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At all times the student will be directly supervised by one of the attending preceptors. In the clinic there will be the opportunity to observe the evaluation and management of patients presenting with all aspects of Oculoplastic disease including trauma, neoplasia, aging, and congenital defects involving the ocular adnexae seen. In the operating room, there will be observation of surgical techniques and opportunity to scrub in and assist on cases. The student will be assigned a library research project due at the end of the rotation as a PowerPoint presentation. The project will be on an Oculoplastic issue, disease, or surgery of interest to the student. Prerequisites: Technical background appropriate to the planned project, if necessary. This elective affords the student the opportunity to work with faculty from ophthalmology in the field of medical informatics. The student will be allowed to develop either a research project or practical experience focused on the use of computers and information technology in ophthalmology. Examples of possible projects include: development of user interfaces for electronic patient records; computer-aided analysis and/or diagnosis of ophthalmic images; assessment of information needs in ophthalmology; assessment of the impact of information technology on ophthalmology; development and assessment of electronic patient education material; and development and assessment of clinician decision support. Students will be expected to generate a formal report describing their project and will be evaluated on their ability to plan and carry out that project. Opportunity to assist in design and conduct of epidemiologic studies of visual impairment and trachoma in selected populations in the U. Prerequisites: Electronics or engineering background or experience would be welcome. The student will conduct a pertinent literature search in a particular area of cornea/external diseases. Exposure to basic laboratory techniques (including cell cultures, immunohistochemical/fluorescein staining) will be available for interested students. Prerequisites:Completion of basic sciences portion of an approved medical school program. The rotation will include attendance in retina clinic and the retina operating room. There will be assigned readings and a retina related project that will contribute to a publication level document. Visitation to the retina laboratory where in vitro and in vivo work related to retinal disease is on-going and will be incorporated into the experience. This rotation will expose students to medical and surgical retina through time in the retina clinic and operating rooms. This elective provides the student with an introduction to the physical principles, hardware design, and signal processing techniques used in ophthalmic optics and electronics. The course is designed for students who wish to pursue research in ophthalmic optics. Emphasis will be placed on optical sensors, amplifiers and filters, noise reduction, pattern recognition, and data analysis in time, and frequency domains. The project may include elements of computer programming, modeling, and optimization; possibly also decision making. The end goal is to develop algorithms to be applied in functional and reliable diagnostic devices. This one month elective in Oculoplastic Surgery provides clinical and surgical experience for the medical student in this subspecialty. In the clinic there will be the opportunity to observe the evaluation and management of patients presenting with all aspects of oculoplastic disease including trauma, neoplasia, aging, and congenital defects involving the ocular adnexae. There will be opportunity to do portions of the workups and then present to the preceptor(s). Supervised clinical rotation with full time Wilmer faculty at Green Spring Station. This course will focus on diagnosis and treatment of many common eye diseases, with particular attention to conditions of the anterior segment, including cataract, cornea, and refractive surgery.

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Cognitive behavioral therapy requires fewer sessions than other traditional forms of psychotherapy. Availability of therapists in the community and coverage of services for patients with and without insurance must be addressed. In some instances, especially for patients in rural areas, these barriers can limit psychotherapy as a treatment option. Pharmacotherapy For the steps for pharmacotherapy, see Table 1-2; the medications used are listed in Table 1-3. Buspirone may not be as robust for anxiety, and antidepressants are often preferred (Bystritsky 2016). Buspirone is usually used when the patient has a history of substance abuse because it lacks abuse potential. Buspirone may also be used as an adjunctive medication when the patient has had a partial response to an antidepressant. The dose can be titrated every 2 weeks until a therapeutic dose is achieved or until the highest dose the patient can tolerate is achieved. The dose can be reassessed and adjusted every 1­2 weeks until a therapeutic dose is achieved. An important consideration when using these medications is that patients often have activating adverse effects like agitation, restlessness, and insomnia. Patients should be educated about the possibility that their anxiety becomes worse during initial therapy. A short-term, small dose of benzodiazepine (if the patient has no history of substance abuse) or hydroxyzine can help patients through this period (Craske 2016b) if their symptoms are severe enough to warrant it. If a benzodiazepine is added, it is usually prescribed for 2­4 weeks and then discontinued. Symptoms of discontinuation syndrome include dizziness, anxiety, irritability, paresthesia, nausea, and vomiting. Venlafaxine can cause increased blood pressure, especially at the higher end of the dose range, where noradrenergic actions are more prominent. Patients taking 150 mg/day or more should consider monitoring their blood pressure, and this medication should be avoided in patients with uncontrolled hypertension. Finally, all antidepressants carry a boxed warning for increased risk of suicidal thoughts and behaviors, particularly early in therapy or when the dose is changed in children, adolescents, and young adults up to age 24. Patients should be made aware of these concerns associated with long-term treatment. However, they do play a role in initial therapy if the symptoms are severe or the patient is significantly impaired, provided the patient has no history of substance abuse. This effect may lead some patients to prefer them to the antidepressants; however, they are not appropriate for long-term therapy in most instances. Max 4 mg/day Elderly: Consider 50% reduction in dose and titrate carefully Start 7. Max 40 mg/day Elderly: Start 1-2 mg once or twice daily and titrate as tolerated Start 0. Max 120 mg/day Elderly: Start 10 mg three times daily and titrate as tolerated to 15 mg 3-4 times daily. Recommendations vary for how to taper benzodiazepines that have been prescribed chronically; however, a 25% reduction in the daily dose every 2 weeks until the lowest dose is reached followed by discontinuation is reasonable (Melton 2016). If the patient has had prior problems with discontinuation, the rate can be slowed and tapered over 6 months. Monitoring Patients should be seen every 1­2 weeks when treatment is started or if treatment is changed. The medication dose can be adjusted as needed and tolerated until the therapeutic range is reached. Patients should also be assessed for treatment adherence and potential adverse effects of therapy. Step 5: Modify Psychotherapy or Pharmacotherapy Therapy should be modified for patients with poor or partial responses to therapy or for those who did not tolerate the initial approach. If patients are not taking the medication, the reasons for this should be explored and the barriers addressed. If they are taking the medication, and it has been given in a therapeutic dose for an adequate time, a change in therapy should be made. Except for fluoxetine, the first antidepressant should be tapered to avoid discontinuation syndrome.

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Sized at 160x600, these ads are positioned on the top right of our web pages directly adjacent to our content listing. SpringerLink currently offers 2, 774 fully peer-reviewed journals and 55, 459 books online. General and detailed information about our journals, books, software and other products is available on our corporate website Springer. Watch our online tutorial to find out how to browse, search, access, order, and more on SpringerLink. SpringerLink Stats: SpringerLink receives over 3 million page impressions daily (Source: Google Analytics) In 2016 SpringerLink. Every day, around the globe, our brands and imprints support the important work of millions of people ­ helping students to learn, researchers and scientists to discover and professionals to achieve their goals and ambitions. Our products and services include scientific communications, promotional medical education and marketing programs, prescriber and patient education materials, independent medical news services, commercial market analysis and pharmaceutical sales force training. With our in-depth knowledge, vast experience, unique global footprint, and flexible, innovative solutions covering every stage of the product lifecycle, we are the medical communications partner of choice. Please contact your sales representative, for more information about online advertising opportunities. Consistently histories are illustrative of the proposed different diagnosis, they are concise and accurate Masters the science and the art of bed side examination. Physical Exam (general) Rarely interpret findings according clinical context, missing most elements. Clinical Diagnosis/Problem Formulation Thromboembolic Disease Rarely identifies patient at risks and struggle identifying the disease. Generally has shown appropriate assessment skills for fitness and risks involved with proposed surgery. Consistently capable of using clinical presentation, screening and confirmatory test expertly. Consistently displays an excellent understanding of risk and fitness assessment even with most challenging cases. Consistently capable of achieving best results in difficult situations without antagonizing others. Superior at dealing expertly with the most difficult patient / family extreme stressors and exemplary behavior with end of life decision making. Is learning how to best use his critical thinking ability without creating any patient or interdisciplinary incident. Superior critical thinker who regularly integrates his critical appraisal structured approach to his bedside. Self Assessment Ability Values and Ethics Consistently capable of integrating personal, cultural, and gender considerations. Describe any difficulties you might foresee for this resident in the future: 4. No part of this book may be reproduced in any form by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U. Printed in China Library of Congress Cataloging-in-Publication Data Pocket medicine / edited by Marc S. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 223-2320. In an era of information glut, it will logically be asked, "Why another manual for medical house officers? Pocket Medicine is the joint venture between house staff and faculty expert in a number of medical specialties.

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They saw these actions (such as changes in zoning, particularly downzoning) as potentially reducing property values and were concerned about the legal implications of such actions. To empower localities to use management type options, they suggested that action needed to come from the state first. They felt this would require a "core group" who could motivate and educate others in the state. Stakeholders suggested that more meetings and stakeholder groups would be a good way to further the discussion at both the state and local levels. Which does the public perceive as a bigger problem, precipitation or tidal/storm surge flooding? Category: Temporary, Permanent, Land Use Management Stakeholders were also asked to identify desired goals and outcomes for the state and localities regarding flooding issues, to prioritize actions to achieves those goals, and indicate the responsible parties for those actions. Recurrent flooding is a significant issue in Virginia coastal localities and one which is predicted to become worse over reasonable planning horizons (20-50 years). The risks associated with recurrent flooding are not the same throughout all areas of Tidewater Virginia. Data is often lacking for comprehensive and/or fine resolution analysis of flood risk sin the region. Given the long time frame necessary to effectively address recurrent flooding and sea level rise issues and given the speed at which risks are projected to increase, Virginia and its coastal localities should immediately begin comprehensive and coordinated planning efforts. The State should initiate identification, collection and analysis of data needed to support effective planning for response to recurrent flooding issues in Virginia. Accessing relevant federal resources for planning and mitigation may be enhanced through state mediation. Flooding problems are linked to water bodies and therefore often transcend locality boundaries. The State should request an expert review of local government legal authority to address current and projected flooding risks and what levels of evidence are likely to be required to justify locality action. Part of that strategy should include prioritization of areas for flood management actions based (in part) on risk b. Cost/benefit of identified strategies 60 Section 3: Figures Figure Legends Figure 1. Data presented is the number of repetitive loss properties aggregated by census block. Vulnerability to Storm Surge with Predicted Sea Level Rise, Region 1: A map of the potentially inundated areas assuming a 1. Vulnerability to Storm Surge with Predicted Sea Level Rise, Region 2: A map of the potentially inundated areas assuming a 1. Vulnerability to Storm Surge with Predicted Sea Level Rise, Region 3: A map of the potentially inundated areas assuming a 1. Vulnerability to Storm Surge with Predicted Sea Level Rise, Region 4: A map of the potentially inundated areas assuming a 1. Vulnerability to Storm Surge with Predicted Sea Level Rise, Region 5: A map of the potentially inundated areas assuming a 1. Predictions of Future Sea Level Rise Rates: A graph showing several future sea level rise scenarios, including an estimate of local subsidence. Ь Kilometers 0 0 10 10 20 30 Miles 20 40 30 40 County or City Boundary Each red dot represents one Repetitive Loss Property within a census block. The challenge for appropriate flood management planning is to reduce risks to people, property and ecosystems associated with existing development while managing or preventing new development in high risk areas (Kim and Karp 2012). Adaptation strategies fall into 3 main categories: Management/retreat (zoning policies and similar), Accommodation (elevation of roads and buildings, evacuation scenarios, etc. Most localities have addressed flooding and flood mitigation strategies to some extent, either through zoning policies, floodplain management ordinances, comprehensive plans, floodplain management plans or hazard mitigation plans (which are typically regional plans). Only a few localities have detailed adaptation strategies, while most rely on a more general set of decision making guidance.

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Impact of advertisements promoting candy-like flavoured e-cigarettes on appeal of tobacco smoking among children: an experimental study. Longitudinal study of e-cigarette use and onset of cigarette smoking among high school students in Hawaii. This chapter highlights the scientific literature that addresses potential adverse health effects caused by direct exposure to aerosolized nicotine, flavorants, chemicals, and other particulates of e-cigarettes; secondhand exposure to e-cigarette aerosol; and exposure to the surface-deposited aerosol contaminants. Literature regarding harmful consequences of close contact with malfunctioning e-cigarette devices and ingestion of the nicotine-containing liquids (e-liquids) are also explored. This chapter examines available data on e-cigarettes and youth, reviews established human and animal data on harmful developmental effects of nicotine (prenatal and adolescent), and reviews data on e-cigarettes among adults when data on youth are not available. Of note, given the relatively recent emergence of e-cigarettes, data are not yet available that address the long-term health effects of use or exposure over several years compared with nonuse or exposure to air free from secondhand tobacco smoke and aerosol from e-cigarettes; thus, the discussion is limited in that regard. The enormous knowledge base on tobacco smoking and human health is also relevant to this discussion. That literature, which has been accumulating for more than 50 years, provides incontrovertible evidence that smoking is a cause of disease in almost every organ of the body (U. Laboratory research has characterized the components of tobacco smoke and probed the mechanisms by which these constituents cause addiction and injury to cells, tissues, organs, and the developing fetus. The evidence on the harmful consequences of nicotine exposure in conventional cigarettes, including addiction, and other adverse effects, is particularly relevant to e-cigarettes. Nicotine doses from e-cigarettes vary tremendously depending on characteristics of the user (experience with smoking conventional cigarettes or e-cigarettes), technical aspects of the e-cigarette, and levels of nicotine in the e-liquid. Although studies of nicotine doses in youth and young adults are lacking, studies of adults have found delivery of nicotine from e-cigarettes in doses ranging from negligible to as large as (Lopez et al. Similarly, passive exposure to secondhand nicotine from e-cigarettes is just as large library/reports/ (Flouris et al. The findings of scientific research on smoking and involuntary exposure to tobacco smoke have been reviewed thoroughly in the 32 reports on smoking and health produced by the Surgeon General to date (there is one report on smokeless tobacco) (Table 3. Everett Koop, was the first to characterize smoking as addictive, and it identified nicotine as ". The pharmacologic and behavioral processes that determine tobacco addiction are similar to those that determine addiction to drugs such as heroin and cocaine. Nicotine is the key chemical compound that causes and sustains the powerful addicting effects of commercial tobacco products. The powerful addicting effects of commercial tobacco products are mediated by diverse actions of nicotine at multiple types of nicotinic receptors in the brain. Evidence is suggestive that there may be psychosocial, biologic, and genetic determinants associated with different trajectories observed among population subgroups as they move from experimentation to heavy smoking. Evidence is consistent that individual differences in smoking histories and severity of withdrawal symptoms are related to successful recovery from nicotine addiction. Cigarette smoking by youth and young adults has immediate adverse health consequences, including addiction, and accelerates the development of chronic diseases across the full life course. Prevention efforts must focus on both adolescents and young adults because among adults who become daily smokers, nearly all first use of cigarettes occurs by 18 years of age (88%), with 99% of first use by 26 years of age. Advertising and promotional activities by tobacco companies have been shown to cause the onset and continuation of smoking among adolescents and young adults. After years of steady progress, declines in the use of tobacco by youth and young adults have slowed for cigarette smoking and stalled for smokeless tobacco use. Coordinated, multicomponent interventions that combine mass media campaigns, price increases including those that result from tax increases, school-based policies and programs, and statewide or community-wide changes in smokefree policies and norms are effective in reducing the initiation, prevalence, and intensity of smoking among youth and young adults. Social, Environmental, Cognitive, and Genetic Influences on the Use of Tobacco Among Youth 1. Given their developmental stage, adolescents and young adults are uniquely susceptible to social and environmental influences to use tobacco. Socioeconomic factors and educational attainment influence the development of youth smoking behavior. The adolescents most likely to begin to use tobacco and progress to regular use are those who have lower academic achievement. The evidence is sufficient to conclude that there is a causal relationship between peer group social influences and the initiation and maintenance of smoking behaviors during adolescence. Affective processes play an important role in youth smoking behavior, with a strong association between youth smoking and negative affect.

Syndromes

  • Swallowing a poisonous substance
  • Airway fluoroscopy
  • Cholesteatoma
  • Eye weakness
  • Euphoria ("drunk" feeling)
  • Pregnancy
  • Avoiding foods that you know cause gas, such as beans.

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If you have already registered at this link because you will be attending more events, we ask you to re-register in the one provided above. In order to register yourselves, please check the box "Climate Finance Study Group Meeting" at the end of the form, after filling your data in. Kotlikoff, William Fairfield Warren Distinguished Professor, Boston University Alan Auerbach, Robert D. This footnote also confirms that our email communications may be monitored to ensure the secure and effective operation of our systems and for other lawful purposes, and that this email has been swept for malware and viruses. For each of these sources, what measures would be required to mobilize them and what are the impediments, consequences and advantages of these measures? There can be no uniform prescription for mobilizing the sources and instruments of climate finance as described in the Report to the G20 on Mobilizing Climate Finance. A variety of factors are likely contributing to the fact that such legislation has not been enacted to date, and we cannot speculate on the range of these factors. A significant body of literature has emerged evaluating the distributional effects of carbon pricing and opportunities to address those effects through the targeted use of revenue from carbon pricing, or the targeted use of the value of emission allowances that would be created if a cap-and-trade system were enacted. Available at 2012-08-054 000000000002373 potential for unilateral carbon pricing to lead to "leakage, " whereby unilateral domestic carbon pricing can lead to a shift in certain emissions overseas as a result of increases in the relative cost of domestic production of energy-intensive internationally-traded goods, relative to production in countries not implementing carbon pricing. In the case of any carbon pricing policy that might be proposed, careful consideration would need to be given to the specifics of the proposal and its potential effects. Any analysis of alternative policy designs would require careful consideration of the specific facts of and circumstances surrounding each policy proposal. Yet, again holding constant the level of the carbon price, more narrowly targeted carbon pricing will have more limited distributional consequences. There are many potential competing uses of any revenues that may be created by a carbon pricing proposal. It is difficult to predict what share of revenues would go to each of these potential uses, including international climate finance, in any legislation that might be enacted. Government analysis of issues surrounding leakage and of the provisions in particular proposed legislation to address this issue, see the Effects of H. National tax authorities have significant experience with administering a variety of excise tax systems, suggesting that it may be logical to have them administer the collection of any revenues. As with any other revenue source, the funds saved through elimination of fossil fuel subsidies should be disbursed by national governments according to their standard budgetary procedures. Governments may also choose to use a portion of savings to pursue other objectives, including those that fossil fuel subsidies may have been intended to accomplish (for example, enhancing energy security through support for renewable energy technologies). To the extent that there is a desire to adjust the level of carbon pricing, that too can be influenced by policy design. Leveraging private finance through the careful, targeted use of public finance tools can be an effective way to incentivize transformational change. Development finance institutions can invest in risk mitigation, provide technical advisory services, and finance demonstration and deployment of new technologies and business models. Any use of public money must come with appropriate accountability measures and safeguards. To be most effective, investments and investment policies should be coherent with country development strategies. Finally, finance ministries should also seek opportunities to identify and phase out inefficient policies that promote non-green investment at the expense of green investment, including fossil fuel subsidies. Reforms implemented by some countries in the G20 demonstrate that it is possible to make choices that may be politically difficult now, but will provide clear longterm benefits. The World Bank reported over $6 billion committed from internal resources in 2011 for climate mitigation alone. This financing will promote inclusive economic development while also protecting the environment. Lael knows this inside and out already, and will look more to the leg part of the memo going into each meeting. Could we please get 3 updated top line talking points on the latest update for Europe to include in her memo? After the briefing, I understand that Lael would like additional information to add to the Legislative Memo. So, if you have those additional items ready for the memo (attachments, fact sheets, etc. We thank Professor Edward Barbier of Wyoming University and Professor Mike Young of the University of Adelaide for their review, comments, and suggestions.

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Also covered are essential concepts on the cytoskeleton, cell-cell and cell-extracellular matrix interactions, cell motility, chaperones, and protein turnover. Opportunities for training in cell and developmental biology, physical anthropology and vertebrate paleontology are available for qualified predoctoral and postdoctoral students. This course addresses the pathways and mechanisms of membrane traffic (exocytosis and endocytosis) in eukaryotic cells. Topics include historical and current experimental approaches, as well as dissection of the pathways for cargo trafficking, signals on cargo proteins, and the required cellular machinery. The format will be a combination of lectures and student-led discussions of landmark and current papers. Modern biological research using fluorescence and confocal microscopy has grown tremendously, but the fundamental concepts are sometimes confusing. Not only covering the physics, optics and detector principles, a large portion of this class will cover image processing, including quantitative analysis of fluorescence images using modern analysis packages. Physics topics include the limit of optical resolution and impacts on digitization resolution. Optics topics include the comparison of wide-field, laser-scanning and spinning disk confocals. Quantitative analysis of images range from implications of digitization, image enhancement, to computer-mediated image interpretation, including colocalization analysis. In this course, we will explore the fundamental mechanisms of the cytoskeleton that the cell uses to drive motility and dynamic shape changes. We will emphasize the breadth of research on the cytoskeleton ranging from classic studies of muscle, cytoskeletal structure, enzymological and single molecule studies of motor proteins, rheology, polymer dynamics, cytoskeletal signaling, the cytoskeleton in disease, and chemical approaches to the cytoskeleton. The course format will be a combination of lecture and student-led discussions of hallmark papers. Topics include stem cell biology, cloning, and the relationship between development and disease in addition to the fundamental molecular and cellular mechanisms that control the development of a mature organism from a single cell, the fertilized egg. Emphasis will be place on key experiments or experimental approaches that have yielded significant insight into developmental mechanisms. Some descriptive embryology will be discussed to provide an anatomical basis for the cellular and molecular mechanisms. McCollum Professor and Chair of the Department of Biochemistry and Molecular Biology the Department of Dermatology provides instruction directed at the basic science aspects of the skin and at clinical cutaneous disease during each of the medical school years. The emphasis of the department is upon the pathophysiology of cutaneous reaction patterns, a correlation of skin lesions (gross Pathology) with microscopic changes, the recognition and treatment of diseases that primarily affect the skin and the identification of skin changes that reflect diseases in other organ systems. Students are encouraged to participate in all didactic activities including Grand Rounds and faculty lectures during the time spent in the department. Prerequisites: Internal Medicine, Surgery, Pediatrics, Pathology, and Clinical Clerkship in Dermatology. Students may apply during their 3rd or 4th year for an elective in dermatopathology. Students will attend daily sign out where they will be exposed to a large volume of cases. Additional exposure will come through the use of study sets which are available to the students. The students will attend the Dermatology weekly Grand Rounds where they will see patients and participate in the discussion and presentation of the Pathology for those patients. Additionally, the students will attend two formal dermatopathology teaching sessions per week. Prerequisites: Internal Medicine, Surgery, and Pediatics Students may apply towards the end of their 3rd or 4th year of medical school for a clinical elective in dermatology where the focus is placed on intensive exposure to a large number of patients in different clinical settings. Students will spend time exclusively at the Johns Hopkins facilities (Outpatient Center, Greenspring Station, Bayview Medical Center and Harriett Lane Pediatric Center). Our clinical services at these locations provide an excellent opportunity for students to interact with different types of patients and to be exposed to a wide range of skin problems. Parallel to the clinical activities, there are didactic sessions most mornings and occasionally at the end of the workday as well. Formal lectures on basic dermatology topics are given by dermatology residents and sessions at a more advanced level are taught by faculty members.

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Flat or declining fees from public and private payers appear to be a major contributor to the trend (Tu and Ginsburg, 2006). Although the committee did not locate a 6 8 6 4 Percent Change 2 0 All Physicians ­2 ­4 ­6 ­8 ­10 ­10. Physician income data are based on reported net income from the practice of medicine (after expenses and before taxes). Physician Payment and Conflicts of Interest Researchers and policy makers have devoted considerable attention to the day-to-day incentives for inappropriate clinical practice related to physician payment arrangements. In addition, the appropriate pricing of specific services and categories of services is a concern (see. In general, payment methods have become more complex as public and private health insurers have offered incentive payments to physicians related to quality standards, patient satisfaction, and better patient outcomes (see. Self-Referral and Physician Ownership of Health Care Facilities A former editor of the New England Journal of Medicine observed that "[p]hysicians have been conflicted about their dual roles as professionals and businessmen for millennia, but this dilemma has sharpened in recent years as income from the practice of medicine has faltered" (Kassirer, 2001, p. The dilemma is particularly evident, first, in the growth of physician ownership of (or other business arrangements with) outpatient diagnostic or treatment centers and specialty hospitals to which they refer patients and, second, in the increase in expensive in-office ancillary equipment. As described by Pham and Ginsburg (2007) the allure of profitable services has led to increased physician ownership of ambulatory surgical, imaging, and endoscopy centers and other freestanding facilities such as specialty hospitals. For example, the number of cardiac and orthopedic specialty hospitals serving Medicare patients grew from twenty-one in 1998 to sixty-seven in 2003, the majority of which were for-profit and owned in part by physicians. In addition, physicians have brought the capacity for more diagnostic and therapeutic procedures into their practices. In fact, some research has contradicted claims that physician ownership improves access for underserved populations (see. Concerns about physician self-referral have prompted the passage of complex federal legislation and the implementation of regulations (often collectively referred to as the "Stark laws, " after the sponsor of relevant provisions in the Omnibus Budget Reconciliation Act of 1989 and other legislation). It is too early to evaluate the experience with this requirement, although the discussion reviewed in Chapter 3 suggests that the need for caution in assuming the effectiveness of disclosure alone as a safeguard against making biased recommendations. Department of Health and Human Services submit a report on the types and prevalence of financial arrangements between physicians and hospitals. A recent analysis estimated that pharmaceutical company expenditures for promotional activities were $57. Designated health services include clinical laboratory services; inpatient and outpatient hospital services; diagnostic radiology services; radiation therapy services and supplies; durable medical equipment and supplies; prosthetics, orthotics, and prosthetic devices and supplies; home health care services; physical therapy services; outpatient prescription drugs; occupational therapy services; and parenteral and enteral nutrients, equipment, and supplies. Little information is available on the marketing of medical devices and biologics. Pharmaceutical company representatives use a variety of interpersonal techniques, including gift giving, to establish relationships with physicians and promote their products. In addition, companies have information on individual physician prescribing practices that they can use to target physicians and then monitor the effects of their relationships (Steinbrook, 2006). For example, an article in the Wall Street Journal reported data from a market research firm showing that in 2004 pharmaceutical companies sponsored some 237, 000 meetings or talks that featured physicians and 134, 000 meetings or talks conducted by sales representatives, up from about 60, 000 talks of each type in 1998 (Hensley and Martinez, 2005). The same article also cited an internal study conducted by Merck that estimated that discussion groups led by physicians yield almost twice the benefit in terms of additional prescriptions as discussion groups led by sales representatives. A specific example of the use of physicians for marketing involved a new vaccine for human papillomavirus and cervical cancer. Between July 1, 2006, and June 30, 2007, pharmaceutical companies in that state spent almost $3, 140, 000 on payments to physicians and other providers; 52 percent of the payments were for speaker fees and 30 percent were for food (Sorrell, 2008). As discussed below, companies may A press release from PeopleMetrics Rx about a study of the influence of drug sales representatives on physician prescribing practices stated that the study found "that sales representatives must develop personal relationships with their physicians to achieve the highest levels of engagement" and that "emotional components such as friendship with the reps are the strongest indicators of Fully Engaged physicians [which]. Surveys of Physician Relationships with Industry Surveys show that relationships with industry are common among physicians across the nation. In a national probability sample of more than 3, 100 physicians, 94 percent reported that they had had some type of relationship with industry during the preceding year. These relationships were primarily the receipt of food in the workplace (83 percent) or drug samples (78 percent) (Campbell et al. Thirty-five percent received industry reimbursement for costs associated with professional meetings or continuing medical education; and 28 percent received payments for activities such as consulting, serving on a speakers bureau, or enrolling patients in clinical trials.

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Are the policies administered in a way that appropriately considers the likelihood of bias, the seriousness of the harm, and the potential benefits of the conflicting secondary interest (as noted above)? Do the policies and their application unnecessarily interfere with the conduct of legitimate research, teaching, and clinical practice? Do the anticipated benefits of the policies outweigh their various costs, such as administrative burdens, and any negative consequences? The effectiveness of a specific policy can be judged only after that policy has been in use for a period of time. Insofar as experience and evaluations have raised questions about the effectiveness of similar policies already adopted, however, these questions can guide the design and implementation of new policies. Finally, whether policies can achieve their overall aims will also depend on their congruence with other criteria, such as fairness and transparency, that contribute to effectiveness and that are also important for their own sake. The criterion of proportionality should also be applied in individual situations when an assessment is made of whether a financial relationship constitutes a conflict of interest and, if there is a conflict, how it should be handled. This may sometimes mean that an institution should allow an individual with a conflict of interest to participate in an activity because the expected benefits exceed the risks and because the risks have been lowered to an acceptable level. For example, an academic medical center may allow a scientist who holds the patent on a promising discovery to participate in developing a product and designing an early-stage clinical trial to evaluate an intervention because his or her involvement may be necessary to ensure that the product is safely and correctly administered. Transparent policies are readily available in clear and simple language, together with explanations and essential information about their application. Transparency is essential to determine whether conflict of interest policies are reasonable and if they are being implemented fairly. Conflict of interest policies may require the public disclosure of financial and some other relationships under certain circumstances, as described in Chapter 3. In addition, the values of transparency are also served when institutions explain their judgments in certain cases, for example, when they allow an investigator with a financial stake in the outcome of a study with human participants to conduct that research (see Chapter 4). Rights of privacy and protection of confidentiality place some limits on how much information an institution discloses and to whom. For example, physicians have a countervailing privacy interest when it is proposed that their financial relationships (and perhaps those of their family members) be disclosed to the public, as noted in the discussion in Appendix F of public disclosure of personal information reported to academic medical centers and other institutions. Disclosures beyond the institution can be limited to the minimum amount of identifiable personal information that is needed to carry out policy goals. For some purposes, reporting aggregate or deidentified information to the public is sufficient. Transparency can also help improve conflict of interest policies across institutions. Accountability Accountable individuals and institutions explain and take responsibility for their conduct and decisions. Thus, just as a physician explains the rationale for clinical decisions to patients and researchers explain the rationale for research and research procedures, so too will leaders of accountable institutions explain their policies and their application to the individuals who are directly affected and respond to questions and suggestions. Taking responsibility for the consequences of individual or institutional actions and decisions may involve offering apologies or compensation to those harmed by these actions and acknowledging the appropriateness of penalties when a representative of the institution has acted improperly or illegally. To demonstrate that it is accountable, an institution not only will develop explicit conflict of interest policies and procedures for implementing its policies but also will devise ways to communicate how they are applied in practice. Institutional leaders will be prepared to explain how judgments about conflicts of interest are reasonably consistent across similar cases and why, for example, they determined that it was sufficient to require only the disclosure of a relationship in one case but appropriate to manage or prohibit the relationship in another case. Finally, institutional leaders will be ready to respond to questions about their own interests and impartiality. As discussed in Chapter 8, leaders should establish procedures for dealing with the conflicts that their own institutions may have. For example, accountability is generally enhanced if public representatives serve on institutional panels that review individual relationships that may present conflicts of interest. To cite a somewhat parallel situation, federal regulations require institutional review boards to include at least one member not affiliated with the institution. Also, as part of a commitment to openness and accountability, organizations may invite public comment on their conflict of interest policies and may take seriously suggestions for revisions. Public participation can enhance the credibility and trustworthiness of decisions about individual cases as well as more general policies. A final aspect of accountability is a commitment to improving conflict of interest policies and their implementation. Setting benchmarks for performance and tracking outcomes can stimulate quality improvement activities, as has been demonstrated with other activities in health care organizations.

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Paul Fields is a research scientist with Agriculture and Agri-Food Canada in Winnipeg, Manitoba. He is internationally recognized for his studies on stored-product pest insects, which have been published in 91 peer-reviewed papers, one of which has been cited almost 400 times. He also has authored or co-authored 12 book chapters and 89 conference proceedings. In this latter role, he was instrumental in streamlining the production process to lead the Bulletin into the digital age. Paul also has been a long-time member of the Entomological Society of America (since 1983) and of the Entomological Society of Manitoba (since 1988; president in 2002 and 2015), and was a member of Sigma Xi for 18 years (secretary 1991-1994). Dr Paul Fields est chercheur scientifique а Agriculture et agroalimentaire Canada а Winnipeg, Manitoba. Il est reconnu internationalement pour ses йtudes sur les insectes ravageurs des produits entreposйs, qui ont йtй publiйs dans 91 articles scientifiques, dont un ayant йtй citй presque 400 fois. Il a йgalement йcrit ou co-йcrit 12 chapitres de livres et 89 comptes rendus de confйrences. Monique Keiran received a bachelor of journalism degree from Carleton University in 1989 and has maintained an interest in scientific writing ever since. For a number of years, she worked with the Royal Tyrrell Museum of Palaeontology in Drumheller, Alberta, where she authored many articles and reports, including the book Pachyrhinosaurus: the Mystery of the Horned Dinosaur (Heritage House Publishing, 2006). In 2012 Monique left the Canadian Forest Service to become a freelance journalist, publishing regularly in the newspaper the Victoria Times Colonist. En 2003, elle a dйmйnagй а Victoria, Colombie-Britannique, pour travailler comme agente des publications au Service canadien des forкts. En 2012, Monique a quittй le Service canadien des forкts pour devenir journaliste а la pige, publiant rйguliиrement dans le journal the Victoria Times Colonist. А cette йpoque, elle a йgalement commencй а offrir bйnйvolement de son temps dans la rйvision de manuscrits acceptйs pour publication dans Journal of the Entomological Society of British Columbia. Ashley studied behavior of vervet monkeys for her undergraduate thesis research at Johns Hopkins University, graduating in 2009. She completed internships at the Smithsonian Environmental Research Center, the National Zoo, and the Smithsonian Conservation Biology Institute between her undergraduate and graduate studies. In 2015, she began her current position in the Department of Entomology and Wildlife Ecology at University of Delaware. Outside the realm of entomology, she enjoys volunteering with her therapy dog, running, reading, and costume parties. Ximena Cibils-Stewart (International Branch) grew up in Colonia del Sacramento, Uruguay (South America). In the past, Ximena has been a recipient of numerous awards, including the Research Training Program Stipend Scholarship, supported by the Australian Government Research (2017); Plant Insect Ecosystems Legends of Entomology Award for Masters Student Achievement (2013); and Outstanding Graduate Research Assistant of the Year, sponsored by the Golden Key Honour Society, Kansas State University Chapter (2013). Her focus is on the insect causal agents of two emergent diseases, including thousand cankers disease of walnut and drippy blight disease of red oak. Her work has also looked at insecticide resistance in the European elm scale, the life history of the kermes scale involved in drippy blight disease, and insect involvement in the spread of a bacterial tree pathogen. Forest Service Rocky Mountain Research Station, where she integrates basic entomology, microbiology, and ecology to answer applied research questions that aid management of insect-associated diseases in urban and natural forests. Kunle was born and raised in Lagos, Nigeria, where he received his elementary and high school education. Kunle proceeded to earn a master of science degree in entomology at Auburn University, Alabama, graduating in summer 2015 under the direction of Dr. In the future, Kunle hopes to secure an academic faculty position, where he intends to use the triad of research, teaching, and extension to address food security, especially through crop protection and pest management. His dissertation research focused on several aspects of urban pest behavior, physiology, evolution, and management. Specifically, he evaluated the efficacy and exposure risks associated with total release foggers ("bug bombs") used for German cockroach control.

References:

  • https://www.ennispediatrics.com/storage/app/media/handouts/strep-throat.pdf
  • https://www.hopkinsmedicine.org/gastroenterology_hepatology/_pdfs/liver/hemochromatosis.pdf
  • https://cardiology.medicine.ufl.edu/files/2011/10/EHAC-for-Community-Education.pdf
  • https://www.ucsfbenioffchildrens.org/pdf/manuals/44_Candidiasis.pdf
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