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It is mentioned only once in Conditions of Women order genuine ponstel online spasms parvon plus,as an alternate therapy for menstrual retention (¶) cheap 250 mg ponstel overnight delivery spasms in throat. These were not simply used to di- rect odors to thevagina and womb discount ponstel 500mg spasms falling asleep, but were also a means of introducing medi- cations for menstrual retention (¶), a retained afterbirth (¶), and uterine pain (¶). The variety of fumigation pots and stools depicted in a fifteenth- century Dutch translation of the Trotula (fig. Again, the late medieval Dutch manuscripts are the only ones to offer us depictions of pessaries (fig. The late twelfth- or early thirteenth-century writer Roger de Baron gives a particu- larly well-articulated rationale for the use of pessaries: ‘‘Just as. For to the degree that the former organs are remote from the organs of nutrition and to the degree that substances coming to the bowels are weak- ened in strength in proportion to their remoteness, not only by the length of the distance [they have to travel] but also by the narrowness of the passages, to thatdegreetheyhavenoefficacy. We have seen in this extended analysis of menstrual disorders and uterine Figures  and . Depictions of fumigation pots and pessaries from a fifteenth-century Dutch translation of the Trotula. These same principles of physiology, pathology, 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. Treatments for Women takes these theoretical precepts for granted, however, rarely articulating a physiological (let alone an anatomi-  Introduction cal) basis for the malfunctions of the female reproductive organs that it enu- merates. Treatments for Women makes its theoretical allegiances clear in its open- ing sentence: ‘‘So that we might make a succinct exposition on the treatment of women, it ought to be determined which women are hot and which are cold, for which purpose we perform this test. On the theory that ‘‘contraries are cured by their contraries,’’ for a woman suffering from heat the author recommends several ‘‘cold’’ substances—roses, marsh mallows, and violets—to be placed in water and administered by means of a vaginal suffumigation. In calling these substances ‘‘cold,’’ medieval medical theory did not mean that they were neces- sarilycold to the touch but that they induced a chilling effect on the body when used as medicines. Thus, one of the leading Salernitan texts on materia medica, the Circa instans, described roses as cold in the first degree (out of a possible four) and dry in the second; mallow was cold in the second degree and moist in the second; violets were cold in the first degree and moist in the second. Likewise, women suffering from cold are to be treated with ‘‘hot’’ substances: pennyroyal (warm in the third, dry in the third), laurel leaves (warm and dry, no degree being specified), and small fleabane (warm and dry in the third). The notion of elemental properties is part of the rational if unarticulated framework of diagnosis and therapy that underlies other treatments in the text. In ¶, ‘‘phlegmatic and emaciated’’ women and men who cannot conceive because they are too cold are treated with a bath of the ‘‘hot’’ herbs juniper, catmint, pennyroyal, spurge laurel, wormwood, mugwort, hyssop, ‘‘and other Introduction  hot herbs of this kind. For uterine prolapse and induration caused by the ex- cessive size of the male member during coitus (¶), a cloth is to be anointed ‘‘with some hot oil, either pennyroyal or musk or walnut,’’ and placed in the vagina.

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Both the appetite and the sensa- r Behaviour modification including examining the tionofsatiety(fullness)areimplicated buy ponstel online pills muscle relaxant use in elderly. Centraladiposity background of the individual order generic ponstel on line spasms lower back pain, the eating behaviour (waist-to-hipratiomeasurements>0 generic 250mg ponstel visa spasms pelvic floor. Diets include hormones and nutrients: balanced low-calorie diets, low-fat diets and low- r Leptin production correlates with body fat mass; a carbohydrate diets, which are ketogenic possibly in- leptin receptor has been identified in the ventromedial ducing calcium loss and tend to be high in saturated region of the hypothalamus. Mono- 1 Sibutramine is a noradrenaline and serotonin re- amines, including noradrenaline and serotonin, also uptake inhibitor and promotes a feeling of satiety. The remaining 20% of energy expenditure is due scribed for patients aged 18–75 years who have lost to physical activity and exercise. Blood pressure, cardiovascular risk factors and viewed at 4 and 6 months to confirm that weight diabetes should all be reviewed. Its use is confined to patients with Chapter 13: Nutritional disorders 509 morbid obesity, i. Surgery is considered only if a r Children with kwashiorkor develop oedema, conceal- patient has been receiving intensive management in a ing the loss of fat and soft tissues, the hair may be specialised hospital or obesity clinic, is over 18 and all discoloured and an enlarged liver may be found. Previously jejunoileal and gastric bypass proce- Complications dures were performed, which despite being effective Malnutrition greatly increases the susceptibility to infec- were associated with significant side effects. In children it has been shown to affect brain growth banded gastroplasty either by laparoscopic surgery or and development. Often oral rehydration is safest, fol- and mortality from diabetic-related illness and cardio- lowed by nutritional replacement therapy. Nutritional replacement is gradually increased Malnutrition (including kwashiorkor until 200 kcal/kg/day. Aetiology Many countries in the developing world are on the verge Aetiology/pathophysiology of malnutrition. Drought, crop failure, severe illness and Lipids are found in dietary fat and are an important en- war often precipitate malnutrition in epidemics. The two main lipids are triglycerides and choles- Pathophysiology terol, which are found in dietary fat and may also be It is unclear why insufficient energy and protein in- synthesised in the liver and adipose tissue (see Fig. The oedema seen in kwashiorkor results from in- eride, cholesterol and apoproteins). These are then creased permeability of capillaries and low colloid on- transported to the liver where the triglyceride is re- cotic pressure (low serum albumin). Oncotic pressure moved and the remaining cholesterol-containing par- is produced by the large molecules within the blood ticle is also taken up by the liver. The end product, deplete r Adults and children with marasmus have loss of mus- of triglyceride, is termed an intermediate-density cleandsubcutaneousfatwithwrinkledoverlyingskin. Hyperlipidaemias are classified as primary and sec- Clinical features ondary (see Table 13. The clinical signs of hypercholesterolaemia are pre- Primary hyperlipidaemia is a group of inherited condi- mature corneal arcus, xanthelasmata and tendon xan- tions subdivided into those that cause hypertriglyceri- thomata. Acute pancreatitis and eruptive xanthomata daemia, hypercholesterolaemia and combined hyperlip- are features of hypertriglyceridaemia. Nutritional Obesity, anorexia nervosa, alcohol abuse disorders Drug induced High dose thiazides, corticosteroids, sex Investigations hormones Random, non-fasting plasma cholesterol is used as a Renal dysfunction Nephrotic syndrome, chronic renal failure screen in low-risk populations. Bitot’s spots, which are flecks caused by heaped up desquamated cells occur and progress to corneal xerosis, and eventually corneal clouding ul- Management ceration and scaring. Patients are at risk of secondary The management of hyperlipidaemia is based on an as- infection. Management r General measures include weight loss, lipid-lowering r Prevention of eye disease with adequate diet and diets, reduction of alcohol intake, stopping smoking supplementation in patients with disorders of fat and increasing exercise. In pregnant women, vitamin A but not r Control of hypertension is important preferably β carotene is teratogenic. Corneal transplant may be required 1 Cholesterol-lowering drugs include resins, which for irreversible corneal ulceration. Vitamin B1 (thiamine) deficiency Vitamin deficiencies See also Wernicke–Korsakoff syndrome in Chapter 7 (Nervous System; page 317) Vitamin A deficiency Definition Definition Deficiency of thiamine (vitamin B1). Deficiency of vitamin A, a fat-soluble vitamin, is a major cause of blindness in many areas of the world. Aetiology Insufficient intake of thiamine, which is present in for- Aetiology tified wheat flour (the natural thiamine is removed by Insufficient intake of carotenoids, especially β-carotene milling, so it is replaced in most countries), fortified found in carrots and dark green leafy vegetables and breakfast cereals, milk, eggs, yeast extract and fruit. Occasionally it can be seen in disorders of fat malabsorption, such as cystic fibrosis, cholestatic Pathophysiology liver disease and inflammatory bowel disease. Thiamine is an essential factor for the maintenance of the peripheral nervous system and the heart. It is also involved in glycolytic pathways, mediating carbohydrate Pathophysiology metabolism. Vitamin A is required for maintenance of mucosal sur- faces, the formation of epithelium and production of Clinical features mucus. Dry beriberi is an endemic form of polyneuritis re- Retinal function is dependent on retinol, a constituent sulting from a diet consisting of polished rice deficient of the retinal pigment rhodopsin. The neuropathy predominantly affects the 512 Chapter 13: Nutritional and metabolic disorders legs with weakness, parasthesia and loss of ankle jerks. Wet beriberi is the high output heart failure caused by thiamine deficiency resulting in Management oedema. Supplementation with nicotinic acid and treatment of other coexisting deficiencies. Erythrocyte transketolase activity and blood pyruvate Vitamin B6 (pyridoxine) deficiency are increased. Definition Deficiency of pyridoxine is rarely a primary disorder, but Management it does occur as a secondary disorder. The cardiac failure usually responds rapidly, but Aetiology neuropathies may only partially resolve if they are long- Important sources of Vitamin B6 are similar to those of standing. Deficiency may occur with malabsorp- Niacin deficiency (pellagra) tion such as coeliac disease, dietary lack in alcoholism and drug toxicity especially isoniazid. Definition Niacin (vitamin B3) has two principle forms: nicotinic Pathophysiology acid and nicotinamide. Deficiency of niacin causes pel- Pyridoxine is important in the metabolism of amino lagra. In some rare metabolic disorders, pyridoxine deficiency is as- Aetiology sociated with infantile convulsions and sideroblastic Niacin is found in plants, meat and fish. Clinical features Othercausesincludeincreasedtryptophanconsumption Marginal deficiency may cause stomatitis, glossitis, dry in the carcinoid syndrome, prolonged use of isoniazid lips, irritability and confusion. Deficiency causes men- and Hartnup disease, an autosomal recessive congenital tal confusion, glossitis, dry skin lesions and peripheral disorder with reduced absorption of tryptophan from neuropathy. Management Pathophysiology Oral replacement; however, high doses may cause Nicotinic acid is involved in energy utilisation.

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Improving the diagnosis of acute hepatitis C infection using expanded viral load criteria buy ponstel with paypal muscle relaxant little yellow house. Acute hepatitis C virus infection in incarceratedAcute hepatitis C virus infection in incarcerated injection drug users buy ponstel visa muscle relaxant trade names. Acute hepatitis B virus infection: Relation of age to the clinical expression of disease and subsequent development of the carrier state purchase cheapest ponstel muscle relaxant drugs methocarbamol. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Utilizing disease intervention specialist for follow-up on hepatitis C in indi- viduals between the ages of and years: A -month pilot program. A comparison of the completeness and timeliness of automated electronic laboratory reporting and spontaneous reporting of notifable conditions. Automatic electronic laboratory-based reporting of notifable infectious diseases at a large health system. Nonhospital health care-associated hepatitis B and C virus transmission: United States, 1998-2008. Major decline of hepatitis C virusMajor decline of hepatitis C virus incidence rate over two decades in a cohort of drug users. Persistence of viremia and the importance of long-term follow-up after acute hepatitis C infection. PrevalencePrevalence and clinical outcome of hepatitis C infectionand clinical outcome of hepatitis C infection in children who underwent cardiac surgery before the implementation of blood-donor screening. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Evaluation of the timeliness and completeness of a web-based notifable disease reporting system by a local health depart- ment. Electronic reporting improves timeliness and completeness of infectious disease notifcation, the Netherlands, 2003. Electronic laboratory reporting for the infectious diseases physician and clinical microbiologist. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. However, there is relatively poor awareness about these infections among health-care providers, social-service providers, and the general public. Lack of aware- ness about the prevalence of chronic viral hepatitis in the United States and about the proper methods and target populations for screening and medical management of chronic hepatitis B and hepatitis C probably contributes to continuing transmission; missing of opportunities for prevention, including vaccination; missing of opportunities for early diagnosis and medical care; and poor health outcomes in infected people. The prevalence of chronic infections remains high for several reasons, and the aging of the chronically infected population has contributed to the tripling of liver-cancer incidence during the last three decades (Altekruse et al. The frst addresses knowledge and awareness about hepatitis B and hepatitis C in health-care providers Copyright © National Academy of Sciences. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Each section begins by describing what is known about the levels of knowledge and awareness about hepatitis B and hepatitis C and how gaps in education about these diseases are affecting prevention, screening and testing, and treatment op- portunities. Those summaries are followed by the committee’s recommen- dations for addressing the gaps and the rationale and supportive evidence for the recommendations. Although there have been no large-scale, controlled studies of health-care providers’ knowledge about chronic hepatitis B and hepatitis C, it is clear that knowledge has been imperfect among providers in all the surveys whose results have been published. Subjects of defcient knowledge include • The prevalence of chronic hepatitis B and hepatitis C in the general and high-risk populations in the United States. However, current studies of provider knowledge about chronic viral hepatitis have not identifed why health-care providers fail to follow national recommended guidelines. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. However, 83% of the respondents were interested in receiving education about chronic viral hepatitis. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. State screening laws do not necessarily translate into higher testing rates, because they often do not include an enforcement mechanism or sanctions for noncompliance (Euler et al. In a study of family physicians in New Jersey, a state with a maternal screening law, Ferrante et al. At the 2009 International Symposium on Viral Hepatitis and Liver Disease, Chao et al. Hepatitis C Health-care providers’ knowledge about hepatitis C appears to be similarly insuffcient, although there is far less published research on this topic (Ascione et al. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. One-fourth incorrectly indicated that blood transfusion continues to be a risk factor, and 19% erroneously be- lieved that casual household contact is a major risk factor. A previous study by the same researchers had also found substantial gaps in primary care providers’ knowledge about hepatitis C (Shehab et al. The gaps persisted even though 95% of the respondents in the 2001 study reported having used at least one educational tool about hepatitis C in the preceding 2 years; this suggests that primary care providers misreport their Copyright © National Academy of Sciences. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Recommendation Many providers are not aware of the high prevalence of chronic hepa- titis B and hepatitis C in some populations. On the basis of the evidence described above, the committee concludes that insuffcient provider knowledge leads to critical missed opportunities for providers to educate patients about prevention of hepatitis B and hepa- Copyright © National Academy of Sciences. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. To address that issue, the committee offers the following recommendation: Recommendation 3-1. The Centers for Disease Control and Prevention should work with key stakeholders (other federal agencies, state and local governments, professional organizations, health-care organiza- tions, and educational institutions) to develop hepatitis B and hepatitis C educational programs for health-care and social-service providers. Educational programs and materials for health-care and social-service providers should focus on improving provider awareness and adherence to practice guidelines for hepatitis B and hepatitis C. The educational programs should be targeted to primary care providers, appropriate social-service providers (such as staff of drug-treatment facilities and immigrant-services centers), and licensed and unlicensed alternative-medicine professionals (such as acupuncturists and traditional Chinese medicine practitioners) that serve at-risk populations. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Educational Institutions Schools of medicine, nursing, physician assistants, complementary and alternative medicine, and public health should develop improved curricula to ensure that their graduates are knowledgeable about chronic hepatitis B and hepatitis C. The curricula should include information on disease preva- lence, risk factors, preventive actions, appropriate diagnostics, selection of persons for testing, and appropriate followup for chronically infected patients and those susceptible to infection. Drug-treatment counselors’ education and certif- cation examinations should also include hepatitis B and hepatitis C. Although there has been no systematic effort to determine whether continuing-medical-education courses and certifcation examina- tions include questions about hepatitis B and hepatitis C, the shortcomings in knowledge among health-care providers suggest that current efforts are insuffcient, and that new approaches are needed to improve knowledge. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www.

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Syndromes

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However order discount ponstel line muscle relaxant for children, data storage and database management technologies were so primitive safe 250 mg ponstel spasms near tailbone, and computing power so modest buy 250mg ponstel with mastercard gastric spasms symptoms, that it was extremely cumbersome for physicians to retrieve information at the point of care (e. Until the advent of the Apple Macintosh and, later, the Windows operating system in the mid-1980s, physicians who wanted to undertake computerized physician order entry had to learn an awkward language of computer commands and type those commands into the computer to manage their patients or to retrieve or use clinical information. As will be seen in Chapter 3, these efforts were also hampered by the highly fragmented record structure of hospitals. Hospitals 32 Digital Medicine have historically maintained separate record systems in each clinical department (for the laboratory, the operating room, the radiology department, the emergency room, etc. These so-called “legacy” systems were constructed primarily for billing purposes, not for care management. Legacy clinical systems are like a gigantic tangle of weedy undergrowth that strangles the care process as well as the efforts of those nurses, physicians, and other caregivers who use them. Even small hospitals may have as many as two dozen legacy clin- ical information systems. Unbelievably, large health systems with multiple hospitals may have as many as 500 legacy systems, pur- chased from different vendors, written in different software lan- guages, and operating on different, often incompatible hardware. As a consequence of this tangle, slightly different versions of our clinical reality exist in as many as 15 different places inside the hospital. The fact that there is no unified picture of an individual’s health status is a hazard to that person’s health. Creating a unified repository of all information requires a common format for clinical information, a single patient identifier applied across departments, and an agreement by all those who provide care to contribute what they know to the digital record. Clinical Decision Support Clinical decision support played an increasingly prominent role in emerging clinical systems. In the mid-1980s, intensive care special- ists at George Washington University led by Dr. Altogether, these tools may be the most complex commercial software products ever built, considering that they are automating what may be the most complex process in the economy—health service. Clinical systems are becoming “context aware,” meaning that they will be wired to diagnostic devices and patient monitoring equipment. They can track real-time changes in the patient’s health and will follow patients as they move through different levels of care—from an ambulatory diagnosis through surgery, into recov- ery, or even into home healthcare. These new systems now alert care providers when the patient’s condition changes, prompting the clinical team to take specific actions to deal with an emerging problem. Most importantly, however, clinical systems are reaching a suf- ficient level of intelligence to bring up-to-date medical knowledge to the physician’s office, exam room, or hospital bed. As medical science better defines how to treat patients, that knowledge will flow through computer systems to the point of care. The clinical system will prompt physicians, nurses, and others involved in patient care to follow the care pathway that holds the most promise for improving the patient’s health. The Clinician’s Role These systems do not relieve physicians and the care team of their professional and moral obligation in making patient care decisions. Just as those who use a navigational system in an airplane have Digital Medicine 35 the ultimate responsibility for reaching the destination safely, the clinical team is going to remain accountable—to patients, family members, colleagues, the courts, and society—for making the right decisions. However, clinical decision support is transforming the electronic medical record into a powerful advocate for patient safety, as well as a research tool for recording and investigating what works in medicine (Figure 2. Physicians who want to understand the basis for the system’s rec- ommendations will be able to look behind the recommendations to the research studies and clinical drug trial results and even review the outcomes of care for the last several hundred patients who received a particular treatment in the hospital to see what clinical strategies have worked best. The traditional medical record documents a patient’s health his- tory and any treatments provided. The clinical information systems presented here will be more like navigational systems in an airliner. It will locate the patient in the sphere of medical risk, constantly update the clinical team on his or her condition, and indicate a trajectory based on the latest scientific knowledge to help the care team negotiate the patient through an episode of care. The system will present a clinical “dashboard” to the physician each morning, in whatever form and venue he or she chooses (home or office desktop, portable laptop or tablet computer, or personal digital assistant). Clinical systems will be intelligent enough to rec- ognize their users by their past inquiries and even their different cognitive styles. This latter capability is especially helpful, because physicians do not all think about a medical problem the same way. Most physicians will bridle against a rigid, prepackaged approach to making care decisions. As clinical systems evolve, they will be able to recognize those cognitive differences and enable physicians or other caregivers to acquire and process information in a way with which they are comfortable. Clinical software will enable physicians to stratify their pa- tients, active and inactive, into risk groups and will both orga- nize and maintain communication with them to ensure not only that their inquiries are answered, but also that they are comply- ing with treatment recommendations. It will “remember” prescrip- tions and communicate with patients or family members about whether the therapy is producing the desired results. Clinical soft- ware will automatically schedule follow-up appointments and send patients information electronically on their illness and treatment options. Information systems will also link them automatically to disease management programs, managed by voice-response tools such as Eliza, to interact with patients to ensure that they are taking their medications as prescribed and managing their own health effectively. The remote patient monitoring systems discussed earlier, whether they are wearable devices like the wireless cardiac monitor, passive sensors like those used in the smart house, or implantable devices like Medtronic’s intelligent pacemakers, will connect “pa- tients” to physicians or the care team through their clinical infor- mation systems. We need a new term for people at medical risk that does not imply that they are institu- tionalized or under active care. Until very recently, medical science has been remark- ably incurious about what treatments actually improve the patient’s health. Safety, not efficacy, has been the principal focus both of research and of regulation. With the advent of what is now known as the Agency for Health Research and Quality in the Department of Health and Human Services, the federal government in 1989 began funding research into clinical outcomes. Additionally, more than 180 organizations, including medical and surgical specialty societies, academic health centers, and commercial companies, are developing scientifically based clinical guidelines. Natural Language Processing Another important constraint is the interface with the clinician. Although moving from typing to pointing and clicking helped make clinical software more accessible, the ability of clinicians to enter new information and interact with the system still depends more than it ought to on a mouse or keypad. Physicians do not like to type; they are used to dictating (and correcting, and reviewing, and correcting again). Removing typing or pointing and clicking from the process of interacting with the clinical system will require advances not in speech recognition, which is surprisingly powerful today, but in something called “natural language processing. Prying common meanings loose from the stream of words recognized by a computer system is the technical challenge that stands between today’s clinical systems that rely on typing or point-and-click interfaces and a truly interactive voice- response capability. According to Gartner, a respected technology evaluation firm, this capability may still be a decade off. How to present clinical information and treatment options in a way that clinicians find accessible and easy to use is a less visible, but very significant, barrier to adoption by clinicians. The “desktop” may not be the best visual metaphor to use in organizing this information. David Gelernter, a brilliant computer scientist, has proposed a chronological stream or ordering of ideas or documents by the time they first connected to the user as an alternative to the more static idea of a desktop. Stabilizing and Strengthening Wireless Technology Many clinicians want to be able to practice medicine from any- where and not be chained to a computer terminal in their offices or the hospital.

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