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In diagnosis was inappropriately delayed in 9% purchase lasix mastercard, and a third this section buy lasix without a prescription, we review data from a wide variety of sources 29 of these reflected misreading of the mammogram cheap lasix online american express. Several studies have ex- frequently recommending biopsies for what turn out to be amined changes in diagnosis after a second opinion. Given the differences regarding insurance 17 coverage and the medical malpractice systems between and associates, using telemedicine consultations with spe- cialists in a variety of fields, found a 5% change in diagno- the United States and the United Kingdom, it is not sis. There is a wealth of information in the perceptual surprising that women in the United States are twice as specialties using second opinions to judge the rate of diag- likely as women in the United Kingdom to have a neg- 30 nostic error. It is important to emphasize that only a fraction of the 18,27,31–46 studies that have measured the rate of diagnos- discordance in these studies was found to cause harm. An unsettling consistency emerges: the frequency of diagnostic error is disappoint- Dermatology. For exam- tions and disorders where rapid and accurate diagnosis is ple, in a study of 5,136 biopsies, a major change in diag- essential, such as myocardial infarction, pulmonary em- nosis was encountered in 11% on second review. Of6 at ien t w ho died o fp ulm o n ar y em b o li m , he diagn o s i w as n o t us ect ed clin ically in L eder le et al( up ur ed ao r ic an eur ys m eview o fallcas es at a in gle m edicalcen t er o ver a yr er io d. Of2 cas es in vo lvin g ab do m in alan eur ys m s vo n o do li ch et al diagn o s i o fr up ur ed an eur ys m w as in iially m i ed in in at ien t es en t in g w ih ches ain , ( diagn o s i o fdi ect in g an eur ys m o ft he p o xim alao r a w as m i ed in o fcas es E dlo w Sub ar achn o id hem o r hage Up dat ed eview o fp ub li hed udies o n ub ar achn o id hem o r hage: ar e m i diagn o s ed o n in iialevaluat io n B ur o n et al( an cer det ect io n ut o p y s udy at a in gle ho s ial o ft he 2 m align an t n eo p las m s fo un d at aut o p y, w er e eiher m i diagn o s ed o r un diagn o s ed, an d in o ft he cas es he caus e o fdeat h w as judged o b e r elat ed o he can cer B eam et al( eas can cer accr edied cen t er agr eed o eview m am m o gr am s o f7 w o m en , o fw ho m had b r eas can cer he can cer w o uld have b een m i ed in M cG in n i et al( elan o m a Seco n d eview o f5 b io p y s am p les diagn o s i chan ged in fo m b en ign o m align an t fo m m align an t o b en ign , an d had a chan ge in um o r gr ade) Per li i o lar di o r der The in iialdiagn o s i w as w r o n g in o fp at ien t w ih b i o lar di o r der an d delays in es ab li hin g he co r ect diagn o s i w er e co m m o n G affet al( en dicii et o s ect ive s udy at ho s ial o fp at ien t w ih ab do m in alp ain an d o p er at io n s fo r ap en dicii Of1 p at ien t w ho had ur ger y, her e w as n o ap en dicii in o f9 at ien t w ih a fin aldiagn o s i o f ap en dicii he diagn o s i w as m i ed o r w r o n g in R aab et al( an cer at ho lo gy The feq uen cy o fer o r in diagn o s in g can cer w as m eas ur ed at ho s ial o ver a yr er io d. The autopsy has been described as “the What Percentage of Adverse Events is 47 most powerful tool in the history of medicine” and the Attributable to Diagnostic Errors and What “gold standard” for detecting diagnostic errors. Richard Percentage of Diagnostic Errors Leads to Cabot correlated case records with autopsy findings in Adverse Events? In the Harvard Medical Practice Study of tween clinical and autopsy diagnoses were found in a 30,195 hospital records, diagnostic errors accounted for more recent study of geriatric patients in the Nether- 58,59 50 17% of adverse events. On average, 10% of autopsies revealed that the study of 15,000 records from Colorado and Utah reported clinical diagnosis was wrong, and 25% revealed a new that diagnostic errors contributed to 6. Using the same methodology, the Canadian a fraction of these discrepancies reflected incidental find- Adverse Events Study found that 10. The Qual- crepancies that potentially could have changed the out- ity in Australian Health Care Study identified 2,351 ad- come were found in approximately 10% of all verse events related to hospitalization, of which 20% 32,51 autopsies. A large study in New Zealand examined 6,579 cause the diagnostic error rate is almost certainly lower inpatient medical records from admissions in 1998 and among patients with the condition who are still alive, found that diagnostic errors accounted for 8% of adverse 63 error rates measured solely from autopsy data may be events; 11. That is, clinicians are attempting to make the diagnosis among living patients before death, so the more Error Databases. Although of limited use in quantifying relevant statistic in this setting is the sensitivity of clin- the absolute incidence of diagnostic errors, voluntary error- ical diagnosis. For example, whereas autopsy studies reporting systems provide insight into the relative incidence suggest that fatal pulmonary embolism is misdiagnosed of diagnostic errors compared with medication errors, treat- approximately 55% of the time (see Table 1), the misdi- ment errors, and other major categories. Out of 805 volun- agnosis rate for all cases of pulmonary embolism is only tary reports of medical errors from 324 Australian physi- 32 cians, there were 275 diagnostic errors (34%) submitted 4%. Shojania and associates argue that a large discrep- 64 ancy also exists regarding the misdiagnosis rate for myo- over a 20-month period. Compared with medication and treatment errors, diagnostic errors were judged to have cardial infarction: although autopsy data suggest roughly caused the most harm, but were the least preventable. A 20% of these events are missed, data from the clinical smaller study reported a 14% relative incidence of diagnos- setting (patients presenting with chest pain or other rel- tic errors from Australian physicians and 12% from physi- evant symptoms) indicate that only 2% to 4% are missed. Mandatory error-reporting sys- tems that rely on self-reporting typically yield fewer error reports than are found using other methodologies. One method of test- ample, only 9 diagnostic errors were reported out of almost ing diagnostic accuracy is to control for variations in case 1 million ambulatory visits over a 5. One such Diagnostic errors are the most common adverse event approach is to incorporate what are termed standardized 67,68 reported by medical trainees. Other studies using different majority of claims filed reflect a very small subset of diag- types of standardized cases have found that not only is noses. For example, 93% of claims in the Australian registry there variation between providers who analyze the same reflect just 6 scenarios (failure to diagnose cancer, injuries 27,56 case but that physicians can even disagree with them- after trauma, surgical problems, infections, heart attacks, selves when presented again with a case they have pre- 73 and venous thromboembolic disease). As hand, given the fragmentation of care in the outpatient 75 76 77 Schiff, Redelmeier, and Gandhi and colleagues advo- setting, the difficulty of tracking patients, and the amount of cate, much better methods for tracking and follow-up of time it often takes for a clear picture of the disease to patients are needed. For some authors, diagnostic errors that emerge, these data may actually underestimate the extent of 82 do not result in serious harm are not even considered mis- error, especially in ambulatory settings. This is little consolation, however, for the act frequency may be difficult to determine precisely, it is patients who suffer the consequences of these mistakes. The clear that an extensive and ever-growing literature confirms increasing adoption of electronic medical records, espe- that diagnostic errors exist at nontrivial and sometimes cially in ambulatory practices, will lead to better data for alarming rates. These studies span every specialty and vir- answering this question; research should be conducted to tually every dimension of both inpatient and outpatient care. We don’t the many advances in medical imaging and diagnostic test- need an autopsy to find out. Although the autopsy rate 78 decreased over these years from 88% to 36%, the misdiag- As Kirch and Schafii note, autopsies not only docu- 78 ment the presence of diagnostic errors, they also provide an nosis rate was stable. The rate of autopsy ably reflects 2 factors that offset each other: diagnostic in the United States is not measured any more, but is widely accuracy actually has improved over time (more knowl- assumed to be significantly 10%. To the extent that this edge, better tests, more skills), but as the autopsy rate important feedback mechanism is no longer a realistic op- declines, there is a tendency to select only the more chal- tion, clinicians have an increasingly distorted view of their lenging clinical cases for autopsy, which then have a higher own error rates. A longitudinal study of au- above quote by Gawande indicates, physician overconfi- topsies in Switzerland (constant 90% autopsy rate) supports dence may prevent them from taking advantage of these that the absolute rate of diagnostic errors is, as suggested, important lessons. In this section, we review studies related 81 to physician overconfidence and explore the possibility that decreasing over time. Overconfidence may have both attitudinal as well as cog- Summary nitive components and should be distinguished from com- In aggregate, studies consistently demonstrate a rate of placency. For example, noncompliance with clinical guidelines relates to the soci- the evidence discussed above—that autopsies are on the ology of what it means to be a professional. Being a pro- decline despite their providing useful data—inferentially fessional connotes possessing expert knowledge in an area provides support for the conclusion that physicians do not and functioning relatively autonomously. Substantially more Tanenbaum worries that evidence-based medicine will data are available on a similar line of evidence, namely, the decrease the “professionalism” of the physician. Research shows that phy- side to professionalism, the converse, a pervasive attitude of sicians admit to having many questions that could be im- overconfidence, is certainly a possible explanation for the portant at the point of care, but which they do not pur- 105 87–89 frequent overrides. Even when information resources are automated years ago, the discomfort in admitting uncertainty to pa- and easily accessible at the point of care with a computer, 90 tients that many physicians feel can mask inherent uncer- Rosenbloom and colleagues found that a tiny fraction of tainties in clinical practice even to the physicians them- the resources were actually used. Physicians do not tolerate uncertainty well, nor do accessing resources affected the degree to which they were their patients. A the clinician thinks he/she has the correct diagnosis, but is second area related to the attitudinal aspect is research on wrong. Rarely, the reason for not knowing may be lack of physician response to clinical guidelines and to output from knowledge per se, such as seeing a patient with a disease computerized decision-support systems, often in the form of that the physician has never encountered before. A comprehensive review monly, cognitive errors reflect problems gathering data, of medical practice in the United States found that the care such as failing to elicit complete and accurate information provided deviated from recommended best practices half of 91 from the patient; failure to recognize the significance of the time.

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Moreover best buy lasix, if the hospital wants the dozen or more separate pa- tient records for each patient to actually come together order lasix with a visa, it must hire a consulting firm to provide “systems integration best buy lasix. Each time the hospital adds a new computer system, someone must write custom software code to get the new system to talk to the other, older systems. In enterprisewide computing, the hospital has a single (digital) clinical record, a single patient identifier that every department and professional uses, a common repository for clinical and financial information, and an ability to retrieve that information quickly anywhere in the organization that it is needed. The problem is that replacing all the information systems in a hospital is costly and painful. Kleinke wrote in an oft- quoted 1998 analysis, enterprise software in hospitals has been a costly disappointment for most institutions. Certainly this has been a real (and continuing) problem—vendors promising complex applica- tions that are not completed. However, I believe the problem is larger than the reality of how hard it is to build complex tools that work. The fact that it has been so difficult to automate what hospitals do reflects the almost crippling complexity of what hospitals do and, indeed, what they are. Healthcare is the most complex thing our economy produces; there is more variability and uncertainty at the point of care in an emergency room, intensive care unit, or hospital operating suite than in just about any other part of our economy. However, the fundamental reason why enterprise computing has been so difficult to implement in hospitals is that many of them are not really enterprises. They look like enterprises, with buildings, budgets, and or- ganizational charts, but they function more like loose collections of professions uncomfortably housed in the same physical structures. A coral reef is such a structure, much more a colorful Darwinian ecology than a sentient being. The nervous sys- tem for a jellyfish is going to look and function differently than the nervous system for a higher, thinking organism. Hospitals are like large amoeboid organisms with poorly developed central nervous systems. One can design a nervous system for a collaborative enterprise, but one should not be surprised if it does not work very well if the actors in the enterprise really do not effectively collaborate. Hospitals 53 In addition to the physiology of the organism, there is a work- force problem. Until very recently, health executive and professional education ignored information technology. Vendors as well as providers struggle to find qualified workers at every skill level. Clinical Quality and Decision Support The previous chapter describes the promise of the intelligent clinical information system, undergirded by clinical decision support and care guidelines. The increasing intelligence of clinical information systems has the potential for markedly reducing medical errors. Rules engines built into clinical software will examine the orders themselves to ensure that they are what the physician or nurse intended, compare them to what is known about the patient’s present condition, and provide a “reality” check on care decisions automatically. The central challenge these new clinical tools pose to hospital managements is that they fundamentally challenge the fragmenta- tion of the hospital experience—and an operating culture that places 54 Digital Medicine the needs of hospital departments and professions above the needs of the patient. Computer systems could help alleviate, but are not going to eliminate, professional burnout, poor morale, rivalries among professional groups, continuity problems between clinical departments (“it’s not my department; she’s not my patient”), and the potential for “dropped batons” in a complex hospitalization. Thoughtfully designed computer systems can make the practice of medicine much easier, but in the final analysis, how effectively the right decisions are made ultimately determines whether patients are safe. Until clinical care becomes truly team based and an ethos of “how would I want my loved one treated here? Information systems will not absolve clinicians of their moral and professional responsibilities to make thoughtful decisions in the patient’s interests. In other words, changing the culture of healthcare is something we cannot rely on technology alone to accomplish. Capital spending is no substitute for compassion, patient-centered values, and, most of all, leadership. Absent the leadership, all the expensive tools in the world are not going to be used to the ultimate benefit of the patient and society. One medical informatics pioneer, Clem McDonald, offered the metaphor of network computing as a rain forest canopy, where arboreal creatures (presumably physicians) could move effortlessly across the canopy picking fruit (clinical information) without the need to climb all of the individual trees. One has to wade into all those messy departmental systems (emergency department, clinical laboratory, pharmacy, etc. Finally, one has to move the information out onto the Internet and send it somewhere to be decoded and used. In other words, you have to do exactly the same things you need to do to make an enterprise system function properly. The answer to this question is simple: information systems linking departments had a far lower funding priority than the latest and slickest version of a laboratory information system or a new billing system. As we will see in Chapter 5, the Internet has become a vehicle by which power over healthcare knowledge and decision making is shifting to consumers. The real leverage for hospitals in using the Internet comes from assisting in that shift toward consumers. Hos- pital executives will come to view Internet applications as a rich and diverse toolbox for restructuring their relationships with consumers 56 Digital Medicine and reducing the cost of resolving their health problems. Equally important, the Internet will support business process outsourcing, replacing many inadequately performing in-house administrative and (some) clinical processes with electronic processes managed by others, which are less costly and more responsive and transparent to their users. Improving Service to Consumers Many hospitals enrage consumers with awkward and user- unfriendly scheduling and chronically inept and unresponsive billing systems. The only way to make an appointment or check the status of a bill is to telephone the scheduling or billing office and endure an often lengthy wait on hold. Fixing these problems through network computing is a major opportunity for hospitals to use the Internet, but to do this, these processes need to be digitized in order to be accessible through electronic networks. Scheduling, billing, medical information management, prescrib- ing and renewing prescriptions, patient education, and dozens more processes need to be renovated electronically to make them accessi- ble to consumers from outside the organization. There is no tech- nical reason why patients cannot check the status of their bills over the Internet or make appointments or retrieve test results. At the consumer’s discretion, this record can be sent to any facility where a family member receives care and can also be used at home to review medical histories and problems. The most obvious application will be replacing the shoeboxes in which many mothers store their children’s immunization and other important health records with a convenient and easily accessible electronic record maintained on a hospital or health system server. Hospitals or doctors in other communities can then read the enclosed data if the consumer needs healthcare away from home. The fact that self-reported records do not link to hospital or physician records means that they will contain only those things consumers themselves remember. Consumers would also have to authorize their physicians, local pharmacies, and other health services locations to contribute a consumer’s medical encounter in- formation (diagnoses, test results, prescriptions, etc. An important test of this strategy is being pursued by the Cerner Corporation in the community of Winona, Minnesota, which has ubiquitous fiberoptic broadband in every home and provider site.

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Obligatory nitrogen losses and factorial calculations of protein requirements of pre-school children purchase discount lasix online. Human protein requirements: Nitrogen balance response to graded levels of egg protein in elderly men and women buy lasix online from canada. Obligatory urinary and faecal nitrogen losses in young Chilean men fed two levels of dietary energy intake purchase lasix master card. The pattern of intestinal substrate oxidation is altered by protein restriction in pigs. New equations for estimating body fat mass in pregnancy from body density or total body water. Qualitative analysis of human milk produced by women consuming a maize-predominant diet typical of rural Mexico. Integumental nitrogen losses of pre-school children with different levels and sources of dietary protein intake. Muscle amino acid metabolism at rest and during exercise: Role in human physiology and metabolism. Experimental phenylketonuria in infant monkeys: A high phenylalanine diet produces abnormalities simulating those of the hereditary disease. Transurethral resection of the prostate, serum glycine levels, and ocular evoked potentials. The assessment of protein nutrition and metabolism in the whole animal, with special reference to man. Homocysteinemia, ischemic heart disease, and the carrier state for homocystinuria. Threonine requirement in young men determined by indicator amino acid oxidation with use of L-[1-13C]- phenylalanine. The effects of monosodium glutamate in adults with asthma who perceive themselves to be monosodium glutamate-intolerant. Carbohydrate craving in obese people: Suppression by treatments affecting serotoninergic transmission. Effect of excessive levels of lysine and threonine on the metabolism of these amino acids in rats. Capacity of the Chilean mixed diet to meet the protein and energy requirements of young adult males. The monosodium glutamate symptom complex: Assessment in a double-blind, placebo-controlled, random- ized study. Effect of dietary administration of monoso- dium L-glutamate on growth and reproductive functions in mice. Effect of tryptophan administration on tryptophan, 5- hydroxyindoleacetic acid and indoleacetic acid in human lumbar and cister- nal cerebrospinal fluid. Kinetics of human amino acid metabolism: Nutritional implications and some lessons. Nitrogen and amino acid requirements: The Massa- chusetts Institute of Technology Amino Acid Requirement Pattern. Current concepts concerning indispensable amino acid needs in adults and their implications for international nutrition plan- ning. Estimate of loss of labile body nitro- gen during acute protein deprivation in young adults. Plasma amino acid response curve and amino acid requirements in young men: Valine and lysine. Protein requirements of man: Efficiency of egg protein utilization at maintenance and sub-maintenance levels in young men. Protein requirements of man: Comparative nitrogen balance response within the submaintenance-to-maintenance range of intakes of wheat and beef proteins. Total human body protein synthesis in relation to protein requirements at various ages. Evaluation of the protein quality of an isolated soy protein in young men: Relative nitrogen requirements and effect of methionine supplementation. Leucine kinetics during three weeks at submaintenance-to-maintenance intakes of leucine in men: Adaptation and accommodation. A theoretical basis for increasing current estimates of the amino acid requirements in adult man, with experimental support. Rates of urea production and hydrolysis and leucine oxidation change linearly over widely varying protein intakes in healthy adults. Phenylalanine flux, oxidation and conver- sion to tyrosine in humans studied with L-[1-13C]phenylalanine. Dietary lysine requirement of young adult males determined by oxidation of L-[1-13C]phenylalanine. Recent advances in methods of assessing dietary amino acid requirements for adult humans. Nitrogen retention in men fed isolated soybean protein supplemented with L-methionine, D-methionine, N-acetyl-L-methionine, or inorganic sulfate. Nitrogen retention in men fed varying levels of amino acids from soy protein with or without added L-methionine. Nutrient interactions with total parenteral nutrition: Effect of histidine and cysteine intake on urinary zinc excretion. The upper boundary corresponds to the highest α-linolenic acid intakes from foods consumed by indi- viduals in the United States and Canada. This maximal intake level is based on ensuring sufficient intakes of certain essential micronutrients that are not present in foods and beverages that contain added sugars. A daily intake of added sugars that individuals should aim for to achieve a healthy diet was not set. This chapter provides some guidance in ways of minimizing the intakes of these three nutrients while consuming a nutritionally adequate diet. Thus, for a certain level of energy intake, increasing the proportion of one macronutrient necessitates decreasing the proportion of one or both of the other macronutrients. Therefore, a high fat diet (high percent of energy from fat) is usually low in carbohydrate and vice versa. In addition to these macronutrients, alcohol can provide on average up to 3 percent of energy of the adult diet (Appendix Table E-18). A small amount of carbohydrate and as n-6 (linoleic acid) and n-3 (α-linolenic acid) polyunsaturated fatty acids and a number of amino acids that are essential for metabolic and physiological processes, are needed by the brain. The amounts needed, however, each constitute only a small percentage of total energy requirements. While some nutrients are present in both animal- and plant-derived foods, others are only present or are more abundant in either animal or plant foods. For example, animal-derived foods contain significant amounts of protein, saturated fatty acids, long-chain n-3 polyunsaturated fatty acids, and the micronutrients iron, zinc, and vitamin B12, while plant-derived foods provide greater amounts of carbohydrate, Dietary Fiber, linoleic and α-linolenic acids, and micronutrients such as vitamin C and the B vitamins. It may be difficult to achieve sufficient intakes of certain micronutrients when consuming foods that contain very low amounts of a particular macronutrient. Alternatively, if intake of certain macronutrients from nutrient-poor sources is too high, it may also be difficult to consume sufficient micronutrients and still remain in energy balance. Therefore, a diet containing a variety of foods is considered the best approach to ensure sufficient intakes of all nutrients.

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