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The Canadian Journal of Psychiatry / La Revue canadienne de psychiatrie 2004;49(1):24-30 buy phenazopyridine 200mg. Cost-benefit analysis of a new health insurance card and electronic prescription in Germany 200mg phenazopyridine amex. Information technology for clinical guideline implementation: Perceptions of multidisciplinary stakeholders generic phenazopyridine 200mg with amex. Implementation of an electronic medication system and disregarded power of the record. A randomised, clinical trial comparing the effectiveness of hospital and community-based reminder systems for increasing uptake of influenza and pneumococcal vaccine in hospitalised patients aged 65 years and over. Decision support considerations in the development and implementation of an electronic medical record. Bar code medication administration: Lessons learned from three years of preparation. Employing clinical decision support to attain our strategic goal: the safe care of the surgical patient. Venous thromboembolism prevention: A systematic review of methods to improve prophylaxis and decrease events in the hospitalized patient. Remote automated dispensing system reduces costs and improves inpatient hospice care. Results and imapct of electronic prescribing (e-Rx) use: 3rd Teleconference in a series of four on the medicare modernization act e-Rx pilot evaluation. A European survey on the possibilities and obstacles of electronic prescriptions in cross-border healthcare. Evaluation of infusion pump errors and the potential impact of “smart” pump technology. End-user perceptions of a computerized medication system: is there resistance to change? Primary Care Health Information System: a hybrid electronic-paper medical record system. The association between quality of care and the intensity of diabetes disease management programs. Computerized physician order entry: Strategic issues for Australian hospital pharmacists. Steps to design and implement a system to meet your institution needs: Case study. Northwestern Medical Center - Experiences in the development, implementation and testing of an ideal medication management system. The impact of a computerized potassium alert on adverse drug events and pharmacists’ interventions. Design, implementation and management of automated pharmacy application and medication management standards for 69 facilities within a nationwide for- profit healthcare organization. A prospective controlled study of a computer- assisted acenocoumarol dosage program. Proceedings - the Annual Symposium on Computer Applications in Medical Care 1994;846-50. Information technology for medication administration: Assessing bedside readiness among nurses in Lebanon. Improving influenza vaccination rates in a pediatric asthma management program by utilization of an electronic medical record. 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Perfecting the handheld computer for older adults: From cognitive theory to practical application. Effects of the clinical environment on physicians’ response to postgraduate medical education. Randomised controlled trial of computer assisted management of hypertension in primary care. Multidisciplinary process to ensure effective implementation of an advanced physician order entry system. Rising the bar: An Illinois medical center decides “really good” isn’t good enough and sets out to lower an already low adverse drug event rate. The New York City health and hospitals corporation: Transforming a public safety net delivery system to achieve higher performance. Implementation of a barcoded medication software system within an intravenous admixture area to track medication preparation and delivery, and improve workflow. Lessons from a randomized controlled trial designed to evaluate computer decision support software to improve the management of asthma. The medical gopher - A microcomputer system to help find, organize and decide about patient data. Effects of computer reminders for influenza vaccination on morbidity during influenza epidemics. A study of perceived efficiency and perceived effectiveness when using healthcare informatics: A study at the District of Columbia Veterans Affairs Hospital The George Washington UniversityEditor. Electronic information access in support of clinical decision making: a comparative study of the impact on rural health care outcomes. Development of custom, barcode- enabled label printing software to improve the safety of medication repackaging. Improving adherence to dyslipidemia medication guidelines in hospitalized diabetic patients using a technology-assisted pharmacist intervention. A comparison of community pharmacy-based studies of pharmaceutical care for patients with asthma. Value of medication reconciliation in reducing medication errors on admission to hospital.

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Almost every cancer site can metastasize to the liver buy 200 mg phenazopyridine overnight delivery, and liver metastases represent systemic disease purchase 200mg phenazopyridine amex. Only in the specific setting of colon and rectal cancer can liver metastases poten- tially represent regional disease without systemic spread phenazopyridine 200mg for sale. Patients with one or several metastases technically amenable to resection and no sign of systemic disease can expect a 25% to 35% 5-year survival 414 T. Patients with symptomatic liver metastases from neuroendocrine tumors also benefit from liver resection even if this is not curative. Primary malignant liver tumors are rare in the United States, but worldwide these represent a significant cancer burden. Hepatocellular carcinoma (also known as hepatoma) usually arises in patients with cirrhosis. The underlying parenchymal liver disease severely limits the ability to safely perform liver resection in most patients. Patients undergoing liver transplantation for end-stage liver disease sometimes have incidentally discovered small hepatomas. Other forms of primary liver tumors include intrahepatic cholangiocarcinoma and angiosarcoma. The diagnosis usually can be obtained with core needle biopsy or fine- needle aspiration. Occasionally, biopsy requires laparoscopic or open surgical techniques, but this situation is rare. In South American or Mediterranean countries and Australia, echinococcal (hydatid) cysts are prevalent. Examination of patient selection and outcome for hepatic resection for metastatic disease. Resection of the liver of colorectal carcinoma metastases: a multi- institutional study of indications for resection. One hundred patients with hepatic metastases from colorectal cancer treated by resection: analysis of prognostic determinants. Perioperative blood transfusion and determinants of survival after liver resection for metastatic colorectal carcinoma. Experience in hepatic resection for metastatic colorectal cancer: analysis of clinical and pathologic risk factors. A new macroscopic classification predicts prognosis for patient with liver metas- tases from colorectal cancer. Resection of hepatic and pulmonary metastases in patients with colorectal car- cinoma. Treatment requires excision of the cyst, with special care taken to avoid spillage of the parasitic contents. Pyogenic bac- terial abscess usually follows an episode of biliary or gastrointestinal tract sepsis. Treatment with metronidazole is effective, and drain- age is required only in complicated cases. Pancreatic Masses In Case 2, the patient’s history and examination immediately do not suggest the cause of her problem. The head and body of the pancreas were well visualized, but the tail seemed to blend into the mass. The mass did not appear to invade surround- ing structures and radiographically appeared resectable. The pancreatic duct in the tail of the pan- creas did not communicate with the mass, but it was displaced cau- dally. The presentation of a pancreatic mass is dependent on the location and nature of the mass. Masses in the head of the pancreas (usually neoplasms) obstruct the common bile duct due to proximity. These patients present with obstructive jaundice, and the masses tend to be only a few centimeters in diameter. Neoplasms in the body or tail of the pancreas grow larger and cause symptoms by impinging on sur- rounding structures. In this case, the mass had caused splenic vein thrombosis, leading to bleeding gastric varices from left-sided portal hypertension. Pancreatic enlargement associated with pan- creatitis usually involves signs of systemic inflammation. An algorithm for the evaluation and treatment of pancreatic masses is pre- sented in Algorithm 22. Classically, tumors of the body and tail of the pancreas grow silently and eventually produce symp- toms by invasion of surrounding organs. Tumors of the head of the pancreas occasionally come to attention earlier due to the development of obstructive jaundice. Kearney of the common bile duct to the head of the pancreas allows small pan- creatic tumors the opportunity to obstruct the bile duct. A patient with painless obstructive jaundice should be assumed to have pancreatic cancer until proven otherwise. A small proportion of such patients (15%) have no evidence of systemic disease on imaging. These patients are candidates for curative pancreaticoduodenectomy (Whipple proce- dure). Patients with potentially resectable cancers of the head of the pancreas should not undergo percutaneous needle biopsy. This pro- cedure may risk seeding the abdominal cavity and eliminating a chance of cure. The techniques of pancreatic surgery are advanced enough that mortality rates should be under 3% at specialized centers. If the tumor is technically resectable, the surgeon must be pre- pared to perform definitive resection without a tissue diagnosis. Five- year survival may be as high as 20% with truly localized disease resected with a negative margin and combined with adjuvant therapy. The differential diagnosis is between a true cystic neoplasm and a pancreatic pseudocyst. Persistent pain and the development of an abdominal mass follow- ing a bout of acute pancreatitis should raise suspicion about a pseudo- cyst. About one third to one half of acute pseudocysts resolve spontaneously within about 6 weeks. Chronic pseudocysts with symptoms of pain, obstruction, and infection usually require treatment.

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The physician who treats these management of visual disorders cheap 200 mg phenazopyridine overnight delivery, the medical services disorders is called an otolaryngologist generic 200mg phenazopyridine fast delivery. Audiologists are the medical specialty concerned with disorders of the allied health-care professionals who work with eye buy 200mg phenazopyridine with amex. The physician who treats these disorders is called patients with hearing, balance, and related problems. Optometrists work with ophthal- They perform hearing examinations, evaluate hear- mologists in a medical practice or practice independ- ing loss, clean and irrigate the ear canal, fit and dis- ently. They diagnose vision provide audiological rehabilitation, including audi- problems and eye disease,prescribe eyeglasses and con- tory training and instruction in speech or lip reading. Although they cannot perform surgery, they common- Eye Disorders ly provide preoperative and postoperative care. A complete examination myopia, the eyeball is too short and the image falls of the eye and its adnexa is necessary to identify behind the retina. Distant objects are seen and lacrimal structures are examined and intraoc- clearly, but near objects are not in proper focus. If infection is another form of ametropia called astigmatism detected, it must be located and identified by cul- (Ast), the cornea or lens has a defective curvature. An alternative to cor- important because many eye disorders have a genet- rective lenses is laser-assisted in situ ker- ic predisposition, including glaucoma. This procedure disorders include errors of refraction, cataracts, changes the shape of the cornea and, in most glaucoma, strabismus, and macular degeneration. The flap Errors of Refraction is lifted to the side while a laser reshapes the An error of refraction (ametropia) exists when underlying corneal tissue. The proce- may be due to a defect in the lens, cornea, or the dure usually takes less than 15 minutes. Some image falls in front of the retina, causing near- medical conditions, certain medications, or the sightedness. Glaucoma may occur as a primary or con- Cataracts are opacities that form on the lens and genital disease or secondary to other causes, such impair vision. These opacities are commonly pro- as injury, infection, surgery, or prolonged topical duced by protein that slowly builds up over time until corticosteroid use. Chronic glaucoma may produce result of genetic defects or maternal rubella during no symptoms except gradual loss of peripheral the first trimester of pregnancy. Headaches, blurred cataract is treated in the same manner as age-related vision, and dull pain in the eye may also be pres- cataract. Cupping of the optic discs may be noted on ed lens by emulsifying it using ultrasound or a laser ophthalmoscopic examination. If particles that can be removed through the tiny inci- untreated, acute glaucoma causes complete and sion. The surgery ing test that measures intraocular pressure by is usually performed using a topical anesthetic, and determining the resistance of the eyeball to inden- the incision normally does not require stitches. Treatment for glaucoma all of them eventually lead to blindness unless the includes medications that cause the pupils to con- condition is detected and treated in its early strict (miotics), which permits aqueous humor to Artificial lens Lens capsule Cataract removal Artificial lens insertion Figure 15-5. Eye showing normal flow of aqueous humor (yellow arrows) and abnormal flow of aqueous humor (red arrow) causing destruction of optic nerve. The devi- Strabismus ation may be a constant condition or may arise Strabismus, also called heterotropia or tropia, is a intermittently with stress, exhaustion, or illness. Applanation tonometry using a slit lamp to measure intraoc- ular pressure (courtesy of Richard H. Blood and other fluids leak but not always, associated with “lazy-eye syn- from these vessels and destroy the visual cells, leading drome” (amblyopia). Vision is suppressed in the to severe loss of central vision and permanent visual “lazy” eye so that the child uses only the “good” eye impairment. The vision pathway fails to develop in gery can be employed to destroy the newly forming the “lazy” eye. There is a critical period during which ambly- It is successful in about one half of the patients with opia must be corrected, usually before age 6. However, the effects of the procedure detected and treated early in life, amblyopia can commonly do not last and new vessels begin to form. It commonly drusen develop on the macula and interfere with consists of covering the normal eye, forcing the central vision. However, the most common culprit is most commonly affected is the stapes, the bone Streptococcus pneumoniae. In the patient perceives a ringing sound (tinnitus) its most severe form, otitis media may lead to infec- within the ear, along with dizziness and a progres- tion of the mastoid process (mastoiditis) or inflam- sive loss of hearing, especially of low tones. De- mation of brain tissue near the middle ear (otoen- velopment of otosclerosis is typically closely tied cephalitis). Recurrent episodes of otitis media may to genetic factors; if one or both parents have the cause scarring of the tympanic membrane, leading disorder, the child is at high risk for developing to hearing loss. Surgical correction involves removing medications to relieve pain (analgesics), and part of the stapes (stapedectomy or, more com- antibiotics. Occasionally, an incision of the eardrum monly, stapedotomy) and implanting a prosthetic (myringotomy, tympanotomy) may be necessary device that allows sound waves to pass to the inner to relieve pressure and promote drainage. The procedure requires only a local anesthetic The usual treatment for children with recurrent and usually lasts only 45 minutes. Hearing is infection is the use of pressure-equalizing tubes immediately restored. Malignant tumors of the ear include basal cell retinoblastoma, found primarily in children, and carcinoma and squamous cell tumors. Most re- common ear malignancy is basal cell carcinoma, tinoblastomas tend to be familial. The cell involved which usually occurs on the top of the pinna as is the retinal neuron. It is found more com- about 30% of patients, the disease is found in both monly in elderly patients or those with fair eyes (bilateral). Small, craterlike ulcers form as the disease the bony cavity of the eyeball, the iris, or the ciliary progresses. Basal cell carcinoma does not readily body, but it arises most commonly in the pigment- metastasize; however, failure to treat it in a time- ed cells of the choroid. The disease is usually asymp- ly manner may result in the need for extensive tomatic until there is a hemorrhage into the anteri- surgery to remove the tumor. Any discrete, fleshy mass on the iris cinoma, on the other hand, is much more inva- should be examined by an ophthalmologist. Squamous cell carcinoma the removal of the affected eye(s) (enucleation), grows more slowly than basal cell carcinoma; followed by radiation.

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Especially um cheap 200 mg phenazopyridine with amex, most people that develop a mental illness phenazopyridine 200 mg with visa, they won’t um buy generic phenazopyridine 200 mg line, want to accept it straight away. And um, they’ll always just say, I had plans for my life and whether it’s-, you’re older or younger you know, it’s not a nice feeling. You may, you may enjoy it when you’re manic a little bit but the downer way outweighs that. But um, I have to say to you, the first step is, is, is you know, there’s a few different steps in the acceptance, one is like, ok, so I’ve got an illness but the other is to move forward and start making things happen for your life. My friends were out partying, doing everything that teenagers should be doing, you know 91 and I was sitting at home, hearing voices, hyper-ventilating and sleeping about two hours a night so um- Travis illustrates the difficulty of accepting that one has a mental illness by contrasting his late teenage years with those of typical, mentally- healthy peers; “My friends were out partying, doing everything that teenagers should be doing, you know and I was sitting at home, hearing voices, hyper-ventilating and sleeping about two hours a night”. Travis’ contrast between him and his friends when younger also functions to highlight how mental illness can be isolating and, thus, acceptance of one’s diagnosis and that one is different from their peers could be undesirable, similar to Cassie in the earlier extract. Therefore, as with Cassie, denial of having a mental illness could serve a protective function for first-episode consumers as they avoid dealing with the realities of having a mental illness. Travis indicates that only once acceptance takes place can positive actions ensue. It is implied that adherence is one of these positive actions that can follow once awareness that one has a mental illness is gained. As was the case with Bill and Cassie in earlier extracts, taking medication represented admitting to being different for Travis and was, thus, avoided in the early stages of his illness. In addition to highlighting how denial of having a mental illness can lead to non-adherence, as previous extracts have done, the following extract also indicates that once insight that one has an illness is gained, adherence to treatment may follow. Ryan, 26/09/2008 92 R: It’s a positive sign if they uh, if they uh, say own up to what they’re experiencing. Sometimes it’s just like I was the first time, just um, deny that they have a problem and then it’s kinda like, they just detain you in hospital for longer until I do realise, work out that it is a problem, then treat it with the medication. Based on his personal experiences, Ryan states that it is a “positive sign” if consumers are able to acknowledge their mental illness but points out that, unfortunately, denial is common amongst first episode consumers, consistent with his experience. Ryan indicates that denial often leads to longer periods of detainment in hospital, which can lead the consumer to then “realise” or “work out” that their mental illness is problematic and requires treatment with medication. He does not indicate the mechanism by which this realization is gained but rather frames it as merely proceeding hospitalisation. Thus, it is unclear as to whether Ryan is suggesting that he, like other consumers, gained insight from being able to self-reflect, for example, in hospital, or whether he noticed how medication improved his symptoms. Alternatively, Ryan could be interpreted as indicating that prolonged incarceration of consumers leads them to conclude that they must be sick or that the only means of being discharged from hospital is for them to be medication adherent. The following extract highlights how medication non-adherence and relapse can represent a vicious cycle, especially for consumers whose insight into having an illness depletes as their symptoms exacerbate. This extract provides support for lack of insight as a diagnostic criterion for schizophrenia, which may become more pronounced during symptom flare- ups. If you don’t think you’re sick I guess you’re not going to take your medication either. I’ve got people on the inside [peers] who know if they’re getting ill so they seek help quick. L: So it kind of reaches a point maybe, like when you get sick, you find you just can’t tell what’s real and what’s not. In the above extract, whilst Matthew states that he has retrospective insight that he has a mental illness, he indicates that during episodes, he lacks insight (“Now I’ve got insight but when I’m unwell, I haven’t”). That is, as Matthew’s symptoms worsen, so too does his awareness of his symptoms (“I’m sick and I don’t know I’m sick”). It could be assumed that some consumers, like Matthew, for example, may become encompassed by their symptoms such as delusions and hallucinations which may compromise their abilities to identify such experiences as illness symptoms, which could thereby lead to non-adherence. This extract is different from previous extracts, which primarily related to first or early episode experiences of consumers who were in denial about having a mental illness as Matthew states that he loses insight when his symptoms become worse and concurs 94 with the interviewer that he then stops taking his medication. Matthew indicates that whilst early intervention is possible for peers who are aware that they have schizophrenia and can recognize when their symptoms are returning, he has to wait for other people to detect signs that he is relapsing. Specifically his “mum” and his “mental health” team have been able to identify warning signs of symptom fluctuations in the past. Matthew could be interpreted to imply that insight in relation to warning signs or triggers for symptom relapse can assist with adherence or at least enhance outcomes for consumers in terms of illness stability, by highlighting that his peers who have insight seek help as needed, thus, potentially avoiding negative consequences (“I’ve got people on the inside who know if they’re getting ill so they seek help quick. That is, rather than attributing their auditory hallucinations, for example, to mental illness, they attribute them to external sources, such that a consumer may believe that they are actually talking to God, as is the example used by Katherine. Whilst Katherine talks in general terms about spiritual experiences, Margaret describes how she used to believe the voices she was hearing were real. Katherine, 05/02/2009 L: So could you think of any strategies, or anything that you think could be useful to encourage some of these people then to stay adherent? K: Um, it’s really difficult because a lot of them don’t have insight, like a lot of schizophrenics, like you said, think it’s a gift. K: Because they don’t see the, like, they might think, yes they do talk to God and why should I take this medication? Margaret, 04/02/2009 M: I mean I believed in ‘em implicitly til about two to three years back when I thought, you know, this is not a gift. And it was once I started accepting that that I got better and took my medication. In the first extract, Katherine constructs a consumer’s interpretation of their hallucinations as spiritual experiences and not as illness symptoms as a barrier to adherence (“like a lot of schizophrenics, like you said, think it’s a gift. According to Katherine, this type of insight, which again involves a denial of having a mental illness, leads consumers to perceive medication as unnecessary or as interfering with their “gift” and, thus, non- adherence seems a logical choice following this reasoning (“why should I take this medication? Katherine frames overcoming this lack of awareness of illness symptoms as extremely “difficult”, possibly because it involves challenging consumers’ subjective experiences and belief systems. In the second extract, Margaret recalls how she interpreted her symptoms as a “gift” in the past and “believed in” her hallucinations/delusions. Although not included in this extract, during her interview, Margaret stated that she refused to take her medication in the past on the grounds that she did not see the need for it nor did she want her “gift” 96 interfered with. Margaret connects gaining insight and, thus, “accepting” her illness diagnosis “two to three years back”, to improved outcomes and medication adherence (“I got better and took my medication”). The above interviewees both, therefore, frame a lack of awareness of the symptoms of schizophrenia, such as hallucinations, and attributions of symptoms to sources other than mental illness, as negatively influencing adherence; insight into diagnoses and “acceptance” of diagnoses are framed as integral to adherence. That is, consumers may be unaware of the risk of relapse following medication non-adherence. In extracts presented in this sub-code, interviewees frequently attributed medication non-adherence to subjective feelings of improvement or wellness. A common justification for medication non-adherence as a result of feeling better was simply the misperception that they were cured once their symptoms were relieved by medication. It is also possible that some interviewees did not necessarily assume they were cured but did not associate subjective feelings of wellness and symptom relief with taking medication. Interviewees often attributed their past lack of insight which led to non-adherence to inadequate professional advice in relation to the consequences of non-adherence.