By R. Dudley. Hilbert College.

In addition cheap 30gm elimite mastercard, the studies were limited to opiate- substitution programs order elimite 30 gm with mastercard; cocaine injectors and other non-opiate injectors may not experience similar benefts buy elimite 30gm low cost. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www cheap 30 gm elimite. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Drug users who are successful in avoiding infection have developed strategies to maintain control over their chaotic lives. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Safe-redrawn injection strategies require access to sterile syringes and other equipmentR01623 Hepatitis and education to promote adoption and maintenance of safe behavior. Drug treatment will reduce injection frequency and assist a modest proportion of injectors to achieve abstinence. Federal, state, and local agencies should expand programs to reduce the risk of hepatitis C virus infection through injection-drug use by providing comprehensive hepatitis C virus pre- vention programs. At a minimum, the programs should include access to sterile needle syringes and drug-preparation equipment because the shared use of these materials has been shown to lead to transmission of hepatitis C virus. Federal and state governments should expand services to reduce the harm caused by chronic hepatitis B and hepati- Copyright © National Academy of Sciences. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. The services should include testing to detect infection, counseling to reduce alcohol use and secondary transmission, hepatitis B vaccina- tion, and referral for or provision of medical management. Programs should include education about safe drug use (avoiding the shared use of implements to administer drugs by smoking or inhalation) and reduction in sex-related risks, and all participants in the programs should be offered the hepatitis B vaccine. Innovative, effective, multicomponent hepatitis C virus prevention strategies for injection-drug users and non-injection- drug users should be developed and evaluated to achieve greater con- trol of hepatitis C virus transmission. In particular, • Hepatitis C prevention programs for persons who smoke or sniff heroin, cocaine, and other drugs should be developed and tested. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. The programs are administered by state and local public-health departments and vary in reach and intensity. As mentioned in Chapter 2, many programs simply provide surveillance, and others provide comprehensive case management that even includes client home visits by local coordinators. Perinatal hepatitis B programs identify twice as many household and sexual contacts per infant as was reported to the national database, with high rates of programmatic compliance in households of foreign-born people (Euler et al. This gap has a two-fold effect in that chronically infected women do not receive the appropriate medical management and referral and perinatal transmission continues to occur. Those women require followup services to ensure that they are knowledgeable about risks posed by their chronic infection and that they receive appropriate referral for long-term medical management. Cases among household contacts are not uncommon when this risk group is pur- sued aggressively for testing. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Hepatitis B services for foreign-born pregnant women are in need of improved resources that are more culturally and linguistically appropriate. The coordinators are restricted in their ability to fulfll that responsibility in culturally relevant ways, because of inadequate training and resources (Chao et al. The Centers for Disease Control and Prevention should provide additional resources and guidance to perinatal hepa- titis B prevention program coordinators to expand and enhance the capacity to identify chronically infected pregnant women and provide case-management services, including referral for appropriate medical management. Preventing Perinatal Transmission Practice guidelines and additional recommendations focused on vac- cination to prevent perinatal transmission are detailed in Chapter 4. However, the study was small, and large randomized, Copyright © National Academy of Sciences. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. The National Institutes of Health should sup- port a study of the effectiveness and safety of peripartum antiviral therapy to reduce and possibly eliminate perinatal hepatitis B virus transmission from women at high risk for perinatal transmission. Correctional facilities present a unique opportunity to bring viral hepatitis services to at-risk populations. The period of incarceration is opportune for education about hepatitis B and hepatitis C (see Chapter 3). Jails are operated by county and local jurisdictions and house people who have been arrested and are awaiting trial, people who have been convicted of misdemeanor crimes, and people who have been convicted of felony crimes with short- term sentences (usually less than one year). They house people who have been convicted of felony crimes with sentences generally of one year or longer. The high prevalence in this population is not pri- marily a result of incarceration but rather indicative of people who engage in risky behavior and were in risky settings before incarceration. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Correctional systems are constitutionally required to provide necessary health care to inmates that is consistent with the community standard of care. Al- though screening, testing, and treatment could impose an economic burden (Spaulding et al. Texas and Michigan inmate vaccination uptake rates have been reportedly been 60–80% (Vallabhaneni et al. Such prevention interventions save society money because they reduce postincarceration morbidity and mortality (Pisu et al. To capitalize on inmate readiness to participate in hepatitis prevention and control activities, correctional systems and public-health departments need to collaborate to provide targeted testing, appropriate standard-of- care medical management during incarceration, and followup medical ser- vices after release into the community. Health departments and correctional facilities do not always exchange health information, and it can be diffcult to track prisoners once they are released. State registries for hepatitis B and hepatitis C cases are needed so that incarcerated persons with these diseases can be quickly identifed and properly managed once returned into local commu- nities. Obstacles to collaboration between correctional systems and govern- ment health institutions can be overcome. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. The Centers for Disease Control and Preven- tion and the Department of Justice should create an initiative to foster partnerships between health departments and corrections systems to ensure the availability of comprehensive viral hepatitis services for incarcerated people. The initiative should include at least the following: • All incarcerated people should be offered screening and testing for hepatitis B and hepatitis C. Community Health Facilities There is a great deal of variation in the types of viral hepatitis ser- vices available within the United States. Several states—including Florida, California, Massachusetts, and Texas—have attempted to introduce some hepatitis services into publicly funded settings because of a lack of adequate federal funding for hepatitis B and hepatitis C services. Florida has been offering laboratory testing and vaccination through county health depart- ments since 1999 by using a Hepatitis Prevention Program established and funded by the state legislature (Baldy et al.

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Thus order 30 gm elimite visa, the reference amino acid scoring patterns shown in Table 10-24 are designed for use in the evaluation of dietary protein quality generic 30 gm elimite with amex. However elimite 30 gm with visa, two important statistical considerations need to be raised here: first best 30gm elimite, the extent to which there is a correlation between nitrogen (protein) and the requirement for a specific indispensable amino acid; second, the impact of the variance for both protein and amino acid requirements on the derived amino acid reference pattern. The extent to which the requirements for specific indis- pensable amino acids and total protein are correlated is not known. In this report it is assumed that the variance in requirement for each indispens- able amino acid is the same as that for the adult protein requirement. This analysis illustrates one of the uncertainties faced in establishing a reference or scoring pattern and judging the nutritional value of a protein source for an individual. However, on the basis of different experimental studies in groups of subjects, experience shows that a reasonable approxi- mation of the mean value for the relative quality of a protein source or mixture of proteins can be obtained by use of the amino acid scoring pattern proposed in Table 10-26 and a standard amino acid scoring approach, examples of which are given in the following section. Comments on Protein Quality for Adults While the importance of considering protein quality in relation to the protein nutrition of the young has been firmly established and accepted over the years, the significance of protein quality (other than digestibility) of protein sources in adults has been controversial or less clear. The amino acid scoring pattern given in Table 10-24 for adults is not markedly differ- ent from that for the preschool age group, implying that protein quality should also be an important consideration in adult protein nutrition. It is important to realize however, that this aggregate analysis does not suggest that dietary protein quality is of no importance in adult protein nutrition. The examined and aggregated studies included an analysis of those that were designed to compare good quality soy protein (Istfan et al. The results of these studies showed clearly that the quality of well-processed soy proteins was equivalent to animal protein in the adults evaluated (which would be predicted from the amino acid reference pattern in Table 10-26), while wheat proteins were used with significantly lower efficiency than the animal protein (beef) (again this would be predicted from the procedure above). Thus, the aggregate analyses of all available studies analyzed by Rand and coworkers (2003) obscured these results and illustrate the conservative nature of their meta-analysis of the primary nitrogen balance. Moreover, this discussion and presentation of data in Table 10-27 underscores the fact that while lysine is likely to be the most limiting of the indispensable amino acids in diets based predominantly on cereal proteins, the risk of a lysine inadequacy is essentially removed by inclusion of relatively modest amounts of animal or other vegetable proteins, such as those from legumes and oilseeds, or through lysine fortification of cereal flour. Food Sources Protein from animal sources such as meat, poultry, fish, eggs, milk, cheese, and yogurt provide all nine indispensable amino acids, and for this reason are referred to as “complete proteins. The protein content of 1 cup of yogurt is approximately 8 g, 1 cup of milk is 8 g, and 1 egg or 1 ounce of cheese contains about 6 g. In the United States, the median dietary intake of protein by adult men dur- ing 1994–1996 and 1998 ranged from 71 to 101 g/d for various age groups (Appendix Table E-16). For both men and women, protein provided approximately 15 per- cent of total calories (Appendix Table E-17). Similarly, in Canada, protein provided approximately 15 percent of total calories for adults (Appendix Table F-5). The median dietary intake of threonine by adult men during 1988–1994 ranged from 2. The median dietary intake of tryptophan by adult men and women during 1988–1994 ranged from 0. As intake is increased, the concentrations of free amino acids and urea in the blood increase postprandially. These changes are part of the normal regu- lation of the amino acids and nitrogen and represent no hazards per se, at least within the range of intakes normally consumed by apparently healthy individuals. Nonetheless, a number of adverse effects have been reported, especially at the very high intakes that might be achieved with supplement use, but also at more modest levels. In addition, some naturally occurring proteins are allergenic to certain sensitive individuals; for example, the glycoprotein fractions of foods have been implicated in allergic responses. However, relatively few protein foods cause most allergic reactions: milk, eggs, peanuts, and soy in children; and fish, shellfish, peanuts, and tree nuts in adults. Even when meat is the dominant food, diets of a wide range of populations do not usually contain more than about 40 percent of energy as protein (Speth, 1989). Indeed, Eskimos, when eating only meat, maintain a protein intake below 50 percent of energy by eating fat; protein intake estimated from data collected in 1855 was estimated to be about 44 percent (Krogh and Krogh, 1913). Two arctic explorers, Stefansson and Andersen, ate only meat for a whole year while living in New York City (Lieb, 1929; McClellan and Du Bois, 1930; McClellan et al. For most of the period, the diet contained 15 to 25 percent of energy as protein, with fat (75 to 85 percent) and carbohydrate (1 to 2 percent) providing the rest, and no ill effects were observed (McClellan and Du Bois, 1930). However, consumption of greater portions of lean meat (45 percent of calories from protein) by one of the two explorers led rapidly to the development of weakness, nausea, and diarrhea, which was resolved when the dietary protein content was reduced to 20 to 25 percent of calories (McClellan and Du Bois, 1930). If continued, a diet too high in protein results in death after several weeks, a condition known as “rabbit starvation” by early American explorers, as rabbit meat contains very little fat (Speth and Spielmann, 1983; Stefansson, 1944a). Similar symptoms of eating only lean meat were described by Lewis and Clark (McGilvery, 1983). Conversely, an all-meat diet with a protein content between 20 and 35 percent has been reported in explorers, trappers, and hunters during the winters in northern America surviving exclusively on pemmican for extended periods with no adverse effects (McGilvery, 1983; Speth, 1989; Stefansson, 1944b). Pemmican is a concentrated food made by taking lean dried meat that has been pounded finely and then blending it with melted fat. It contains about 20 to 35 percent protein; the remainder is fat (Stefansson, 1944b). Nitrogen balance studies at protein intakes of 212 to 300 g/d consistently have shown positive nitrogen balance (Fisher et al. In particular, no negative nitrogen balances were reported, suggesting that the high protein intake had no detrimental effect on protein homeostasis. Rudman and coworkers (1973) studied the effect of meals containing graded levels of protein on the rate of urea production by human liver in vivo. At higher intakes, the rate was not increased further, but the maximum rate continued longer. In a 70-kg sedentary person, this maximum rate corresponds to about 250 g/d of protein, or about 40 percent of energy. The correspondence of this maximum to the apparent upper level of protein intake (45 percent of energy) described in the earlier section related to the experiences reported by explorers has therefore been suggested as cause and effect (Cordain et al. How- ever, this interpretation should be made with caution, as there was no period of adaptation to the meal in the study of Rudman’s group (1973). It is probable that when high protein diets are given, the capacities to oxidize amino acids and synthesize urea are increased, as has been demon- strated in animals (Das and Waterlow, 1974). High protein intakes have also been implicated in chronic diseases such as osteoporosis, renal stones, renal insufficiency, cancer, coronary artery disease, and obesity (see “High Protein Diets” in Chapter 11). However, the current state of the literature does not permit any recommendation of the upper level for protein to be made on the basis of chronic disease risk. Because of the current widespread use of protein supplements, more research is needed to assess the safety of high protein intakes from supplements; until such information is avail- able, caution is warranted. The potential implications of high dietary protein for bone and kidney stone metabolism are not sufficiently clear at present to make recommen- dations for the general population to restrict their protein intake. This life stage group also had the highest reported protein intake at the 99th percentile of intake at 190 g/d, or 2. Risk Characterization The risk of adverse effects resulting from excess intakes of protein from foods appears to be very low at the highest intake noted above. Women over the age of 50 had the highest reported percentage of total energy from protein at the 99th percentile of 23.

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Urea treatment was started and after 3 days the discount elimite 30 gm line, slough was removed thus exposing the underlying tendon elimite 30 gm for sale. The patient was discharged 22 days after the treatment was begun purchase elimite 30 gm with visa, the wound having healed completely cheap 30gm elimite fast delivery. As will be seen from the above, we have used urea in a variety of casualty department cases. Owing to the extreme diffusibility of urea even the deepest wound can be treated effectively. A very definite response to urea treatment is nearly always obtained after two or three applications. Coupled with this is a considerable decrease of edema as the local circulatory conditions improve. For the carbuncles (external staph infections), treated, we found urea preferable to any other dressing after initial incision. In none of the cases of our series did we observe any skin 94 reaction which could be called a urea dermatitis (rash), nor have we evidence of any toxic effects. We never saw a spread of sepsis (infection) under urea treatment or any undermining of the wound edges. The advantages of the urea treatment are as follows: (1) It is cheap, the crystals costing one shilling per pound. Cortisone has been proven to be dangerous and toxic and antibiotics destroy good bacteria along with the bad. Also by using antibiotics routinely, we p p p 95 p p 87Your Own Perfect Medicine have greatly reduced their effectiveness as bacterial strains have developed increasing resistance to them. The researchers reported, among other things, that: 1) urine contains a type of gastric secretory suppressant (or antacid) called urogastrone, that can protect against irritation of the stomach lining that may lead to ulcers. In the report, urine extract therapy is compared to other ulcer drug treatments and diet changes and it was found in human testing that: ". When he contracted tuberculosis at the age of 34 and later diabetes, he went to various doctors for help, but after two years of unsuccessful treatments, decided to look for his own solution to his health problems. His technique was so successful that many hundreds of people with everything from cancer to heart disease, gangrene, kidney disease, venereal disease, obesity, prostrate problems and many other difficult disorders came to Armstrong for help and were cured. Armstrong himself reportedly lived healthily and happily ever after, well into his eighties, by maintaining a good diet, a healthful lifestyle and by ingesting a small daily dose of urine. This study is only one of several conducted on the anti-bacterial properties of urea by the two researchers, Weinstein and McDonald. In this report, they discuss previous research into the antibacterial effect of urea and report that their studies also confirmed that urea will both inhibit the growth and destroy many different types of bacteria such as those that cause dysentery, typhoid, and staph and strep infections: "Urea and urethane are bacteriostatic and bactericidal for a number of gram-negative and gram-positive bacteria. This particular study on urea is also good example of why synthetic drug compounds should not routinely be considered for use in the place of basic or natural medicinal elements. As Weinstein and McDonald stated, they used both urea and a chemically synthesized urea compound called urethane to kill bacteria and they recommended both urea and urethane for medical use as anti-bacterial agents. As the Fourth Annual Report on Carcinogens, 1985 stated: "This substance (urethane] may reasonably be anticipated to be a carcinogen". So you can see how extremely dangerous errors can be made by scientists experimenting with new and "improved" synthetic drugs. And the 100 same is true today of new drugs that initially seem like miracle cures but later tum out to be deadly substances. Compound urine-derivative drugs may seem superior in the minds of medical researchers, and even consumers, but what good are they if they later prove to be harmful or even fatal? Simple urea and urine have been shown to be safe over nearly a full century of scientific study and use, so it certainly makes sense to start using them routinely in medicine before resorting to potentially dangerous compound chemical drugs. Plesch, an English physician, used natural urine injections in his medical practice extensively and with excellent success on a large variety of disease conditions: ". In fact, my recommendation to use the urine of the infected person for auto-vaccination is only an extension of the methods of Jenner and Pasteur and therefore it is strange that auto-urine vaccination has not 101 91Your Own Perfect Medicine been used before. I am convinced from my experience that it is worthwhile investigating this method systematically with respect to all infectious diseases, including poliomyelitis, etc. Moreover, during the application of this therapy, I observed some remarkable effects. Among my first patients whom I treated by urine therapy was a typical case of asthma. Immediately after the first injection and before the vaccination effect had time to develop, this patient lost his daily attacks of asthma. Following up this clue, I found that anaphylactic (allergic) persons could be desensitized by the auto-urine injection. Subsequent investigation convinced me that auto-urine therapy could be used with considerable advantage against all kinds of anaphylactic (allergic) diseases, such as hayfever, urticaria, (hives), disfunction of the intestinal tract such as cramps, etc. Since I started the auto-urine therapy three years ago, I have given several hundred injections and I have not come across a single case where the patient suffered any harm. It is for this reason, and because the method is so simple that is 102 can be used by any practitioner without any difficulties, that I decided to publish my findings at this early stage. The observations which I have quoted are without doubt sufficient to indicate to the expert that a completely new field of research is being opened up which may entail considerable additions to our knowledge of bacteriology, immunology and serology. The fresh urine of men is practically sterile and that of women, too, if the exterior genitalia have been cleaned previously. For purposes of immediate injection the urine may therefore be collected directly into sterile vessels. When using urine as an auto-vaccine I found that usually one injection of a quarter to a half cc. In anaphylactic (allergy) cases I have found it useful to start J 92r C C The Research Evidence and Case Studies with 5 cc. Moreover, the hormonal end products and enzymes contained in the urine make it probable that this method may be useful against metabolic disturbances such as diabetes and gout and against derangements of the ovarial or thyroid, etc. Since 2/1/45 depressed, headaches, no appetite, coated tongue, somewhat increased temperature. Blown up feeling in the abdomen, pains in the right hypogastritum 13/1, Fully developed jaundice, urine dark brown. After hospital treatment the icterus (jaundice) disappeared, a feeling of weakness, intestinal troubles and depression remained. Since then he dragged 104 himself about complaining of loss of appetite, tiredness and indifference, pains in the abdomen after food, constipation, distension and abdominal discomfort with flatulence. In the last two years no digestive troubles, no migraine attacks any more before menstruation. On the day 94The Research Evidence and Case Studies of injection patient feels much better, after 24 hours severe attack of asthma.

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He never saw a paper bill buy generic elimite 30 gm, though he could view the billing process in real time on his health plan’s web site cheap elimite 30 gm with amex. The American health system is on the brink of a fundamen- tal transformation made possible by information technology buy 30 gm elimite overnight delivery. That transformation will be costly and complex to achieve discount elimite 30 gm with amex, but when it has been accomplished, our relationship to the health system and our ability to manage our own health will be dramatically improved. Healthcare’s clinicians are virtually drowning in information, not only about the illnesses they trained to fight, but also about the process of caring for patients. Much of that information is in paper form, inaccessible or unusable when they need it. When that digital transformation is complete, vital information about our health and our specific treatment options will be freed from books, paper medical records, and practitioner memories and become moveable to the point of care or to the patient, literally at the speed of light. Digital information is an anarchic force, and its effects are difficult to predict. Moreover, many of these tools are complex, difficult to install, and difficult to learn to use. However, a health system flexible and powerful enough to ac- commodate individual needs, and to collaborate with us in improv- ing health, is within realization. A safer health system that makes thoughtful, efficient use of the flood of new knowledge, and that is responsive not only to the needs of consumers, but to its workers’ Introduction xxiii values, aspirations, and intellectual curiosity is on the near horizon. This book will help all who work in and use the American health system to understand how to make this achievable future—a more responsive, safer, and more intelligent health system—happen. In fact, this knowledge enterprise, the American health sys- tem, is the size of a large industrial nation. Despite the investment of tens of billions of dollars in information sys- tems, the more than 12 million caregivers and support personnel in the most technologically advanced health system in the world are buried in a blizzard of paper and flurries of unreturned telephone calls. My most vivid memory of the orientation tour was visiting the hospital’s medical records room. It was an enormous room in the basement, stacked floor to ceiling with dusty telephone book–sized paper med- ical records. Dozens of workers protected from the dust by white coats moved piles of these bulging records around the hospital in shopping carts. With so much paper and such haphazard filing, tracking charts inside the two-million-square-foot University of Chicago medical complex was a massive and frustrating logistical challenge. Failure to locate and deliver charts to the clinics and inpatient units de- layed or hampered the care process, resulting in increased cost and frustration for patients, nurses, and physicians alike. That medical records room reminded me of nothing so much as the municipal library in the capital of an underdeveloped country— a record-keeping system more appropriate to Dickens’ London than a modern enterprise. Although the University of Chicago hospital system has subsequently invested millions of dollars in electronic records systems, as well as more capacious plastic shopping carts, the records room, jammed with medicine’s biblical stone tablets, is still there today in 2003. Despite breathtaking advances in other sectors of the Ameri- can economy in applying digital information and communications technologies, medical decision making at the dawn of the twenty- first century remains unhappily yoked to paper, the telephone, and practitioners’ memories. Paper medical records, often unreadable paper prescriptions, paper orders, paper lab reports, paper telephone message slips, fax paper health insurance verifications, paper bills of questionable accuracy: these are the artifacts of an early 1970s information environment. A typical large American hospital may have as many as three dozen separate computer systems, ranging in age from near-Technicolor- quality youth to green-screened senility. That is, a patient may be a different person in the emergency room than he or she is in the clinical laboratory, in the surgical suite, and yet again in the doctor’s office just a day earlier. Each of these different sites of care within the same organization maintains a different medical record of its encounters with same patient. These separate systems were primarily built to bill for each department’s services, not to guide patient care. There is also a nearly impermeable barrier between the hospital’s records and those of the physicians who direct the care. In the typical community hospital, it is impossible for the doctor or any other care worker to access the doctor’s office records from any site other than that doctor’s office because more than 80 percent of those office records are still in paper form. Furthermore, most doctors in private medical practice have been unwilling to support shared digital record-keeping systems with their hospitals because of a profound lack of trust and poor communication with hospital management. Even where it is possible to link all of these fragments of a pa- tient’s history and medical situation electronically, a considerable feat of software engineering is required to move this information around quickly enough that it can actually be used by the physician in making important care decisions. When information reaches a digital dead end, it is printed out and piled up in various in-boxes or paper filing systems. Thus, vital information remains locked up in paper, or in people’s short-term memories, and cannot flow through wire or fiber or the air to where it is needed to make timely and accurate medical decisions. As long as the source documents detailing patient care remain in paper form, the only way to determine whether particular clinical decisions contributed to a positive health outcome is to hire squads of graduate students or nurses to cull the records by hand months later and tabulate the results. The fact that we know so little about 4 Digital Medicine what actually works in medical treatment can be attributed in large part to the prison of paper we have constructed around the care process. Public research in- vestments through the National Institutes of Health and private equity investment, including research and development expendi- tures by the nation’s pharmaceutical and biotechnology firms, are creating new medical knowledge at a stunning pace. In 2001, nearly $51 billion was invested in creating new knowl- edge in medicine just in the United States. The logistics of medical practice itself have become so dauntingly complex that physicians barely have time for their families, let alone time to keep pace with the exciting advances in their own fields. A monthly continuing medical education session at the hospital or local medical society and periodic visits from pharmaceutical salespeople are the principal conduits of new knowledge to most practicing physicians. A visit to a physician’s personal office typically reveals piles of unread medical journals, pink telephone message slips, and scattered samples of new drugs from the last pharmaceutical sales representa- tive to visit the office. The computer in the office is probably turned off, is likely at least three years old, and is surely not configured to The Information Quagmire 5 reach or retain data about current medical practice. Physicians know they are not keeping up, and this both frustrates and frightens them. Professional training and culture in medicine conditioned physi- cians to rely principally on direct peer contact and what they can carry around in their memories to support their advice to patients. The channels by which new information reaches physicians in prac- tice are dangerously narrow and lack the bandwidth and intelligence to organize and transmit the flood of new medical knowledge in a way that it can be absorbed and used in practice. Although major journals have digitized their articles and made them available online, medical knowledge is still largely paper driven. Unless physicians have a good relationship with a medical librarian or, as do a lucky few senior physicians in teaching hospitals, have residents and fellows to research issues for them, the large number of important questions about a patient’s health that occur to a physician during a typical practice day never get answered. How- ever, the reality is that the lack of timely and accurate information at the point of care is a major contributor to patient deaths and injuries, as well as resulting in a waste of time and money. As a vehicle for applying medical knowledge to solving problems, the healthcare system has become increasingly cumbersome, user- unfriendly, and expensive. When the Internet opened up new channels for consumers to access medical knowledge directly, it was rapidly flooded with users. According to a recent Harris poll, roughly 110 million Americans used the Internet to seek health information in 2002. According to Peter Drucker (see Note 1), large healthcare institutions, like urban academic health centers, may be the most complex organizations in human history. Not only do the medical problems presented at the point of service vary tremendously, but no inventory exists; health services are, for the most part, custom manufactured for individual patients on a “just in time” basis.

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