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Evaluation of immigration status imuran 50mg on line muscle relaxant uses, race and language barriers on chronic hepatitis C virus infection management and treatment outcomes purchase 50mg imuran with mastercard spasms near tailbone. Incidence and risk factors for acute hepatitis B in the United States, 1982-1998: Implications for vaccination programs. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Hospital policy and practice regarding the collection of data on race, ethnicity, and birthplace. Cost-effectiveness analysis of behavioral interventions to improve vac- cination compliance in homeless adults. Evaluation of screening criteria to identify persons with hepatitis C virus infec- tion among sexually transmitted disease clinic clients: Results from the San Diego viral hepatitis integration project. Changes in injection risk behavior associated with participa- tion in the Seattle needle-exchange program. Reduced risk of hepatitis B and hepatitis C among injection drug users in the Tacoma syringe exchange program. Meta-regression of hepatitis C virus infection in relation to time since onset of illicit drug injection: The infuence of time and place. Hepatitis C virus seroconversion among young injection drug users: Relationships and risks. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. The infuence of needle exchange programs on injection risk behaviors and infection with hepatitis C virus among young injection drug users in select cities in the United States, 1994-2004. A revisit of prophylactic lamivudine for chemo- therapy-associated hepatitis B reactivation in non-Hodgkin’s lymphoma: A randomized trial. Reducing liver cancer disparities: A community-based hepatitis-B preven- tion program for Asian-American communities. Cost-effectiveness of screening and vaccinating Asian and Pacifc Islander adults for hepatitis B. The effectiveness and safety of syringe vending machines as a component of needle syringe programmes in community settings. The need for more research on language barriers in health care: A proposed research agenda. Essentials of perinatal hepatitis B prevention: A training series for coordinators and case managers—assessment and evaluation. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Managing a perinatal hepatitis B preven- tion program: A guide to life as a program coordinator. Treat- ment alternatives for chronic hepatitis B virus infection: A cost-effectiveness analysis. Does bleach disinfection of syringes protect against hepatitis C infection among young adult injection drug users? Hepatitis B virus infection and vaccination among young injection and non-injection drug users: Missed opportuni- ties to prevent infection. A randomized intervention trial to reduce the lending of used injection equipment among injection drug users infected with hepatitis C. Preemptive use of lamivudine reduces hepatitis B exacerbation after al- logeneic hematopoietic cell transplantation. Early is superior to deferred preemptive lamivudine therapy for hepatitis B patients undergoing chemotherapy. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Lamivudine prophylaxis reduces the incidence and severity of hepatitis in hepatitis B virus carriers who receive chemotherapy for lymphoma.

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Changes in Radiology Two key changes in radiology—teleradiology and machine inter- pretation of radiological images—have been made possible by the successful standardization of formats for digital radiological im- ages generic 50mg imuran amex muscle relaxer sleep aid. With the advent of broad- band Internet connections buy 50mg imuran fast delivery spasms just below rib cage, radiological images can not only be transmitted instantaneously inside hospitals or clinics, but they can also be sent virtually anywhere in the world where someone is avail- able to interpret them. Teleradiology has created service opportunities for isolated rural hospitals and practitioners who cannot afford full-time sub- specialized radiology coverage. Advances in image recognition software will enable radiology equipment to interpret as well as create radiological images. Recent studies have established that machine-read mammograms detect more lesions and stage them more accurately than do human radi- ologists. Human judgment will be focused on the “tough calls,” the machine-identified exceptions that require overreading. Remote Monitoring In Philadelphia recently, a newly formed technology firm, Car- dioNet, created the first regional wireless network to monitor ambu- latory cardiac patients. This device is contained in a wireless sending unit the size of a personal digital assistant, which transmits the signals to a base station where human operators are assisted by continuous computer monitoring of their heart rhythms. If the patient appears to be experiencing cardiac distress, a voice channel will enable the operator to communicate directly with the patient, verify his or her condition orally, and direct him or her to take action. The system automatically alerts the patient’s physician to the problem and can even trigger an ambulance call to bring the patient to the hospital if required. Taking this process to the next step, Medtronic, the technology leader in cardiac pacemakers, has developed an implantable device that monitors, stores, and transmits information about the patient’s cardiac rhythm directly to the patient’s physician. These devices can be programmed (and reprogrammed remotely) to vary pacing depending on the patient’s unique needs and can also administer an electric shock to restart the patient’s heart if it moves into atrial fibrillation. Progress in miniature sensing technologies is creating a new gen- eration of devices that can be worn or embedded in people’s homes to monitor their health noninvasively and automatically alert fam- ily or caregivers if problems arise. The “smart shirt,” for example, enables monitoring of multiple vital signs (heart rhythms and res- piration) and transmittal of aberrant results to family or the care team. These same technologies, when embedded in the home envi- ronment, will enable one to determine if an elderly person has fallen, is having trouble breathing, has taken prescribed medications, or is eating. In November 1999, clinicians in New York City made history by successfully performing a colecystectomy on a patient in Stras- bourg, France. These same technologies will enable students to learn via “virtual” surgical procedures us- ing interactive software that reflects to them real world images of internal organs. Telepresence technologies are producing live, three- dimensional images of internal organs, which enable physicians and their students to “tour” the body of a patient virtually. Voice response technolo- gies are likely to play an important, augmenting role in connecting patients and people at risk to the health system. During the Inter- net frenzy, many observers dismissed the voice channel of telephone communication, assuming that most of it would be displaced by digital data. The software algorithm at the heart of Eliza is so sophisticated that it can recognize and respond to millions of responses to the question, “Is this Jeff Gold- smith? Eliza is so warm and accepting that patients or family members will reliably return its calls if they are not at home to receive the initial call. However, no one would quarrel with the assertion that no technology since the invention of the telephone has created such a sensation as the Internet. The Internet enabled instantaneous and asynchronous commu- nication between any parties connected at first to an existing tele- phone network and later using cable, ground-based wireless, and satellite modalities, allowing the Internet to be accessed in auto- mobiles, airplanes, or literally anywhere in the world where one can receive a wireless signal. With increased bandwidth has come 28 Digital Medicine the ability to transmit virtually any form of digital information, including sound and both still and streaming video files. People who use the Internet are on a mission; they actively use the Internet to seek knowledge and connection to others. Society seemed to awaken in the mid-1990s to discover that it had grown a whole new nervous system. The connections spawned by the Internet have resulted in the spontaneous formation of what futurist Howard Rheingold dubbed “virtual communities” revolv- ing around common interests and issues. Six million people use the Internet to seek health information every day, just in the United States,37 and according to the Pew Trust Internet American Life Project, 62 per- cent of adults connected to the Internet sought health information through it. Internet applications have empowered consumers to define their own medical reality and to reframe and broaden their relationships to physicians. The Internet and Health Plans As discussed in Chapter 6, the Internet has also brought a host of powerful new applications to health plans to communicate with their vast and diffuse networks of subscribers, corporate customers, and the health system itself. These applications form the core of an emerging “consumer directed” model of health insurance.

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Their rates of burnout are high made a complaint about this behaviour to the site director (up to 42 per cent in Canada) 50mg imuran amex muscle relaxer ketorolac, as are their rates of divorce or for education order 50 mg imuran amex muscle relaxant and pain reliever. Born generally before the mid-1940s, this The Canadian medical community embraces a diverse mix senior cohort of physicians has a wealth of experience and tal- of learners and practitioners. Many have now retired from active practice but have had including gender, race, cultural heritage, political alliance a profound and valuable infuence on traditional structures in and philosophical world view. One facet of diversity that is medicine, including practice standards, training methodology becoming increasingly relevant to educational programs is that and professionalism. Obviously, any framework that clusters diverse people into specifc categories is at risk of overgeneralizing; Sources of tension however, the following sketches of today’s generations and The varying experiences and expectations of these generational their traits may be a useful way to conceptualize challenges cohorts can give rise to misunderstandings and tensions arising that arise in training and practice environments. This cohort generally consists of the popula- tion born from the early 1980s to the early 2000s. Boomers and Gen X/Y as the millennial generation and the “net” generation, this seem to be most at risk of confict in this area, as their perspec- cohort came of age in a time of political stability, economic tives are often very different. Regardless of the nature of the advantage and particular encouragement and support. Boomers need to facilitate embrace digital communication and are skilled multi-taskers learning and practice environments that sustain learners while who are not insulted when someone does a Google search on preparing them for the rigours of practice. This is not a par- their iPhone in mid-conversation, responds to an urgent text ticularly easy task and requires careful mentoring, graduated message during small group learning, or accesses the latest responsibility, respect for boundaries/limits, and acknowledge- clinical information through their Blackberry. Finally, they are ment of collective agreements and respectful interpersonal often image-driven, favour self-expression over self-control, communication. They work hard to get a job done but do so in a highly fexible manner and on their own terms. Multi-tasking is • mentored in a supportive, non-judgmental fashion to often viewed with disdain by Boomers, particularly when they achieve their best, manage their weaknesses, gain witness learners communicating with more than one person insight into their own nature and progress to the next at the same time (e. Aspects of multi-tasking require open • consulted on any decisions that will affect them in a discussion and dialogue, as well as fexibility: the X and Y manner that acknowledges that their ideas may be part generations are often able to safely divide their attention across of a solution rather than part of a problem; and multiple domains and do so with no intention of disrespect or • connected to their peers, supervisors, families, disregard. The shift in contemporary culture away from hierarchical expectations in social relation- With fexibility, a sense of humour, honesty and transparency, ships is notable. Respect from others no longer follows auto- all generations can readily engage one another to solve almost matically from a position of authority; rather, it is earned and any challenge they face. Younger generations need to be sensitive to the culture of their more senior col- Case resolution leagues, while Boomers and traditionalists will gain points by The physician attended a seminar on intergenerational demonstrating principles of equity, respect and autonomy. In opportunities and realized that many of the behaviours addition, younger cohorts need to be reminded, often through interpreted as disrespectful were, in fact, the opposite. The physician shortage of physicians in Canada, and many Gen Xers (and, also refected on the healthy boundaries the students set very soon, Gen Ys) will soon be moving into leadership po- between personal and professional life and the physician sitions in education and practice. In the past, Boomers and began to make changes in their own practice in order to traditionalists earned such positions after “paying their dues,” spend time with family and signifcant others. Finally, the learning on the job and having time to develop readiness for physician purchased a smartphone and, after a tutorial leadership. More than ever before, younger generations need with a medical student, found that it improved effciency mentorship and support from more experienced colleagues as remarkably. The more open and fexible the physician they take on heavy responsibilities early in their career. In fact, intergenerational diversity brings with it a Key references remarkable opportunity to integrate and synergize perspectives Smith W. Messages for the learning and practice environment Puddester D, Gray C, Robertson C. Training generation When managing or preventing the many conficts that can arise x: A theme of growing importance. Royal College Outlook 2:1 in an intergenerational training or practice environment, it can Spring; 8–10. The American College of Physicians manual • describe factors that infuence working relationships with states: other health care professionals, peers and faculty; and “Physicians share their commitment to care for all ill • identify steps that can be taken to improve collegiality. The team’s ability to care effectively for the patient depends on the ability of individual persons to treat each other with Case integrity, honesty and respect. Particular attention must be A frst-year resident working in a major urban hospital paid to certain types of relationships and power imbalances is fve months pregnant when she does her rotation and […] such as attending physician and resident, resident and fnds that the nurses are very kind to her. One night Murray Goldstein states this idea more simply “[c]ollegiality while she is on call a woman in labour begins to show signs requires a fostering of the attitude ‘we are in this together’.

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