease, and cardiac and renal failure. Treating raised blood pressure has been associated with a 35–40% reduction in the risk of stroke and at least a 16% reduction in the risk of myocardial infarction (264). Raised blood pressure often coexists with other cardiovascular risk factors, such as tobacco use, overweight or obesity, dyslipidaemia and dysglycaemia, which increase the cardiovascular risk attributable to any level of blood pressure. Worldwide, these coexisting risk factors are often inadequately addressed in patients with raised blood pressure, with the result that, even if their blood pressure is lowered, these people still have high cardiovascular morbidity and mortality rates (265–267). Almost all clinical trials have confirmed the benefits of antihypertensive treatment at blood pres- sure levels of 160 mmHg (systolic) and 100 mmHg (diastolic) and above, regardless of the pres- 40 Prevention of cardiovascular disease ence of other cardiovascular risk factors (264, 268). Observational data support lowering of these systolic and diastolic thresholds (269, 270). Several trials in patients at high cardiovascular risk (271–273) have confirmed these observational data, showing reductions in cardiovascular morbidity and mortality in people whose blood pres- sure is reduced to levels significantly below 160 mmHg systolic and 90 mmHg diastolic. These trials support the view that, in patients at high cardiovascular risk, with blood pressures in the range 140–160 mmHg (systolic) and 90–100 mmHg (diastolic), lowering blood pressure reduces the number of cardiovascular events. These trial results suggest that treatment for such high-risk patients should begin at the lower blood pressure thresholds. Although women are at lower total risk of cardiovascular disease for a given level of blood pressure, and randomized controlled trials generally include a greater proportion of men than women, the treat- ment thresholds for systolic and diastolic pressure should be the same in men and women (274).

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