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J. Fabio. Arkansas Tech University.

Wherewill the clinician be when receiving the intervention order protonix 40mg mastercard stomach ulcer gastritis symptoms, for example discount protonix 40mg without prescription gastritis snacks, with the patient at the bedside or in the office? What should happen if the information becomes available at some future point when the clinician is no longer with the patient to whom the information pertains? Which medium will be used to convey the message, for example, e-mail inbox, wireless and/or handheld device, pager, CIS/CPOE screen, or printed pre-visit encounter sheet? Is there a demonstrable return on investment (ROI) that is due exclusively to the clinical decision support intervention or feature? Numerous attempts have been made to bring various forms of clinical information to the clinician at the point of care. One way to solve this problem is to develop computer applications that stand alone, although often network accessible, and are available to the clinician upon his/her request. Another way is to incorporate the clinical knowledge directly into the clinical information system used by clinicians while giving care. Once it is there, the CIS system can automatically prompt the clinician or the clinician can request help. Recently, a third model for system development has been proposed that enables the clinician to request help from an outside source. Using such a system, a clinician is still completely in-charge of making the request for information and the information can be automatically configured based on a sub-set of patient information (Cimino, 1996). The following diagram (Figure 1) is an attempt to illustrate both the key types of information or knowledge that investigators have focused on along with their mode of interaction [i. The boxes (yellow) represent the type of knowledge and the labels on the links (green) represent some of the key projects or concepts vendors have focused on this particular Copyright © 2005, Idea Group Inc. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. The aim of this figure is to highlight the myriad attempts that have been made to develop clinical knowledge management applications and to help everyone understand how different clinical knowledge resources and applications are both related in terms of what they are trying to accomplish and different in the resources they utilize. Although this diagram is fairly complex, it is only a small, imperfect and incomplete representation of the entire clinical decision support landscape. The first section focuses on “library-type” applications that enable a clinician to look up information in an electronic document. The second section describes a myriad of “real-time clinical decision support systems”. These systems generally deliver clinical guidance to clini- cians at the point of care within the CIS. The third section describes several “hybrid” systems, which combine aspects of knowledge-based clinical decision support systems with library-type information. Finally, section four looks at various attempts to bring clinical knowledge in the form of computable guidelines to the point of care. Library-Type Applications: Front-Ends to Applications That Directly Interact with Clinicians Bibliographic Databases (DBs) Biomedical bibliographic databases contain on the order of millions of records, each representing a unique scientific journal article that has been published. Each record typically contains the title of the article, the authors, their affiliation(s), and the abstract of the article. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. An Overview of Efforts to Bring Clinical Knowledge to the Point of Care 289 For the last 30 years, the National Library of Medicine has maintained the MedLine database, the most common bibliographic database used in clinical medicine. During that period, various attempts have been made to develop easy to use and reliable interfaces to this vast resource including Grateful Med (Cahan, 1989) and COACH (Kingsland, 1993). PubMed relies on a sophisticated free-text query processor to map freetext user queries to MeSH terms, when appropriate, and returns a highly relevant set of documents. For example, Ovid has developed an interesting MeSH mapper and query expander that has gathered outstanding reviews from highly trained librarians. Knowl- edge Finder has developed a fuzzy mapping algorithm that has also generated some good reviews. Unfortunately, none of these systems consistently enables clinicians to retrieve more than half of all the relevant articles on any particular topic (Hersh, 1998). In addition to these variations on a search interface, several projects have used automated differ- ential diagnosis generators, such as DxPlain, as an interface to the bibliographic DBs. Finally, the Science Citation Index uses the reference list at the end of every scientific article published to generate linked lists of references.

Before joining the lung it gives off its upper lobe branch 40mg protonix fast delivery gastritis gagging, and then passes below the pulmonary artery to enter the hilum of the lung purchase 20mg protonix visa gastritis diet �������. It has two important relations: the azygos vein, which arches over it from behind to reach the superior vena cava, and the pulmonary artery which lies first below and then anterior to it. The left main bronchus is nearly 2 in (5cm) long and passes downwards and outwards below the arch of the aorta, in front of the oesophagus and descending aorta. Unlike the right, it gives off no branches until it enters the hilum of the lung, which it reaches opposite T6. The pulmonary artery spirals over the bronchus, lying first anteriorly and then above it. Clinical features 1The greater width and more vertical course of the right bronchus accounts for the greater tendency for foreign bodies and aspirated material to pass into the right bronchus (and thence especially into the middle and lower lobes of the right lung) rather than into the left. The lungs (Figs 18, 19) Each lung is conical in shape, having a blunt apex which reaches above the sternal end of the 1st rib, a concave base overlying the diaphragm, an extensive costovertebral surface moulded to the form of the chest 24 The Thorax Fig. The right lung is slightly larger than the left and is divided into three lobes—upper, middle and lower, by the oblique and horizontal fissures. The lower respiratory tract 25 Blood supply Mixed venous blood is returned to the lungs by the pulmonary arteries; the air passages are themselves supplied by the bronchial arteries, which are small branches of the descending aorta. They maintain the blood supply to the lung parenchyma after pulmonary embolism, so that, if the patient recovers, lung function returns to normal. The superior and inferior pulmonary veins return oxygenated blood to the left atrium, while the bronchial veins drain into the azygos system. Lymphatic drainage The lymphatics of the lung drain centripetally from the pleura towards the hilum. From the bronchopulmonary lymph nodes in the hilum, efferent lymph channels pass to the tracheobronchial nodes at the bifurcation of the trachea, thence to the paratracheal nodes and the mediastinal lymph trunks to drain usually directly into the brachiocephalic veins or, rarely, indirectly via the thoracic or right lymphatic duct. Nerve supply The pulmonary plexuses derive fibres from both the vagi and the sympa- thetic trunk. They supply efferents to the bronchial musculature (sympa- thetic bronchodilator fibres) and receive afferents from the mucous membrane of the bronchioles and from the alveoli. The bronchopulmonary segments of the lungs (Figs 20, 21) A knowledge of the finer arrangement of the bronchial tree is an essential Table 1The named divisions of the main bronchi. Apical Upper lobe bronchus Posterior { Anterior Lateral Right main bronchus Middle lobe bronchus { Medial { Medial (cardiac) Apical Anterior Lower lobe bronchus { Basal { Lateral Posterior Apicoposterior Upper lobe bronchus { Anterior ↓ Superior Lingular bronchus { Left main bronchus Inferior { Anterior Apical Lower lobe bronchus { Lateral Basal Apicoposterior bronchus 2Posterior bronchus 2 3Anterior bronchus 3Anterior bronchus Middle lobe Lingula 4Lateral bronchus 4Superior bronchus 5Medial bronchus 5Inferior bronchus Lower lobe Lower lobe 6Apical bronchus 6Apical bronchus 7Medial basal (cardiac) bronchus 8Anterior basal 8Anterior basal bronchus bronchus 9Lateral basal 9Lateral basal bronchus bronchus Fig. Each lobe of the lung is subdivided into a number of bronchopulmonary segments, each of which is supplied by a segmental bronchus, artery and vein. These segments are wedge-shaped with their apices at the hilum and bases at the lung surface; if excised accurately along their boundaries (which are marked by intersegmental veins), there is little bleeding or alveolar air leakage from the raw lung surface. The names and arrangements of the bronchi are given in Table 1; each bronchopulmonary segment takes its title from that of its supplying seg- mental bronchus (listed in the right-hand column of the table). The left upper lobe has a lingular segment, supplied by the lingular bronchus from the main upper lobe bronchus. This lobe is equivalent to the right middle lobe whose bronchus arises as a branch from the main bronchus. Apart from this, differences between the two sides are very slight; on the left, the upper lobe bronchus gives off a combined apicoposterior segmen- tal bronchus and an anterior branch, whereas all three branches are sepa- rate on the right side. On the right also there is a small medial (or cardiac) lower lobe 28 The Thorax bronchus which is absent on the left, the lower lobes being otherwise mirror images of each other. For descriptive purposes the mediastinum is divided by a line drawn horizontally from the sternal angle to the lower border of T4 (angle of Louis) into superior and inferior mediastinum. The inferior medi- astinum is further subdivided into the anterior in front of the pericardium, a middle mediastinum containing the pericardium itself with the heart and great vessels, and posterior mediastinum between the pericardium and the lower eight thoracic vertebrae (Fig. The pericardium The heart and the roots of the great vessels are contained within the conical fibrous pericardium, the apex of which is fused with the adventitia of the Fig. The mediastinum 29 great vessels and the base with the central tendon of the diaphragm. Anteri- orly it is related to the body of the sternum, to which it is attached by the sternopericardial ligament. The 3rd–6th costal cartilages and the anterior borders of the lungs; posteriorly, to the oesophagus, descending aorta, and vertebra T5–T8, and on either side to the roots of the lungs, the mediastinal pleura and the phrenic nerves. The inner aspect of the fibrous pericardium is lined by the parietal layer of serous pericardium. This, in turn, is reflected around the roots of the great vessels to become continuous with the visceral layer or epicardium.

This contributes the small pars membranacea septi cheap protonix 20mg amex gastritis in pregnancy, which completes the separation of the ventricle in such a way that blood on the left of the septum flows into the aorta and on the right into the pulmonary trunk protonix 20mg gastritis symptoms months. The primitive sinus venosus absorbs into the right atrium so that the venae cavae draining into the sinus come to open separately into this atrium. The smooth-walled part of the adult atrium represents the contri- bution of the sinus venosus, the pectinate part represents the portion derived from the primitive atrium. The original single pulmonary venous trunk entering the left atrium becomes absorbed into it, and donates the smooth-walled part of this chamber with the pul- monary veins entering as four separate openings; the trabeculated part of the definitive left atrium is the remains of the original atrial wall. These arteries curve dorsally around the pharynx on either side and join to form two longitudinally placed dorsal aortae which fuse distally into the descending aorta. The 4th arch on the right becomes the brachiocephalic and right subclavian artery; on the left, it differentiates into the definitive aortic arch, gives off the left subclavian artery and links up distally with the descending aorta. When the truncus arteriosus splits longitudinally to form the ascending aorta and pulmonary trunk, the 6th arch, unlike the others, remains linked with the latter and forms the right and left pulmonary arteries. This diagram explains the relationship of the right recurrent laryngeal nerve to the right subclavian artery and the left nerve to the aortic arch and the ligamentum arteriosum (or to a patent ductus arteriosus). This asymmetrical development of the aortic arches accounts for the different course taken by the recurrent laryngeal nerve on each side. In the early fetus the vagus nerve lies lateral to the primitive pharynx, separated from it by the aortic arches. What are to become the recurrent laryngeal nerves pass medially, caudal to the aortic arches, to supply the developing larynx. With elongation of the neck and caudal migration of the heart, the recurrent nerves are caught up and dragged down by the descending aortic arches. On the right side the 5th and distal part of the 6th arch absorb, leaving the nerve to hook round the 4th arch (i. On the left side, the nerve remains looped around the persisting distal part the 6th arch (the ligamentum arteriosum) which is overlapped and dwarfed by the arch of the aorta. Blood is returned from the placenta by the umbilical vein to the inferior vena cava and thence the right atrium, most of it by-passing the liver in the The mediastinum 39 Left common carotid artery Brachiocephalic Left subclavian artery artery Right pulmonary artery Ductus arteriosus Aorta Left pulmonary Superior artery vena cava Septum II Pulmonary trunk Foramen ovale Septum I Aorta Inferior vena cava Umbilical arteries Fig. Relatively little mixing of oxygenated and deoxygenated blood occurs in the right atrium since the valve overlying the orifice of the inferior vena cava serves to direct the flow of oxygenated blood from that vessel through the foramen ovale into the left atrium, while the deoxygenated stream from the superior vena cava is directed through the tricuspid valve into the right ventricle. From the left atrium the oxy- genated blood (together with a small amount of deoxygenated blood from the lungs) passes into the left ventricle and hence into the ascending aorta for the supply of the brain and heart via the vertebral, carotid and coronary arteries. As the lungs of the fetus are inactive, most of the deoxygenated blood from the right ventricle is short-circuited by way of the ductus arteriosus from the pulmonary trunk into the descending aorta. This blood supplies the abdominal viscera and the lower limbs and is shunted to the placenta, for oxygenation, along the umbilical arteries arising from the internal iliac arteries. At birth, expansion of the lungs leads to an increased blood flow in the pulmonary arteries; the resulting pressure changes in the two atria bring the overlapping septum primum and septum secundum into apposition which effectively closes off the foramen ovale. At the same time active contraction of the muscular wall of the ductus arteriosus results in a functional closure 40 The Thorax of this arterial shunt and, in the course of the next 2–3 months, its complete obliteration. Similarly, ligature of the umbilical cord is followed by throm- bosis and obliteration of the umbilical vessels. Congenital abnormalities of the heart and great vessels The complex development of the heart and major arteries accounts for the multitude of congenital abnormalities which may affect these structures, either alone or in combination. Dextro-rotation of the heart means that this organ and its emerging vessels lie as a mirror-image to the normal anatomy. Septal defects At birth, the septum primum and septum secundum are forced together, closing the flap valve of the foramen ovale. However, the two septa overlap and this patency of the foramen ovale is of no functional significance. If the septum secundum is too short to cover the foramen secundum in the septum primum, an atrial septal defect persists after the septum primum and septum secundum are pressed together at birth. This results in an ostium secundum defect, which allows shunting of blood from the left to the right atrium. This defect lies high up in the atrial wall and is relatively easy to close surgically. A more serious atrial septal defect results if the septum primum fails to fuse with the endocardial cushions. This ostium primum defect lies immediately above the atrioventricular boundary and may be associated with a defect of the pars membranacea septi of the ventricular septum.

Indeed buy 40mg protonix otc gastritis gi bleed, religiously involved persons often have strong social support systems buy protonix 40 mg lowest price gastritis surgery, 57,130–132 the health benefits of which are well known,. Further more, as discussed above, religiously involved persons seem more capable than uninvolved persons of coping with stressful life events. Religious involvement, spirituality and medicine 233 Figure 1 Theoretical model of the effects of religious involvement and spirituality on mental health. New York: Oxford University Press, 2001 In turn, good mental health, strong social support and salutary health behaviors lead to improved physical health. As reviewed previously, religiously involved persons are more likely to embrace health-promoting behaviors, such as eating a proper diet, to eschew risky behaviors such as smoking, to seek preventive services and to adhere with prescribed treatments. Positive emotions, in turn, can limit the activation of the sympathetic branch of the autonomic nervous system and the hypothalamic-pituitary- adrenal axis (and decreased release of stress hormones such as norepinephrine (noradrenaline) and cortisol). In fact, compared with 51 uninvolved persons, religiously involved persons have enhanced immune function. Complementary therapies in neurology 234 Finally, the placebo effect is a commonly observed phenomenon in medical research and practice. Religiously involved persons may have greater optimism and expectation 130 for better health outcomes and, hence, benefit from the placebo effect. Not all the mechanisms by which religious involvement and spirituality affect health are understood, and more studies are needed for better definition of them. These mechanisms undoubtedly involve complex interactions of psychosocial-behavioral and 51 biological processes. Nevertheless, theoretical models of the effects of religious involvement and spirituality on mental and physical health that account for these interactions have been developed (Figures 1 and 2). Figure 2 Theoretical model of the effects of religious involvement and spirituality on physical health. First, patients regard their spiritual health and physical health as equally 8 important. Fourth, many patients base 139 their health-care decisions on their spiritual or religious beliefs. Finally, patients suffering from religious, spiritual, and existential concerns may not inform their 139 clinicians about them. Because the goals of medicine are to cure disease when possible 140 and to relieve suffering always, including spirituality in clinical practice should be within the purview of the physician. First, many clinicians practice in the biomedical model in which spiritual matters seem less relevant. Second, fewer physicians than patients describe themselves as religious or maintain 9,141,142 spiritual orientations. Hence, the importance of spiritual matters to patients may be underestimated or unrecognized. Third, the effect of religious involvement and 141 spirituality on health outcomes is taught infrequently in medical training. Finally, the spiritual concerns of patients may not be addressed because of time constraints, lack of confidence in the effectiveness of spiritual care and 144 role uncertainty (e. Complementary therapies in neurology 236 Ethical issues Ethical issues are raised when one includes patient spirituality in clinical practice. Many patients derive hope and strength from their personal religious beliefs, and proselytizing to them may cause unnecessary harm. The ethical clinician would not make such recommendations, just as she or he would not recommend that patients marry or have 145 children, even though these activities are associated with health benefits. Finally, 25 religious and spiritual practices should not replace effective allopathic treatments. Some authors, however, claim that the religious and spiritual concerns of patients are private 145 and that clinicians should not inquire about them. However, a similar case could be made regarding inquiries about patient sexuality, substance abuse and other sensitive matters. These matters, formerly shunned by clinicians, are now discussed openly because of their potential effect on health. Indeed, lack of appropriate spiritual care may constitute a form of 138 negligence. Some authors suggest that clinicians ignore patient spirituality because they may not have the knowledge or skills to engage religiously diverse patients in meaningful 145 discussions about their spiritual needs without offending them.