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By W. Kalan. Caldwell College.

As these rate control mechanisms are applicable to many other drug delivery systems levitra extra dosage 40mg with mastercard, this chapter also serves as a general introduction to the methods of rate control which are achievable using advanced drug delivery and targeting strategies cheap levitra extra dosage 60 mg with visa. Implants are available in many forms purchase levitra extra dosage 40mg with amex, including: • polymers buy levitra extra dosage 40 mg low price, which can be biodegradable or non-degradable and are available in various shapes (rod, cylinder, ring, film, etc. They are commonly implanted subcutaneously, either into the loose interstitial tissues of the outer surface of the upper arm, the anterior surface of the thigh or the lower portion of the abdomen. However, implants may also be surgically placed in, for example, the vitreous cavity of the eye (intravitreal implant), or intraperitoneally. Scientists further fabricated pellet-type implants comprising other steroidal hormones including testosterone, progesterone, deoxycorticosterone and dromostanolone propionate. Release from such pellet-type implants is governed by the dissolution of the particular drug moiety in the body fluids and thus is not amenable to external control. A pellet-type implant also lacks pellet-to-pellet reproducibility in the rate of drug release. In the early 1960s, it was reported that hydrophobic small molecular weight compounds permeated through a silicone rubber capsule at relatively low rates. When implanted in animals, the system released drugs at reasonably constant rates and also elicited little inflammation at the site of implantation. The use of a silicone elastomer as a diffusion barrier to control the release of compounds such as steroidal hormones, insecticides, anesthetics and antibiotics was later demonstrated. The rate of drug release was subject to external control by manipulating the thickness, surface area, geometry and chemical composition of the silicone elastomers. As a silicone rubber membrane is not permeable to hydrophilic or high molecular weight compounds, concerted efforts were made to develop other biocompatible polymers for use in implantable devices. Such polymers include poly(ethylene-co-vinyl acetate), poly (ethylene), poly(propylene), poly(hydroxymethyl methacrylate), poly(lactide-co-glycolide), poly (anhydrides) and poly(ortho esters). The characteristics and applications of each important polymer family will be discussed later in this chapter. A brief overview of both the advantages and disadvantages of implantable drug delivery is given below. However, under these regimens, patients are often required to stay in hospital during administration for continuous medical monitoring. A short-acting drug exacerbates the situation, as the number of injections or the infusion rate must be increased, in order to maintain a therapeutically effective level of the drug. In contrast, implantation therapy permits patients to receive medication outside the hospital setting, with minimal medical surveillance. Implantation therapy is also characterized by a lower incidence of infection-related complications in comparison to an indwelling catheter-based infusion system. A person can forget to take a tablet, but drug delivery from an implant is largely independent of patient input. Some implantable systems involve periodical refilling, but despite this factor the patient has less involvement in delivering the required medication. This bypassing effect is particularly of benefit to drugs which are either absorbed poorly or easily inactivated in the gastrointestinal tract and/or the liver before systemic distribution. From a regulatory perspective, it is regarded as a new drug product and can extend the market protection of the drug for an additional 5 years (for a new drug entity) or 3 years (for existing drugs). This requires the appropriate surgical personnel, and may be traumatic, time-consuming, cause some scar formation at the site of implantation and, in a very small portion of patients, may result in surgery- related complications. Although a biodegradable polymeric implant does not require surgical retrieval, its continuing biodegradation makes it difficult to terminate drug delivery, or to maintain the correct dose at the end of its lifetime. Therefore, most systems have a limited loading capacity, so that often only quite potent drugs, such as hormones, may be suitable for delivery by implantable devices. If a new biomaterial is proposed to fabricate an implant, its safety and biocompatibility must be thoroughly evaluated to secure the approval of regulatory authorities. These issues can attribute to significant delay in the development, marketing and cost of a new implant. Adverse effects may be caused by: • The intact polymer: this may be due to the chemical reactivity of end or side groups in a polymer, organometallics used as polymerization initiators, or extractable polymeric fragments. In the case of a bioerodible poly(vinylpyrrolidone), the accumulation of the dissolved polymer in the liver raises a longterm toxicity issue. If the surface of an implant has an affinity towards specific chemicals, an abnormal boundary layer will develop. The subsequent intra-layer rearrangement or reactions with other species then trigger tissue reactions. The defence reactions of the host tissue often lead to encapsulation of an 77 implant by layers of fibrous tissues. Since the encapsulation frequently impedes drug release, in vitro drug release data may not permit the prediction of in vivo drug release patterns. High local drug concentrations at the site of implantation over extended periods of time can also cause severe local irritation or adverse tissue reactions. The performance and response of the host toward an implanted material is indicated in terms of biocompatibility. Major initial evaluation tests used to assess the biocompatibility of an implant are listed in Table 4. These tests include: • observation of the implant/tissue interactions at the site of implantation; Table 4. The choice of whether to select a reservoir-type, or a matrix-type, implantable system depends on a number of factors, including: • the drug’s physicochemical properties; • the desired drug release rate; • desired delivery duration; • availability of a manufacturing facility. For example, it is generally easier to fabricate a matrix-type implant than a reservoir system, so this may determine the selection of a matrix system. However, if drug release is the overriding concern, a reservoir system may be chosen in preference to a matrix system. This is because reservoir systems can provide zero- order controlled release, whereas drug release generally decreases with time if a matrix system is used. They vary in molecular weight, filler content, R and R, and1 2 1 2 the type of reactive silicone ligands for cross-linking. Variations in these parameters permit the synthesis of a wide range of material types such as fluids, foams, soft and solid elastomers (Figure 4. These copolymers have the advantages of: • Ease of fabrication: the copolymers are thermoplastic in nature, thus an implantable device is easily fabricated by extrusion, film casting or injection molding. As the ethylene domain is crystalline, an increase in the content of ethylene unit affects the crystallinity and the solubility parameter of the copolymer. Other polymeric materials commonly used as non-porous, rate-controlling membranes are given in Table 4. The penetration of a solvent, usually water, into a polymeric implant initiates drug release via a diffusion process. Diffusion of drug molecules through non-porous polymer membranes depends on the size of the drug molecules and the spaces available between the polymeric chains. Even through the space between the polymer chains may be smaller than the size of the drug molecules, drug can still diffuse through the polymer chains due to the continuous movement of polymer chains by Brownian motion. For transport through the membrane, there are three barriers to be circumvented (Figure 4. The drug molecules in the reservoir compartment initially partition into the membrane, then diffuse through it, and finally partition into the implantation site. C −C where Cr and C denote the drug concentrations in the reservoirr i i and at the site of implantation respectively. The release rate of a drug from different polymeric membranes can be compared from the corresponding P values. This is the familiar form1 of a first-order rate equation and indicates that the rate of diffusion is proportional to drug concentration. However, in this system, the drug reservoir consists of either: • solid drug particles, or • a suspension of solid drug particles in a dispersion medium so that the concentration of drug (C ) in the system always remainsr constant, so that Equation 4. Thus the release rate of a drug from this type of implantable device is constant during the entire time that the implant remains in the body. Microporous membranes can be prepared by making hydrophobic polymer membranes in the presence of water-soluble materials such as poly(ethylene glycol), which can be subsequently removed from the polymer matrix by dissolving in aqueous solution. Cellulose esters, loosely cross-linked hydrogels and other polymers given in Table 4. In microporous reservoir systems, drug molecules are released by diffusion through the micropores, which are usually filled with either water or oil (e. Solvent-loading of a porous membrane device is achieved simply by immersing the device in the solvent. When this technique presents some difficulty, the implantable device is placed inside a pressure vessel and pressure is then applied to facilitate the filling of the solvent into pores. The selection of a solvent is obviously of paramount importance, since it affects drug permeability and solubility. In this system, the pathway of drug transport is no longer straight, but tortuous. The porosity ε of the membrane and the tortuosity τ of the pathway must therefore also be considered. As for the non-porous reservoir device, in the microporous system, both: • the surface area of the membrane and • the drug concentration in the reservoir compartment remain unchanged, thus “M t” kinetics is again demonstrated and zero-order controlled release is attained (Figure 4. The capsules are surgically implanted subdermally, in a fan-like pattern, in the mid- portion of the upper arm. The implant releases levonorgestrel continuously at the rate of 30 µg/day (the same daily dose provided by the oral uptake of the progestin-only minipill) over a 5-year period. After the capsules are removed, patients are promptly returned to normal fertility. The implant is surgically placed in the vitreous cavity of the eye and delivers therapeutic levels of ganciclovir for up to 32 weeks. Matrix-type implants are fabricated by physically mixing the drug with a polymer powder and shaping the mixture into various geometries (e. The total payload of a drug determines the drug’s physical state in a polymer: • Dissolved: the drug is soluble in the polymer matrix. A dissolved matrix device (also known as a monolithic solution) appears at a low payload. When the drug content occupies more than 30% volume of the polymer matrix, the leaching of drug particles results in the formation of pores or microchannels that are interconnected. Regardless of a drug’s physical state in the polymeric matrix, the release rate of the drug decreases over time. As release continues, molecules must travel a greater distance to reach the exterior of the implant and thus increase the time required for release (Figure 4. This increased diffusion time results in a decrease in the release rate from the device with time (Figure 4. Numerous equations have been developed to describe drug release kinetics obtainable with dissolved, dispersed, and porous-type matrix implants, in different shapes, including spheres, slabs and cylinders.

The gene is needed for normal brain function and its underexpression results in mental retardation order levitra extra dosage 40mg with amex. Females in whom the premutation expands in size to a full mutation transmit the syndrome to all of their male and half of their female offspring 40 mg levitra extra dosage. The size of the fragments and their fluorescence determine which alleles are present cheap levitra extra dosage 40mg with mastercard. A single exclusion can result from laboratory possibility of a mutation having occurred in one of error the loci being tested order levitra extra dosage 40 mg without prescription. A single exclusion can result from germ line sufficiently polymorphic that the mother’s sample is mutation within one locus being tested not necessary to determine paternity. Te biological father may be a blood relative to based on the premise that the biological father must the alleged father have at least one allele in common with the child at D. D Hereditary hemochromatosis is an autosomal Molecular/Apply knowledge of special procedures/ recessive disease with a frequency as high as 0. Hereditary hemochromatosis is the result of which base that results in tyrosine substituting for cysteine type of mutation? The remaining cases Molecular/Correlate clinical and laboratory data/Point are caused by a single-point mutation at position mutations/2 63 on the protein (H63D), which produces a milder 27. N-Myc which activate transcription by up-regulating the Molecular/Apply knowledge of fundamental biological signal transduction pathway of the cell. Talassemia/2 β-Thalassemia may be caused by single base substitutions, deletions, or mutations in the flanking 29. A In flow cytometry, cells can be divided into of cells of interest subpopulations based upon their light-scattering C. Cells to be interrogated by the laser(s) are single antibody selected by identifying the area in which they appear D. B The gated population is selected by evaluating the procedures/Flow cytometry/1 scatterplot of forward light scattering (x axis) and right angular or side scatter (y axis). Which of the following parameters are used to gate within the specified limits are counted. Font surface fluorescence versus incident laser because the former have greater forward scatter and intensity less side scatter. A Forward scatter of light from a laser directed through wavelengths the aperture of the cytometer is directly related to cell D. Right angular scatter (side scatter) is dependent conductance upon the number of granules inside the cytoplasm. Molecular diagnostics/Apply principles of special For example, small lymphocytes that are agranular procedures/Flow cytometry/1 have the lowest forward and side scatter and are easily identified as the cluster of cells closest to the 32. In general, which statement best characterizes the bottom and left of the scatterplot. Forward scatter is related to cell size and side specific antibodies that bind to surface antigens scatter to granularity that characterize their lineage and maturation B. The antibodies are conjugated to fluorescent side scatter to size dyes that are excited by the laser. Forward scatter is inversely related to size and characteristic wavelength emitted by the fluorescent side scatter is directly related to size label is detected, then the cell bound the labeled D. Forward scatter is related to shape and side antibody and is positive for the respective antigen. Since Molecular diagnostics/Apply principles of special they emit green and red light, respectively, they procedures/Flow cytometry/2 can be differentiated in the same sample, allowing 33. Fluorescent dyes most commonly conjugated to two antibodies to be tested simultaneously. Fluorescein isothiocyanate and Texas red simultaneous measurement of more markers. Calcofluor white and Texas red example, different fluorescent dyes can be attached C. Phycoerythrin and fluorescein isothiocyanate to latex beads in different proportions so that up to D. Acridine orange and rhodamine 100 combinations can be discriminated by the optics. Molecular diagnostics/Apply principles of special This allows 100 different markers to be measured in procedures/Flow cytometry/1 the same sample simultaneously. Flow cytometry is used to measure specific plasma proteins and antibodies using fluorescent antibody–coated beads. Tyroid cancer of the gene is involved, giving rise to a 210 dalton Molecular/Apply principles of special laboratory chimeric protein. The absorbance ratio 260:280 was essential thrombocythemia that occurs at disease 1. An absorbance maximum for protein is 280 nm owing to the phenolic rings of tyrosine and tryptophan. Next generation sequencing has made Molecular/Select method/Gene mutation testing/3 clinical applications affordable. Identifying malignant ovarian masses added a laser determines its emission and the base is D. The blocking group and fluorescent dye Molecular/Apply principles of special laboratory are removed and the process repeated for the next procedures/Proteomics/2 base added. A Molecular/Apply principles of special laboratory commercially available test based on proteomics is procedures/Genetic testing/2 available for differentiating malignant from benign ovarian tumors. The test detects the presence of five proteins in serum linked to ovarian cancer, and uses multivariate statistical analysis to derive a number from 1–10 indicating the risk of cancer. A level of maternal contamination below 1% does not guarantee accuracy, but misinterpretation due to maternal contamination is unlikely. Negative genetic tests can be reported, but positive results should be confirmed using cultured cells. K-Ras is used to identify the tissue of origin cancers including colorectal, lung, and pancreatic cancer. A comparison of methods for the determination Answers to Questions 1–3 of alkaline phosphatase is categorized in which domain of educational objectives? B The affective domain of educational objectives Education and management/Apply knowledge of includes those that emphasize values, attitudes, and educational methodology/1 interests that attach a worth to an activity, situation, or phenomenon. Competency examinations use questions of known difficulty and Education and management/Apply knowledge of can be calibrated against established criteria in order educational methodology/1 to evaluate the examinee’s performance. Accuracy of a test Education and management/Apply knowledge of educational testing/1 523 524 Chapter 9 | Education and Management 4. When dealing with the instruction of complex to medical laboratory science students. Te instrumentation, a demonstration by the highest grade was an 85% and the lowest grade instructor is necessary and should include the was a 60%. A quiz as soon as the demonstration is complete educational testing/2 Education and management/Apply knowledge of educational methodology/1 5. A stated competency requirement for a medical laboratory science student is to perform Answers to Questions 4–8 calibration, plot data, and evaluate the acceptability of controls. C This type of test compares the students to each requirement encompasses which educational other rather than grading the students on a set of objective? All of these options of analysis to plot the standards, construct a best-fit calibration line, and determine the Education and management/Apply knowledge of concentration of the controls. The affective educational methodology/3 domain describes the student’s ability to value 6. A chemistry test result from a chemotherapy the results as acceptable or to repeat the patient was within normal limits on Tuesday. B The technologist chose to investigate the situation Monday (“flagged” high and approaching a in order to resolve a discrepancy. Te technologist performing the valuing, and characterization refer to the affective test noted a delta-check error and remembered domain in dealing with the problem presented here. C When a demonstration of a complex instrument is educational methodology/3 necessary, a small group of students should be 7. In general, academic evaluation of students assembled around the instrument to permit clear depends on the ability of the instructor to create a visibility. A diagram with the major functioning test that reflects the stated objectives of the course parts should be provided, along with an assignment material as well as making the test: of a written summary or questions about the A. Written and oral Education and management/Apply knowledge of educational testing/1 Chapter 9 | Education and Management 525 9. Herzberg’s theory relies on motivators that are of students a topic to discuss or a problem to solve part of the job design in order to instill job rather than a formal lecture by the instructor. Tese same motivators can become Each participant is given a portion of the topic dissatisfiers if they are lacking in a job. Tis method of learning is motivators are: popular and used easily with which of the A. Histogram evaluation diminishes Education and management/Apply knowledge of Education and management/Apply knowledge of educational methodology/2 management theory/1 10. An instructor of medical laboratory science was Answers to Questions 9–13 given the task of expanding the curriculum for the senior (baccalaureate degree) medical laboratory 9. Which of the following subjects in problem solving and to utilize the input of all should be included in the curriculum? C The ever-changing role of the medical laboratory scientist in a clinical laboratory prompts the Education and management/Education/Apply curriculum committee to re-evaluate the courses knowledge of entry level skills/1 required by the students on a yearly basis. Respect for the worker and acknowledgment of management in which the employee is his/her ability to perform a task considered a valuable asset. Maslow’s theory of management is based upon: ascending order, are physiological, safety, security, A. Te premise that all workers are unmotivated social, esteem, and self-actualization. A According to Frederick Herzberg, achievement, happy opportunity for advancement, recognition, D. Te professional development of the employee challenging work, responsibility, and a chance for advancement and personal growth are motivators Education and management/Apply knowledge of and should be included as part of a job design. Te laboratory is undergoing a renovation listed, the four core processes for all managers are D. Employees jointly agree to institutional goals planning, organizing, directing, and controlling. Education and management/Apply knowledge of Planning includes formulating of goals and management theory/2 objectives, organizing the tasks, and establishing schedules. Te four essential functions of a manager are: communication, relationships, job descriptions, and A. Directing, leading, forecasting, implementing steps and stages of the plan, including coordination C.

The full enumeration of the total costs needs to be synthesized with the consequences or outcomes of the intervention (i generic 40 mg levitra extra dosage amex. Adoption of newer technologies needs to be based on formal evaluation of whether the additional health benefit (effectiveness) is worth the additional cost discount levitra extra dosage 40 mg on-line. Unintended consequences cheap levitra extra dosage 60mg otc, both positive and negative cheap 60 mg levitra extra dosage mastercard, were found across many of the studies as main endpoints, or were alluded to in others. A tracking system of major and clinically important unintended consequences would be useful for many audiences and should be considered by system developers and funding agencies. Clinicians, administrators, and likely patients and their families have different values and place varying importance on each. Both facilitators and barriers exist that impact movement to implementation of e-Prescribing and two-way communication designed to enhance and streamline prescription optimization. Although we tried to be thorough in our search methods, we feel that we did not capture all potential articles—a very difficult task in new and multidisciplinary areas of study. Further, we concentrated only on the main or major endpoints reported in studies with comparison groups and hypothesis testing. Given the heterogeneity in the literature, it was often difficult to discern main endpoints; where possible we determined main endpoints as those declared as such, or those that were the basis of power calculations (infrequently), or were stated to be main outcome measures in the abstract or objectives. In these cases we gave priority to outcomes related to medication management and clinically important patient outcomes. It has proven difficult to synthesize the evidence on such a range of technologies, implemented in a number of settings and used by various stakeholders. Each intervention is so complex that it is often difficult to tell which studies are assessing the same processes. For example, similar outcomes such as prescribing changes were measured as changes in daily doses; prescribing rates per hospital, per physician, per 1,000 patient days, etc. The number of orders and compliance rates were difficult to extract and synthesize. Our ability to draw conclusions is also reliant on the quality of the evidence we have found. Only a small minority of these studies focus on clinical outcomes—the endpoints that are most important to guide decisions by patients, providers and policymakers, about adopting these interventions. A large number of studies neglected to report the study dates 106 (see Evidence Tables in Appendix C). Although the absence of a contemporaneous comparable control group is a problem with all observational studies, the creation of control groups by comparing intervention patients to those that do not participate, or do not have a problem to those that do is fundamentally far more likely 18 to introduce major bias in the comparison (e. Many observational studies suffered from selecting an outcome that was distantly or only marginally related to the intervention. Moreover, in a substantial proportion of negative studies, minimal adoption was seen. The clinicians failed to adjust therapy or treatment based on recommendations, and thus it is not very surprising to find that the interventions had no effect on outcomes. Finally, the rate of some outcomes such as readmission, mortality, and nosocomial infections was too low to detect clinically meaningful differences if they had existed with the numbers involved in the study. We searched for literature across many domains and reviewed a substantial number of studies. The implications of the report fall within the purview of future research, policy, and evaluation. Certainly the burden of evidence is towards positive effects on process changes and measures of satisfaction and perceived benefits among users. These early indications are logical precursors to changes in demonstrated effects in benefits such as quality of care and clinical outcomes, economic benefits, or both as the technologies advance and mature. A lack of proven effectiveness in improving patient outcomes and a lack of studies on value and cost-effectiveness still exist. Currently, most systems are in their infancy and need to be continued to be scrutinized for effectiveness and safety. This effectiveness information is essential for policymakers who are allocating scarce health care resources which have multiple competing priorities. Clinicians, researchers, policy advisors, and health administrators should be prepared for a major investment of time and resources for implementation and use. They need to consider direct and indirect effects on health care processes such as altered work flows, adverse patient outcomes, and indirect costs. Administrators will be able to plan for implementation better using the quantitative and qualitative findings and results. Researchers should be aware of quality and reporting issues related to research methods as described in this review, as well as the need for research teams to include expertise or consultation from all clinician groups affected by the technology, informaticians, and those with research skills in a wide range of methodologies (research synthesis, complex interventions, pragmatic trials, usability studies, statistical planning and analysis, health technology assessment methods, and knowledge translation skills). The meaningful use objectives should also be deployed in all projects and implementations. Research funders can direct their programs and reinforce use of standard definitions, reporting standards, and meaningful use objectives. They can also encourage multicenter trials and those that have potential for broad applicability. At the same time, incremental studies which show the transferability and reproducibility of findings from one study to other health care settings, systems (vendors), and health care issues (type of disease or patient and setting) should also be encouraged. Effective medication management is important for many people and costly for individuals and society. Medications themselves are changing and becoming more complex with the emergence of new drugs and the integration of health information and genomics research to set the stage for individualized health care. As the population ages, we start to rely more on medications, and polypharmacy becomes standard. Future research should be conducted in those areas we have identified that can build on the existing evidence, address the gaps that have become evident, and to support trends that can improve the quality, efficiency, and cost of health care. Issues of consideration and/or further exploration in future research Research Methods: • Research studies with control groups, statistically appropriate comparisons, and sufficient power and funding to produce unequivocal answers. Most studies seem to focus within a single organization using the same system and often done by those who built or developed the application. Multicenter studies can be supported, including involvement of centers that use different systems. A single study can yield valuable information about the system deployed as well as the organizational culture around the acceptance and use of the system, but understanding and enabling of generalizabilty or applicability and interoperability are more likely to occur with multicenter studies. Tool kits, training sessions, and encouragement to publish usability studies are important steps towards improved usability testing and transfer of knowledge rated to the findings of these usability studies. Issues of consideration and/or further exploration in future research (continued) Research Needs: • Studies for order communication, dispensing and administering phases, and related aspects of medication management such as post-professional and professional education, electronic medication reconciliation, and health information exchange methods and standards. Special consideration needs to be given to adherence to accepted research methods and newer research methods such as cluster randomization. Studies must include multiple stakeholders: clinicians, other health care providers, patients, caregivers, administrators, vendors, computer programmers, etc. The prescribing and monitoring phases have a strong base of studies and systematic reviews. For this report we provide the numbers of studies and research methods used (Table 29). In addition, we used the bibliographies and summaries from more than 100 systematic and narrative review articles for this report. We need well-designed research studies with control groups and appropriate analysis. This is shown by the low quality scores, most of which were in the range of four to five out of nine points. Many authors did not test or adjust for clustering so that complex analyses could be accomplished appropriately. We also identified problems with poor application of methods in most other research studies. Training informaticians in research methodology and statistical methods is crucial. National Library of Medicine and other institutions are graduating health informaticians. Adult ambulatory care clinics were also well-represented in the literature, although studies of errors and error prevention have not been done. Additional studies are especially needed in the nursing home setting, where some 1. Other long-term care settings such as assisted living and home-based primary care also need more research. Studies conducted in pediatric hospitals are warranted because these patients are particularly vulnerable to medication errors and those medication errors that do occur have three times the 847 potential to cause harm. Community pharmacies and the newer mail-order and online pharmacy services were not studied. Our data suggest that interventions that focused on laboratory-based medication monitoring (22 of 29 studies) were associated with the most number of interventions, and showed statistically significant changes in at least half of its main endpoints. Mental health professionals and other health care workers who prescribe, including dentists, are studied even less than nurses and pharmacists. The move to patient- centered care and chronic disease management also make the study of patients and their informal caregivers an important area for research and development. Medical Research Council provides a framework for individuals to consider when planning complex intervention projects (http://www. Classical evaluation and research methods dictate that what is being evaluated needs to be stable over the time period of the study. This makes research harder to do and provides barriers to the most common government-based funding sources. Another challenge to research methods is that often the existing evaluations have been done by system developers or implementers. Some evidence exists that evaluation of one’s own system contributes to biases towards the system being found to be 725 positive. In some cases, issues such as rage against the machine, guilt, embarrassment associated with reminders and alerts, and frustration have been reported. More of these studies of the effects of these technologies on people, clinicians, and individuals need to be done in various settings and with all technologies. Workflow and communication are ideally studied using qualitative and mixed methods. We could not find an agreed upon definition and used one from Australia: “the ability of a health service to provide ongoing access to appropriate quality care in a cost effective and health-effective manner. Once this is established, research needs to be done to identify our current “sustained” systems and determine the factors that are associated with them. Qualitative and quantitative studies are essential and they need to be done by people with strong content and methods background and sufficient financial backing. Standards are necessary for interoperability and smooth functioning of existing systems and large scale integration of data at State and national levels. Leadership, probably more than research efforts, continues to be needed in this domain.

One of the biggest and most helpful questions that you can ask yourself when you’re stressed is simply buy cheap levitra extra dosage 60 mg on-line, “Is this true? It’s a reasonable course of action to examine and fact-check the story that you’re trying to tell yourself while the stressful event is actually happening discount 40mg levitra extra dosage with visa. You’ll usually find that you’ve made a lot of assumptions generic 60 mg levitra extra dosage otc, quite a few jumping to conclusions order levitra extra dosage 60mg free shipping, some catastrophizing (i. However, the stories you tell yourself are your own relative personal truths and they reflect your unique perception of the world. As I mentioned before, another individual 28 • Mindfulness Medication might look at a similar situation and see something completely opposite about it. When it snows, one person might be happy as it means they can ski, while his or her neighbor is stressed because that person has to shovel the driveway. For now, simply allow yourself to be open to the reality that your stories are true for you only and there is more than one way to look at any situation. Consider the following topics and see what beliefs or stories come up when you think of them. Briefly examine your beliefs about politics, homosexuality, abortion and religion. How you look at marriage, work, or finances, is shaped by your belief system and the stories it generates. These in turn, are all influenced by the belief systems that you were exposed to by your parents, relatives, friends and caregivers. You may also have been exposed to belief systems through various media, in your school, in your workplace, as well as in society in general. You adopted bits and pieces of these belief systems and subsequently shaped what was to become your own unique belief system. Most of what comprises your belief system originated in your childhood and came to you via your parents or caregivers. Can you think of a belief that you hold that came to you through your parent(s)/caregivers? Think about whether your own experiences, your friends, or society may have also influenced this belief. Your beliefs are likely shaped, in part, by all of these inputs but most of the groundwork was The Origin of Thoughts • 29 laid when you were very young. Your stories and beliefs are further influenced by habits, contexts, and experiences. You’re constantly shaping your belief system in response to what goes on both around you and in the arena of your mind. Your childhood is a key component in understanding how you created the belief system that leads to your stories. You initially created a belief system early on in your childhood, which was modeled predominantly on your parents’, or caregivers’ ideas. Children adopt their parents’ standards and beliefs in an attempt to deal with the need for safety and love, as well as an understandable fear of abandonment. If they are “good children” by acting in a way such that their parents would approve, then they feel safer and accepted. Remember, that as a child you internalized much of your own parents’ or caregivers’ belief systems. Subsequently, your exposure to friends, extended family, media, society and religious attitudes also worked to shape your belief system. Genetics also contribute to a child’s personality traits and how he or she responds to the world. A child’s personality may be naturally inclined to be open, closed, friendly, suspicious, frightened or exploring. When an internal or external sensation is received, the mind compares it to the internalized belief system and memories of prior exposures to similar sensations. The sensation is rapidly labeled as pleasant, unpleasant, or neutral depending on whether or not it meets the child’s need to feel safe and loved. They arise in response to your belief system whose patterns of thought have likely been in place since your childhood. By adulthood, these stories and their underlying patterns can sometimes do more harm than good by distancing you from the reality of the experience itself. A lot of the really scary things that your stories have to say are simply not true and never come to pass. If you can teach yourself to recognize that fact in the middle of a stressful event, you’ll be in a better position to act instead of simply reacting. Practice In the last chapter you practiced observing your thoughts on a daily basis and in response to a predetermined daily cue. Try to identify the original thought that came into your mind and then see if you can recognize the story that came after. Try to identify the original thought that came into your mind and then make a note of the story that came after. Whenever you go outside, try to really experience the sensations of nature such as the wind blowing, the sound of thunder, or the feel of the rain. Listen to the sounds around you such as traffic, construction noise, voices, or bird song. Then try to refocus on the pure sensation that you’re experiencing and enjoy it for what it is. Sit in a park, or mall, or wherever people pass by and simply observe the story your mind tells about each passing The Origin of Thoughts • 31 individual. Even though you don’t know these people, your mind has created a judgment about them. You’re teaching yourself to recognize your belief system in action and that’s always the first step in de-stressing. There are many human emotions but the five most universally recognized are happiness, sadness, fear, anger and disgust. These sensations consist of things you see, hear, taste, touch, smell, as well as think. Your brain receives these sensations, identifies them and then decides whether or not they are important to your survival. These labels help to inform you as to whether what you are experiencing is perceived to be beneficial, or detrimental, based on your established belief system. You’re probably beginning to see how powerful your mind is as it creates the constant array of emotions that you experience throughout the day. Your important take-away from this is simply that your feelings are a consequence of your thoughts! When an emotion arises simply note it in your mind, for example, sadness, anger, happiness, etc. When you notice that you’re feeling a certain emotion, see if you can figure out what the original thought, or sensation, was that produced the emotion. Then trace the sequence of reactive thoughts that lead to the development of the emotion. Summary • Emotions are labels that your brain places on thoughts and physical sensations, to tell you whether what’s being experienced is perceived to be helpful or harmful to your existence. I want you to feel the Iitches, the squeezes or cramps, all the sensations of pressure, the fluttering or burning sensations. H Your body is alive with activity and there are always multiple sensations that are occurring without you even being aware of them. When you bring your awareness to your body, you can quickly appreciate the constant physical activity that is present. Normally your brain receives these many superficial and perfectly normal physical sensations and in effect, filters them out so that they don’t reach your conscious awareness. However, there are some individuals, like my patient Larry for example, whose filtering mechanisms are not as effective, or who have a heightened awareness of normal or mildly abnormal sensations and may be extra-aware of them on a regular basis. Completely normal sensations encourage Larry to believe that there is something physically wrong with 35 36 • Mindfulness Medication him. His interpretation of these normal sensations, in other words, the story he tells himself in response to these sensations, gives rise to the emotion of anxiety. The anxiety in turn, encourages Larry to focus even more on the physical sensations, thereby providing additional causes for concern. Larry often gets caught in this loop of his own making without even knowing it, but the end result is genuine physical harm resulting from the ongoing stress and anxiety. As I mentioned earlier, my patient Mika has Irritable Bowel Syndrome, which is a functional gastrointestinal disorder. In response to the abdominal pain, Mika believed that she had bowel cancer at first, which is another example of thinking of the worst possible outcome! Naturally, her stress levels went through the roof in response to this thought, which then further aggravated her condition. When she finally came in to see me she was quite convinced that she was on her deathbed and it took a lot of reassurance to persuade her that she was not. Frequently, people with chest pain may believe that they’re having a heart attack. They usually experience sensations through the filters of their own reactive stories and emotions. These stories and their accompanying emotions can be more painful than the original physical sensation itself! Close your eyes and focus on the physical sensations arising in your body H once again. This time, see if there are any stories emerging about, or from, the sensations that you’re experiencing. Are there any thoughts of anxiety, curiosity or concern that develop because of the sensations? The Physical Consequences of Thought • 37 Can you recall any previous events where you had some troubling concerns over a physical sensation that you were experiencing? So now you’ve seen that physical sensations can trigger your own story production line to kick into gear, which can then trigger your emotions. Now I’d like to re-examine the idea, presented in chapter one, that your body also responds to thoughts and emotions by producing physical sensations. Hans Selyé, a pioneering researcher in the field of biological stress, was instrumental in defining something he called the “stress response. Your body responds to a perceived threat by initiating a series of physiological events that researchers call an alarm reaction. This is your body’s first step in dealing with something that your mind tells you is dangerous. Your brain activates a specific branch of your nervous system, called the sympathetic nervous system, which in turn causes your hypothalamus and pituitary glands to release certain substances. Both adrenalin and cortisol race through your body to prepare you to either fight or run away. This “fight or flight response” results in your heart beating faster, your blood vessels constricting causing your blood pressure to go up, your lungs expanding, your pupils dilating, and your muscles energizing. However, with chronic stress, that is to say if you think the danger never seems to go away and there is always one threat or another, your body enters a Stage of Resistance. Your body starts to adapt to the chronic stress by increasing the production of several hormones such as cortisol, growth hormone, aldosterone and thyroid hormone.

Elliott buy discount levitra extra dosage 60mg on-line, Evidence of natural occurrence of the banned antibiotic chloramphenicol in herbs and grass quality levitra extra dosage 40mg, Anal buy generic levitra extra dosage 40mg on line. Hoffman cheap levitra extra dosage 40 mg free shipping, Determination of chloramphenicol in animal tissues and urine: Liquid chromatography-tandem mass spectrometry versus gas chromatography- mass spectrometry, Anal. Blanca, Determination of chloramphenicol residues in shrimps by liquid chromatography-mass spectrometry, J. Stadler, Determination of the antibiotic chloramphenicol in meat and seafood products by liquid chromatography-electrospray ionization tandem mass spectrometry, J. Meyer-Lehnert, Reversed-Phase Liquid Chromatographic Separation of Enantiomeric and Diastereomeric Bases Related to Chloramphenicol and Thiamphenicol, J. Zhang, Study of chiral separation of chloramphenicol analogs by high performance liquid chromatography, Chinese J. 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Sorensen, Detection of oxytetracycline production by Streptomyces rimosus in soil microcosms by combining whole-cell biomarkers and flow cytometry, Appl. Stolker, Uptake of oxytetracycline, sulfamethoxazole and ketoconazole from fertilised soils by plants, Food Addit. Nomiyama, Plant uptake of pharmaceutical chemicals detected in recycled organic manure and reclaimed wastewater, J. Van Poucke, Can the use of coccidiostats in poultry breeding lead to residues in vegetables? Luo, Occurrence and source analysis of typical veterinary antibiotics in manure, soil, vegetables and groundwater from organic vegetable bases, northern China, Environ. Nielen, Quantitative trace analysis of eight chloramphenicol isomers in urine by chiral liquid chromatography coupled to tandem mass spectrometry, J. Vining, Nitrogen metabolism and chloramphenicol production in Streptomyces venezuelae, Can. Ghaly, A dehydrogenase activity test for monitoring the growth of Streptomyces venezuelae in a nutrient rich medium, J. Veltkamp, Growth and ultrastructure of Streptomyces venezuelae during chloramphenicol production, Microbios 16 (1976) 191-199. Westlake, Nutritional requirements for chloramphenicol biosynthesis in Streptomyces venezuelae, Can. Stolker, Newly identified degradation products of ceftiofur and cephapirin impact the analytical approach for quantitative analysis of kidney, J. Nielen, Assessment of liquid chromatography-tandem mass spectrometry approaches for the analysis of ceftiofur metabolites in poultry muscle, Food Add. Nielen, Comprehensive analysis of ß-lactam antibiotics including penicillins, cephalosporins and carbapenems in poultry muscle using liquid chromatography coupled to tandem mass spectrometry, Anal. General introduction on ß-lactam antibiotic analysis ß-lactam antibiotics ß-lactams are highly effective antibiotics in the treatment of bacterial infections [1]. The ß-lactam antibiotics consist of several groups of which the penicillins, cephalosporins and carbapenems are the most important due to their activity and the number of compounds included. The penicillins derive their activity from the 6-aminopenicillinic acid nucleus which is effective against mainly Gram positive bacteria [1,3,4]. Amoxicillin, ampicillin, penicillin G (benzylpenicillin), penicillin V (phenoxymethylpenicillin), cloxacillin, dicloxacillin, oxacillin and nafcillin (figure 5. The six membered dihydrothiazine ring fused with a four membered ß-lactam ring (figure 5. Cephalosporins are highly effective antibiotics in the treatment of bacterial infections of the respiratory tract [10]. As for the penicillins, many semi-synthetic cephalosporins were developed and in this four generations are distinguished based upon their time of discovery and their range of activity [11]. Cefacetril, cefalonium, st cefazolin, cefalexin and cefapirin (all 1 generation), cefoperazone and ceftiofur rd th (3 generation), and cefquinome (4 generation) are all approved for treatment of mastitis infections in dairy cattle. Cefazolin is approved for the treatment of other ruminants (sheep and goat) as well. Furthermore, cefalexin and cefapirin are approved for the treatment of respiratory disease and foot rot in cattle, cefquinome is approved for the treatment of cattle, swine and horses, and ceftiofur for all food producing mammals [6,11]. The carbapenems are structurally very similar to the penicillins: the sulfur atom has been replaced with a carbon atom and an unsaturation has been introduced (figure 5. As a result the carbapenems possess the broadest antimicrobial activity amongst the ß-lactams [13]. The most common carbapenems are imipenem, meropenem, ertapenem, doripenem and biapenem. The carbapenems are not registered for use in food-producing animals and are used off-label in companion animals [4]. Molecular structure of the carbapenems: meropenem, imipenem, ertapenem, doripenem and biapenem and the penem faropenem. Cephalosporins are more effective and, therefore, in 2007 they were assigned as critically important antimicrobials for human health [23]. Even though these compounds should only be used sparingly, resistance towards cephalosporins is emerging [1,16-18,22,24-29]. As a result, due to the rising resistance to cephalosporins, carbapenem use has increased in the treatment of humans [30]. Not only the antibiotic usage in humans contributes to rising bacterial resistance, also the regular use of antibiotics in veterinary practice contributes to the occurrence of resistant bacteria that can be transferred from animals to humans [32]. Furthermore, due to irresponsible or off-label use of antibiotics in veterinary practice, residues of these antibiotics can end up in the human food chain which contributes to increasing bacterial resistance as well [33]. Penicillins are the most frequently sold antibiotics for treatment of broilers [34] and even though cephalosporins and carbapenems are not registered for use in animal production, due to their high effectiveness their veterinary use, including broilers, cannot be ruled out. To prevent off-label use of ß-lactams in animal breeding and thus to limit the dissemination of bacterial resistance, an effective control strategy for ß-lactam usage in food-producing animals is needed including penicillins, cephalosporins and carbapenems. However, off-label use of cephalosporins should be restricted because of the risk of the development of bacterial resistance. Therefore the use of cephalosporins should be monitored and thus detection of these compounds at levels as low as reasonably possible is mandatory. Ceftiofur and cefapirin are known to rapidly metabolise after intramuscular administration. Based on the results a new approach was developed for the analysis of the total residue levels of ceftiofur and cefapirin in kidney. To study the applicability of this new method it was compared to routinely applied methods for the analysis of ceftiofur in poultry tissues. Other ß-lactam antibiotics were included in the newly developed procedure which resulted, after some alterations of the method, in a multi-ß-lactam method that includes penicillins, cephalosporins and carbapenems. Newly identified degradation products of ceftiofur and cefapirin impact the analytical approach for the quantitative analysis of kidney Abstract This section describes the research on the degradation of ceftiofur and cefapirin at physiological temperatures in kidney extract and in alkaline and acidic solution, conditions that regularly occur during sample preparation. A slight instability of cefapirin and desfuroylceftiofur was observed at elevated temperatures. Ceftiofur and cefapirin degraded immediately and completely in an alkaline environment, resulting in inactive degradation products. Ceftiofur and cefapirin also degraded immediately and completely in kidney extract resulting in both formerly reported metabolites as well as not previously reported products. Our research shows that conditions often occurring during the analysis of ceftiofur or cefapirin result in rapid degradation of both compounds. From this it is concluded that underestimation of the determined amounts of ceftiofur and cefapirin is likely to occur when using conventional methods for the quantitative analysis of these compounds in tissue. Therefore, a new approach is needed for the analysis of both compounds including their degradation products. Because cephalosporins are highly effective antibiotics in the treatment of bacterial infections of the respiratory tract [10], the common use of cephalosporins in veterinary practice is expected. An effective monitoring of 202 Chapter 5 cephalosporin use in animal breeding is mandatory to prevent excessive use, which will contribute to the emergence of bacterial resistance. In monitoring food products, it is not clear that all relevant metabolites and degradation products, such as those produced by the degradation of ceftiofur and cefapirin during sample preparation, are taken into account when current methods are used to test for ceftiofur and cefapirin in tissue samples. The main causes of such degradation can be (1) the use of elevated temperatures, (2) the presence of tissue extract [43] and (3) an acidic or alkaline environment [44]. If degradation caused by these three aspects is not taken into account it is possible that ceftiofur and cefapirin residues are underestimated. Ceftiofur and cefapirin are known to rapidly metabolise after intramuscular administration. Cephalosporin multi-methods that include both ceftiofur and cefapirin are lacking, although methods to detect cetiofur and cefapirin in tissue separately or in combination with a limited number of other cephalospirins have been reported [35,43,45-47]. This method is not very robust so the procedure has to be closely followed to obtain good results and it is limited to the analysis of a few cephalosporins and thus unsuitable as a multi-method. The degradation processes possibly occurring after this time are not taken into account. Accurate mass determination and calculated elemental composition data can be used for structure elucidation. The new identified products indicate that currently applied methods are likely to underestimate the residue levels of ceftiofur and cefapirin found in kidney samples. Furthermore, this research resulted in a new approach for the quantitative analysis of ceftiofur, cefapirin and other cephalosporins in tissue. Preparation of kidney extract A blank bovine kidney sample was defrosted and homogenised at room temperature, after which 5 g was transferred to a 50 mL test tube. The gradient (mobile phase A, 0,05 % ammonia in water, pH adjusted to 8 with acetic acid; mobile phase B, 0. The instrument was operated in the positive W-mode (resolution ≥ 10,000) and was calibrated spanning a range of 90 to 1050 using a solution of sodium formate in 2- propanol to obtain a mass error below 5 ppm.

The study was stopped primarily due to 2 false-positive alert types: Misidentificatio n of medications as contraindicated in pregnancy by the pharmacy information system and misidentificatio n of pregnancy related to delayed transfer of diagnosis information buy 60 mg levitra extra dosage. Study Start: There were no 03/2004 significant Study End: differences in 09/2006 time (in days) from alert to lab test (2 buy cheap levitra extra dosage 60mg line. During the intervention period buy levitra extra dosage 40 mg with visa, the rate for computerized group was higher than the control (36% vs buy levitra extra dosage 40 mg free shipping. Rate of compliance with insulin dose advice was higher in period 2 than 1, and then decreased significantly in period 3 (56% vs. During the intervention period the rate for computerized group was higher than the control (64% vs. Total adherence was higher with diagnoses for which an antibiotic was not indicated (84. However Study Start: the vaccination 00/1995 rate for the Study End: same time 07/2001 period for tetanus vaccine was 100% vs. Physicians in the intervention group prescribed vancomycin for 36% fewer days than physicians in the control group (26. The number of days of vancomycin per course of treatment was also lower for the physicians in the intervention group, mean of 1. Design: Cross- spreadsheets sectional indicated a N = 1,941 relative risk prescriptions reduction of Implementation: 42% (20% vs. We found no evidence of a decrease in use of nonpreferred agents for nonelderly patients. There was an upward, though non­ significant trend in the use of preferred agents in elderly patients following the intervention (p = 0. When test (for alert that was alert was for an triggered for a missing abnormal laboratory test) laboratory value, percentage of times medication order triggered but was not completed increased from 5. The largest effect was noticed when the alert was triggered for a missing laboratory test, the percentage of times the provider ordered the rule-associated laboratory test increased from 43. The rate of discontinuation of inappropriate drugs per 1,000 was not different: 67. There Study End: was no 00/0000 statistically significant difference between the intervention and control group in the proportion of patients who had increases in therapy (28. N = 2,484 patient paper users For the visits computer Implementation: users, 07/1996 compliance Study Start: rates steadily 10/1995 increased year Study End: 2 to year 3 to 01/1998 year 4 (38. The results demonstrated close to 100% compliance with charting of cumulative dose of isotretinoin, pregnancy testing, liver function and lipid profile tests. The results sustained for more than 2 years from January 2005 to June 2007 [no analysis given past 1 year]. Study 2: Variability in standard deviation dosages across medications reduced by 11% following implementation of the dosage guidance application (p <0. Standard deviation of frequency of administration reduced by 30% post- implementation (p <0. The proportion of medications that were potentially inappropriate was also reduced, from 5. Secondary Outcome: When analyzed as a percentage of all medications prescribed by physician subjects, the proportion of medications that were potentially inappropriate was significantly reduced, from 5. There were significantly greater reductions in March 2005 for psychiatrists who had higher percentages of their caseloads on two or more concurrent antipsychotics in January 2004. The overall percentage of patients on 2 or more antipsychotics dropped significantly (54% vs. This decrease in rate was not statistically different from the rate observed in the first period (p = 0. The differences are maintained when hospital teaching status and ownership and number of beds are taken into account. Therefore, the 00/0000 mean time required to review an order was Study Start: 06/2002 increased by 5. Study End: 06/2006 system Turnaround time between drug ordering and administration decreased from 90 minutes to 11 minutes, no stats given. Clinicians who received pharmacists patients * The total rate the prompts had a higher rate of intervening Implementation: of pharmacist with patients overall (1. When the prompts were stopped the rate of aspirin interventions fell to pre-prompt levels. The administrations in Academic benefit was related to a reduction 92 patients associated with errors of wrong Implementation: administration time. The rate of Implementation: pharmacist interventions declined 06/2003 significantly after implementation (3. Total 00/0000 pharmacy time taken on study ward Study End: increased after implementation (1h 8min 00/0000 vs. Turnaround time Study Start: based, between drug ordering and administration 02/2002 Academic decreased from 90 minuets to 11 minutes, Study End: no stats given. Only Study End: minor errors were reduced with the 12/2002 system C-124 Evidence Table 4. The proportion of time Study Start: nurses spent on direct care activities 02/2005 unrelated to medication administration Study End: remained statistically unchanged (20. The overall administration transcription error incidence of medication doses directly Implementation: (2ndary outcome) observed to be administered either early 04/2005 or late decreased from 16. The Implementation: actual and scheduled mean time deviation between actual and 00/0000 administration times*, scheduled administration times did not Study Start: change significantly postimplementation 05/1997 (130 minutes vs. Overall, administration mistakes, 09/2004 pharmacy problems and prescribing Study End: problems accounted for 74% of all 04/2006 variances observed. In addition, after System therapy (days)*, the average duration of therapy was N = 87 patients Integrated Combination- decreased from 10. Combination­ 00/0000 system, Pharmacy escalation rate*, Mean Antimicrobial de-escalation rates were not Study Start: duration of statistically improved upon (67% vs. The average duration of Study End: Antimicrobial therapy therapy was decreased from 12. There was a large effect for Study Start: treatment; treatment of pneumococcal vaccination (12. Study End: warfarin, aspirin or adherence was significantly improved for 06/1996 ticlopidine; treatment of 13 standards (53. There were non significant Implementation: perioperative changes in the proportion of patients 00/0000 antibiotics, proportion of receiving perioperative antibiotics (64% Study Start: patients receiving vs. Supplementation of Mg at 00/0000 hypomagnesemia 1 hour was significantly improved, but not Study Start: treatment guidelines ­ at 24 hrs. Supplementation of K was not 02/2001 synchronous alerts*, improved at 1 or 24 hrs. Synchronous Study End: compliance with alerts resulted in improved compliance at 03/2002 hypokalemia and 1 hr and 24 hrs for bot K and Mg hypomagnesemia supplementation (p <0. The results showed that overall Implementation: positive trends were minimally more 00/0000 prominent in the intervention arm (59. In the control group, Implementation: physicians spontaneously instituted the 00/0000 treatment that would have been Study Start: recommended in 17% of instances in 00/0000 which the recommendation was triggered Study End: but not issued. This 42% relative 00/0000 difference in compliance was statistically significant (p = 0. Sudden increase occurred Implementation: immediately after the start of the 09/1994 intervention (p <0. Other prescribing (3 drugs or drug classes and 4 age groups) did not differ across groups. In the control (prescriptions) group, baseline labs were requested for Implementation: 771 (39%) of the medications. In the 00/2000 intervention group, baseline labs were Study Start: ordered by clinicians in 689 (41%) of the 07/2003 cases. Recommendations for Implementation: regimens* changes to therapeutic regimens were 00/0000 followed in 28% of study events Study Start: compared to 13% of control events 00/0000 (p <0. N = 265 patients system, Pharmacy Inpatient hospital medications with Implementation: based cisapride* 01/1996 Study Start: 00/0000 Study End: 00/0000 C-137 Evidence Table 5. Significant randomized) differences between study and control Implementation: physicians also appear in 24 hour 00/0000 compliance (50. In cases in which a statistically significant difference was demonstrated, improved compliance favored the intervention group 71. Study Start: inhibitor started* 03/2004 Study End: 09/2006 C-140 Evidence Table 5. During the Study Start: intervention period the rate for 00/0000 computerized group was higher than the Study End: control (36% vs. During the intervention period the rate for computerized group was higher than the control (64% vs. Beta- N = 30 clinicians Change in diabetic blocker prescribed or contraindication Implementation: therapy if A1c > 7. Coronary artery disease reminders resulted in the recommended action for overdue items in 22% in the intervention group vs. Implementation: system duplication Resolution of discrepancies in frequency 00/0000 discrepancies* improved by 65% with the tool (18% vs. Total 00/0000 after discharge number of drugs reported by patients on Study Start: admission was 38% and 29% for paper­ 02/1998 based and electronic groups respectively. Study End: The figures on 10 days after discharge 05/1998 were 38% and 28% respectively. Frequency of Study Start: use was negatively 11/2005 associated with age Study End: (p <0. Hospital physicians found mean effort to use discharge software was more difficult than the usual care (6. The accuracy, usefulness, and consistency of checking patient identification improved as well. There Study End: were significant increases in 00/0000 each of the 3 subscales of efficacy, safety and access (p <0. Kralewski Prescribing e-Rx Ambulatory care, proportion of prescriptions Practice-level variables 244 (2008) Academic sent electronically explain most of the variance Design: Survey in the use of e-scripts by N = 93 physicians, although there physicians are significant differences in Implementation: use among specialties as 00/0000 well. General internists have Study Start: slightly lower use rates for e­ 09/2006 Rx and pediatricians have the Study End: highest rates. Larger 10/2006 practices and multispecialty practices have higher use rates, and five practice culture dimensions influence these rates; two have a negative influence and three (organizational trust, adaptive, and a business orientation) have a positive influence. Improved self- 00/0000 Inpatient hospital much and how often the reported perceptions of clear Study Start: based medications were to be instructions on what 09/2004 taken, other instructions on medications to take (p = Study End: taking the medication, 0. Healthcare provider Physician assistants and nurse practitioners reported that patients had clearer instructions on discharge (p = 0. Characteristics related Study Start: to the quality of care, such as 00/1993 reducing error or giving Study End: information, were less 00/1995 strongly correlated with overall satisfaction (r = 0. These problems human factors centered on text psychology) presentation, too much Implementation: information/too many 02/2004 decisions at one time, color Study Start: scheme (monochromatic 00/0000 blue/grey with red used as Study End: accent and not to note 00/0000 caution or problems). Groups did not differ physicians at 2 Pharmacy for use by gender, use of a hospitals.