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According to the doctors involved 20 gm cleocin gel overnight delivery skin care shiseido, this happened in 75 percent of the cases without any observable problems to fulfill of the appropriate treatment buy generic cleocin gel 20 gm on line acne upper lip. Second, it was discovered that the rate of remote consultations given by specialist varied depending on referral urgency. Only 10 percent of the most urgent, priority I referrals lead to the use of remote consultation, while the percentage was 30 for category II, and over 50 for the category III referrals. Third, the number of health center patients whose problems got the attention of a specialist through remote consultation, roughly doubled that is from five to ten patient visits out of hundred. This was due to the learning experience to utilize cooperation with specialists in borderline cases. As a fourth effect it can be added the hard to measure effects that frequent exchange of experiences had on learning on health center side. Encouraged by the positive results achieved in internal medicine, the possibility of expanding the system into other disciplines was discussed at Peijas hospital. Orthopedic surgery was used as a comparative case, since its business process is in many ways different. Internal medicine is, by and large, an intellectual process where specialists Copyright © 2005, Idea Group Inc. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. The information used is reasonably well structured and treatment is often medication. In half of the cases videoconferencing was found to work satisfactorily, however, it did not reduce the number of patients that were eventually sent to the hospital. Thus, the relatively cheap e-mail system in internal medicine yielded a better return on investment than the costly videoconferencing system in orthopedic surgery. M anaging Implicit Knowledge in M edicine: Challenge for Shared Knowledge The limits of transferring knowledge as well as managing it only the basis of rational view of man has proved to be inconsistent with the reality of medical experts in many ways (Ferlie, Wood, & Fitzgerald, 1999; Patel, Arocha, & Kaufman, 1999). Medical profession- als produce a great amount of knowledge, which a doctor has but is unable to articulate or quantify easily. In frame of transferring technology managing knowledge refers more explicit than implicit knowledge. To be more precise, most of medical experts transfer more data than practical know-how to each other. The problems with sharing knowledge among a specific districts of medicine rises from the fact that every each of doctor attach a different meanings to data on the basis of their experiences of previous patients. However, studies of social construction, learning and tacit knowledge gives us a opportunity to approach the dilemma in promising way (Argyris, 1999; Berger & Luckmann, 1966; Dixon, 1994; Koskinen, 2001; Polanyi, 1966; Polanyi & Prosch, 1975; Sternberg & Horvarth, 1999). It is commonly accepted scholars that are two basic types of knowledge: explicit knowledge that can be verbalized, such as knowledge of facts and concepts; and implicit knowledge that cannot be made verbal, such as intuition and knowledge of procedures (Patel et al. Even if the conventional synonym of implicit knowledge is tacit knowledge, some of scholars use the concept of tacit meaning structures as well (cf. Tacit knowledge, by definition, refers to the inarticulate aspects or meaning structures that cannot be taught explicitly and therefore are only learnt via direct experience (Dixon, 1994; Patel et al. According to Polanyi and Prosch (1975) textbooks of medicine are so much empty talk in the absence of personal, that tacit knowledge of their subject matter. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. Towards Knowledge Intensive Inter-Organizational Systems in Healthcare 279 of medical expertise in order to understand the role that the acquisition of tacit knowledge plays in competent and expert performance. According to them intensive care decision- making is characterized by a rapid, serial evaluation of options leafing to immediate action. In this real-time decision-making, the reasoning is schema-driven in a forward direction toward action with minimal interference or justification (ibid. Practically this means that doctors are tend to attach meaning to data more on the basis of their experience than logical interpretation of facts.

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This is true especially of the top- teins and therefore are not readily filtered across the ically applied com pound dorzolam ide (Trusopt) discount cleocin gel 20gm on-line 302 skincare. The pends on carbonic anhydrase cheap 20gm cleocin gel overnight delivery acne natural remedies, acetazolam ide has proved drugs then travel along the nephron, presum ably being to be a useful adjunct to the usual therapy for lowering concentrated as fluid is abstracted, until they reach their intraocular pressure. O ral carbonic anhydrase inhibitors are iazide shows any appreciable carbonic anhydrase in- also useful in preventing or treating acute m ountain hibitory activity. A dverse reactions are m inor; they include loss of appetite, drowsiness, confusion, and tingling in the Renal Response extrem ities. A nim al studies have shown som e terato- genic potential, so the use of carbonic anhydrase in- W hen adm inistered at m axim al doses, chlorothiazide hibitors is not recom m ended during the first trim ester m arkedly increases excretion of Na,K,C l, and of pregnancy. M axim al diuresis m ay approach values as high 3 Thiazide Diuretics Thiazide diuretics consist of two distinct groups: those T A B L E 21. The lat- Generic Name Trade Names ter are called thiazidelike diuretics; they include metola- Bendroflum ethiazide Naturetin zone, xipamide, and indapamide. The major thiazide and Benzthiazide A quatag, Exna thiazidelike drugs available in the United States are Chlorothiazide D iuril bendroflumethiazide, benzthiazide, chlorothiazide, hy- H ydrochlorothiazide Esidrix, H ydroD IU RIL H ydroflum ethiazide Saluron, D iucardin drochlorothiazide, hydroflumethiazide, methyclothiazide, M ethyclothiazide Enduron,A quatensen polythiazide, and trichlormethiazide; and chlorthalidone, Polythiazide Renese indapamide, metolazone, and quinethazone, respectively. Trichlorm ethiazide Naqua, M etahydrin D espite the structural distinctions, the drugs share Chlorthalidone H ygroton the functional attribute of increasing sodium and chlo- Indapam ide Lozol M etolazone Zaroxolyn, D iulo ride excretion by inhibiting Na –Cl cotransport in dis- Q uinethazone H ydrom ox tal convoluted tubules. A t usual clinical gestive heart failure, cirrhosis, prem enstrual tension, doses, however, the thiazide diuretics generally increase and horm one therapy. They are widely used in the treat- excretion of Na and Cl, with an accom panying loss of m ent of hypertension whether or not it is accom panied K. They can be used in patients hibitors, the diuresis produced by thiazide and thiazide- with renal disease; however, their diuretic activity is like diuretics is of NaCl and not NaH CO 3. The urinary proportional to the residual tubular functional capacity K wasting induced by the thiazides is prim arily a con- of the kidney. The thiazides do not prevent toxem ia in sequence of the increased Na delivered to the distal pregnancy, nor are they useful in the treatm ent of it. W ith these com pounds, Na excre- tion is increased, while Ca excretion is decreased, pri- Thiazides should be used cautiously in the presence of m arily and directly because of increased distal Ca re- severe renal and hepatic disease, since azotem ia and absorption, secondarily and indirectly because of a com a m ay result. The m ost im portant toxic effect associ- com pensatory elevation of proxim al solute absorption, ated with this class of diuretics is hypokalem ia, which m aking this class of diuretics useful in treating hypercal- m ay result in m uscular and central nervous system ciuria. This effect, which m ay not be evident upon initial sym ptom s, as well as cardiac sensitization (see adm inistration of the drug, is particularly beneficial in H ypokalem ia). A ppropriate dietary and therapeutic m easures their utility in treating nephrogenic diabetes insipidus. The thiazides also possess som e diabetogenic whose kidneys fail to respond to A D H excrete large potential, and although pancreatitis during thiazide volum es of very dilute urine, not unlike those who have therapy has been reported in a few cases, the m ajor an A D H deficiency. The thiazides reduce glom erular fil- m echanism contributing to the potential for glucose in- tration m odestly and decrease positive free water for- tolerance is not known. These actions com bine to cause patients with nephrogenic di- Hypokalem ia and Potassium -sparing abetes insipidus to excrete a som ewhat reduced urine Diuretics volum e with increased osm olality. Hypokalemia Absorption and Elimination The chronic use of som e diuretics m ay require the oral adm inistration of potassium supplem ents or potassium - O rally adm inistered thiazides are rapidly absorbed from sparing diuretics that reduce urinary K excretion. This the gastrointestinal tract and begin to produce diuresis is true especially for patients with congestive heart fail- in about 1 hour. A pproxim ately 50% of an oral dose is ure and cirrhosis, who are particularly sensitive to K excreted in the urine within 6 hours. The presence or absence of clinical sym ptom s of are organic acids and are actively secreted into the prox- hypokalem ia is quite closely related to serum K con- im al tubular fluid by the organic acid secretory m echa- centrations, and even sm all changes in extracellular K nism. M ost patients begin to show their elim ination involving the hepatic–biliary acid se- sym ptom s when serum K levels fall below 2. Neurological sym ptom s include drowsiness, irritabil- The thiazides have a variable effect on elim ination ity, confusion, loss of sensation, dizziness, and com a. A dm inistration of thiazide diuret- lar weakness, cardiac arrhythm ias, tetany, respiratory ar- ics, especially at low doses, m ay elevate serum uric acid rest, and increased sensitivity of the m yocardium to dig- levels and cause goutlike sym ptom s. Clinical Uses Replacem ent should be gradual, with frequent evalua- Thiazides, especially hydrochlorothiazide (D yazide, tion of both serum K concentrations and cardiac activ- Esidrix, H ydroD IURIL, O retic), are useful adjunctive ity (electrocardiographic m onitoring). K supplem ents 21 Diuretic Drugs 247 can be adm inistered in several form s.

Typically buy 20gm cleocin gel fast delivery skin care for winter, judgment is taught Socratically cheap cleocin gel 20 gm free shipping acne studios, by questioning and answering, by building an internal database containing patient symptoms, common syndromes and their treatments, and knowledge about procedures, outcomes, risks, and recovery times. Judgment is usually considered as a case-by-case set of rules that can be internalized, but which are subject to basic hypotheses, principles, and background knowledge. For example, selecting patients appropriately for surgical approaches often involves taking into account past cases from personal experience along with outcomes cited in the evidence-based literature. Typically performed through an apprentice relationship with senior surgeons, it reflects the model of surgical training pioneered by Halsted. Anatomy and technique are learned through observation of a senior surgeon and directly in a supervised setting. The environment can be relatively limited by time and tension because of potential risks or bad outcomes and may not foster education as the primary goal. Additionally, anatomic exposure is necessarily limited to what is clinically war- ranted, and usually this is minimized to improve recovery time, hampering visual- ization in many situations. In this regard, virtual reality simulators may help residents advance sooner by demonstrating more complete dissections and underlying anatomy. Technical expertise is a combination of practice, supervision providing guidance, and the repetitive use of the hands as needed for motor learning. The technical side is currently handled by direct observation and apprenticeship, with progressive responsibility based on certain steps or levels. One training tool is cadaveric dissection that provides residents the potential to improve anatomic understanding, visuospatial perception, and motor skills. Cadav- eric dissections are interactive, three-dimensional, and relatively transferable to the operating room setting. However, dissection also has important limitations including significant costs (preparation, facilities, instructors, and equipment), limited avail- ability of specimens, and the substantial differences between living and cadaveric tissues. Finally cadaveric dissection involves a substantial time commitment and is not amenable to repeated rehearsal of a specific procedure. Animal dissection provides opportunities to improve visuospatial and motor skills, but the technique has both practical and ethical limitations and the anatomic differences are usually significant. Thus, current training involves a large amount of direct intraoperative assisting to allow direct visualization of human anatomy and exposure and small (but key) cadaveric and small animal dissection experience to augment the clinical experience gained over many years. Technical competence is achieved through “gradual delegation of earned responsibility for investigative and operative care to penultimate levels. Learn to relate and work effectively with colleagues in medicine and surgery and other health care professionals and ensure the development © 2005 by CRC Press LLC of a keen sense of responsibility and compassion toward patients and their families 5. Understand the impacts of neurosurgery on society including medical ethics, health care economics, law, prevention of disease, and promotion of health 6. Develop an understanding of clinical and basic research techniques includ- ing biostatistics and epidemiology Residents must assume graduated responsibility throughout the course of their residencies in terms of background knowledge, pre- and postoperative management, operative experience and independence in decision making. However, supervision is critical to a training program, and feedback from more experienced individuals is essential to education along with a constant and sincere effort to learn on the part of the resident. Patient care is the core background to neurosurgical education and thus intimate knowledge of patients forms the basis for informed decision making and increased participation by residents in patient care decisions and management. The objectives for technical competence build upon progressive training experience in neurosurgical procedures, usually in an apprenticeship mode under direct supervision. The current fixed length residency program is relatively short, compared to the large number of judgment skills, procedures, and care issues that must be adequately taught. For that reason, some flexibility in training length may be important to accommodate and overcome such differences. These limitations are compounded by insufficient exposure to and understanding of less common cases because residents commonly handle more common situations. The skills routinely taught in most residency programs are primarily aimed at a high quality clinical practice situations. They are not necessarily directed toward academic investigations in the fields of basic neuroscience, translational neuro- science, or clinical neuroscience. For many years, the minimum requirement for the adequate pursuit of quality basic neuroscience has been at least 3 to 5 years of experience beyond residency, at the graduate student (i. Unless a clinician investigator is competitive in obtaining funding, it is unlikely that research of sufficiently high quality will continue to make valuable contributions to neurosurgery and the wider field of neuroscience.

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A neonate is given drug A generic cleocin gel 20 gm line acne 6 months after accutane, a compound with a high (A) Impairing diffusion of lipid soluble drugs affinity for plasma proteins discount cleocin gel 20gm free shipping acne quistes, in a dose that does not (B) Preventing the passage of drugs having a mo- exceed the binding capacity of albumin. Neonates having a patent ductus arteriosus can be (A) The free plasma concentration of drug A is de- treated with which agent to induce a relatively rapid creased. Which of the following is an accurate description of (E) The free plasma concentration of drug B changes taking place in elderly individuals com- would likely be markedly increased if drug A were pared to younger adults? He is taking a thi- its albumin binding site and lead to an increase in azide diuretic (A) for mild hypertension, digitalis free drug. The latter is then available to be distrib- (B) for congestive heart failure, and an oral hypo- uted outside the blood compartment and reach tis- glycemic agent (C) for mild type 2 diabetes. The elderly are frequently sensitive to the pul- relief when he broke his arm 30 years ago is pre- monary depressing actions of opioid analgesics. Johnson is seen in These agents should be used with caution in the the emergency department complaining of short- elderly until an adequate dosage has been deter- ness of breath and a feeling of suffocation. This does not mean the drugs he is receiving is a likely possible cause of that the older patient should not be given opioid this particular symptom? The placenta can SUPPLEMENTAL READING carry out a number of drug metabolizing reactions, Avorn J and Gurwitz JH. Jones celebrated her 71st birthday by with active metabolites, such as diazepam, would Mtaking her grandchildren to the park. She has no pain now but is too uncomfortable Jones because of the increase in body fat and with the cast to sleep well. She has tried soothing decreased renal excretion that are typical for music, reading, and relaxing techniques but is still persons of her age. Reasor The discipline of toxicology considers the adverse MANIFESTATIONS OF TOXICITY effects of chemicals, including drugs, and other agents, such as biological toxins and radiation, on biological Organ Toxicity systems. Toxicity associated with drug action can gener- ally be characterized as either an extension of the ther- The events that initiate cell death are not completely apeutic effect, such as the fatal central nervous system understood. The common final stages of necrotic cell (CNS) depression that may follow a barbiturate over- death are disruption of normal metabolic processes and dose, or as an effect that is unrelated to the therapeutic ensuing inability to maintain intracellular electrolyte effect, such as the liver damage that may result from an homeostasis. At the same tissue response associated with the latter type of drug time, other cells show apoptotic cell death, character- toxicity and on the toxicities associated with several im- ized by cell shrinkage, cleavage of DNA between nucle- portant classes of nontherapeutic agents. Some chem- The target organ for the expression of xenobiotic icals are metabolized to reactive products that bind to toxicity is not necessarily the tissue or organ in which cellular macromolecules. If such binding impairs the the drug produces its therapeutic effect, nor is it neces- function of crucial macromolecules, cell viability is lost. Drugs such as acetaminophen cause necrosis in the centrilobular portion of the liver at a site Pulmonary Toxicity of the monooxygenase enzymes that bioactivate the analgesic. Inhaled gases, solid particles, or liquid aerosols may de- It is necessary to distinguish between the intrinsic posit throughout the respiratory system, depending on toxicity of a chemical and the hazard it poses. The large surface chemical may have high intrinsic toxicity, it may pose area of the respiratory passages and alveolar region and little or no hazard if exposure is low. In contrast, a rela- the large volume of air delivered to that area (approxi- tively nontoxic chemical may be quite hazardous if ex- mately 6–7 L/minute in a young man) provide great op- posure is large or the route of exposure is not physio- portunity for interaction between inhaled materials and logical. Examples of inhaled xenobiotics that cause 63 64 I GENERAL PRINCIPLES OF PHARMACOLOGY lung damage and those that have entered the body by midzonal area (midway between the portal triad and ingestion, injection, or dermal absorption are presented central vein). A single large dose of a hepato- number of disease conditions including bronchitis, em- toxin may cause liver necrosis yet resolve with little or physema, asthma, hypersensitivity pneumonitis, pneu- no tissue scarring. During repair, damaged lung agent, however, can result in hepatic cirrhosis and per- alveolar epithelium may be replaced by fibrous tissue manent scarring. Other agents cause severe (chlorpromazine) or mild (estrogens) Hepatotoxicity cholestatic liver damage, including cholestasis and inflam- mation of the portal triad and hepatocellular necrosis. The blood draining the stomach and small intestine is delivered directly to the liver via the hepatic portal vein, Nephrotoxicity thus exposing the liver to relatively large concentrations of ingested drugs or toxicants (e. Hepatic ex- The kidneys are susceptible to toxicity from xenobiotics posure to agents that undergo bioactivation to toxic (Fig. Proximal tubule cells phen or chloroform, that undergo bioactivation to toxic are generally the site of nephrotoxicity, since these cells intermediates cause necrosis of the cells surrounding have an abundance of cytochrome P450 and can trans- the central veins (centrilobular) because the compo- port organic anions and cations from the blood into the nents of the cytochrome P450 system are found in those cells, thereby concentrating these chemicals manyfold. At higher doses or in the presence of Chemically induced kidney damage is typically seen agents that increase the synthesis of cytochrome P450 as acute tubular necrosis (ATN).

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