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Internationally similar principles or rules are common to a myriad of legal cheap red viagra 200mg mastercard yellow 5 impotence, professional discount 200mg red viagra with amex erectile dysfunction foods that help, and research codes and acts that relate to the collection, storage, and utilisation of health information. Assessing the impact, or future consequences of current actions, presents a particular challenge for health knowledge systems. The risk-benefit equation, used to assess how certain information is handled may change over time and we have to question how far forward we can see, or how far forward we are expected to see. Privacy and Security Objectives Privacy and security developments may be focused on addressing a number of key objectives or concerns including medico-legal or patient trust or confidence concerns, within the context of a belief that better integrated information will lead to better Copyright © 2005, Idea Group Inc. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. However what is perceived best by or for an individual may be in conflict with what is perceived as best for the community. Each clinician and health service, depending on their location may be conceptually subject to a multitude of privacy and security codes and laws, for which in reality at the clinical coal face there is only limited compliance due to various combinations of lack of knowledge, attention, priority, will, ability, or perception of unacceptable costs and burden. There may be broad agreement that patient privacy should be protected, but a range of views as to what that pragmatically can or should mean in practice and how much any law or code may achieve this. For example, Marwick (2003) outlines similar views and responses as having greeted the introduction in the USA of the privacy rule of the Health Insurance Portability and Accountability Act. However health organisations need to increasingly strive to create a culture that respects and protects health information, and seek to demonstrate and reinforce that culture through a number of basic or initial communication, human resource or technical steps. These include creating with, and communicating to, their communities clear open policies around the nature and purpose of health information flows and utilisation. These include the risks and benefits of information flowing or not flowing and respective privacy versus sub-optimal care risks. In pragmatic terms this may take the form of conversations, leaflets, posters or web-sites. Human resource processes may include training and development and professionalisation of all healthcare workers in terms of their attitude to health information and clear disciplinary procedures for malicious use. Anderson (1996) has highlighted the impor- tance of training and procedures for the high-risk area of providing patient information on the telephone. Davis, Domm, Konikoff and Miller (1999) have suggested the need for specific medical education on the ethical and legal aspects of the use of computerised patient records. Technical processes may include ensuring that an electronic information system has at least an audit trail that allows who has viewed or accessed a particular piece of health data to be monitored, providing some degree of psychological reassurance to patients and psychological deterrence against malicious use. While having highlighted some of the concerns around restriction of information flows, particularly if the clinician is not advised of the suppression there is of course a place for restricted access for sensitive information. This may include allocating graded access levels to certain categories of information and graded access levels for providers or users, with the user only able to access information for which they have an appropriate level of clearance. The system may also include a “break glass” or override facility for emergencies, which allows access to restricted information, but triggers a formal audit or justification process. Denley & Smith (1999) discuss the use of access controls as proposed by Anderson (1996). However for all these processes we can predict an inverse relationship between complexity and utility (and subsequent uptake or compliance). When planning privacy or security developments, we should strive to make it easier to do the right thing. This can include making login processes as fast and intuitive as possible, so as to decrease the behavioural drivers for clinicians to leave themselves logged in, or the sharing of Copyright © 2005, Idea Group Inc. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. SAFE-diffusibility factors SAFE-Diffusibility factors Scalable Retaining implementability / usability (Fast, Intuitive, Robust, Stable, Trustworthy) Resource/Time/Risk Affordable Individual/Local/National needs Flexible Perceived Equity/Relative Advantage Equitable personal or generic logins or passwords. With unlimited resource or the passage of time and decreasing costs, this may mean installing the latest proximity login or biometric authentication device that can log a clinician in or out as they move towards or away from a information access point, with instantaneous fingerprint or retinal scan verification. However initial steps may involve configuring systems so they minimise the login time, and developing fast, intuitive, and clearly understood administration systems for the issuing (and terminating) of logins or passwords so that new or locum clinicians can immediately access systems without having to utilise generic logins or “borrowing” other clinicians logins. Our vision may be to make a healthy difference by facilitating the development of Health Knowledge Systems that help us provide safe and effective integrated care, within a culture that respects and protects both the value and privacy of health information. However recognising the difficulties of implementing an information system within the complex health environment (Heeks, Salazar & Mundy 1999), each step or building block towards attaining that vision, including privacy and security developments, needs to beSAFE:Scalable(while retaining usability and implementability),Affordable(in terms of resource time and risk);Flexible (enough to meet individual, local and national needs) and Equitable (in that potential stakeholders perceive a relative advantage for them in terms of adopting the change or development) (Table 2). Future Trends As we look to the future we can expect to see both increasing perceived benefits and privacy and security concerns with respect to data mining and risk profiling particularly genetic and geographic profiling, and increasing attention to the related actions of insurance, financial, and health organisations and government.

This will inevitability result in patients (and healthcare professionals) being more frequently confronted with ICT healthcare applications generic 200 mg red viagra impotence blood pressure medication. This buy red viagra 200 mg cheap erectile dysfunction frequency age, coupled with the fact that patients are now demanding a larger role in the management of their own health and healthcare (Beun, 2003), will result in the relationship between patients and healthcare professionals changing. A major factor related to the role the Internet may offer has been its wide scale uptake. Figures would now suggest that nearly one in every two people in Western Europe and the United States have Internet access. This uptake has been propagated into the health domain with General Practitioners and Hospitals now also having increased access to the Internet. This subsequently increases the long term potential for Internet driven healthcare related activities. Figure 2 shows a summary, at a European level, of the percentages of Internet access in the aforementioned healthcare domains (Beolchi, 2003). Examples of Internet-Based Healthcare Although beyond the scope of this article to present an in depth coverage of how the Internet is currently utilized in the healthcare domain, it is nonetheless possible to identify a number of succinct areas in which it is used by both patients and healthcare professionals: Information Provision: The Internet can be effectively used to deliver healthcare information. Already, the Internet provides an immense resource for patient-healthcare Copyright © 2005, Idea Group Inc. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. Internet access for general practitioners and hospitals at a European level Internet Access for GPs and Hospitals 100 90 80 70 60 50 40 30 20 10 0 GP Hospital EU Region information, with thousands of disease support groups, clinical advice forums and disease-specific information resources. According to Provost, Perri, Baujard, and Noyer (2003), patients use the Internet to search for health and drug information, disease description, medical literature, online medical consultation, and to seek second opinions on a medical diagnosis. Health professionals on the other hand use the Internet to search for information on drugs, medical literature and recommend Web sites and support groups to patients (Provost et al. The Internet, can in addition, be seen as a valuable aid to computer assisted learning. A multitude of resources exist, (for example, Physicians Online) which can provide access to a wide range of valuable multimedia learning resources. Electronic Care Communications: Electronic care communications, or healthcare ad- ministration systems, provide the potential for the use of secure local and wide area networks to speed up: scheduling appointments; referrals between healthcare profes- sionals; communication of outcomes and discharge letters. The Internet can also be useful to spread policies (Policies, Medical Practice Management) and can be used as an assistance tool in the entry point in hospitals. For example, in Chonnam National University Hospital of Korea (Korea Chonnam Hospital), an institution with about 4,000 patient visits per day, the Internet is used to manage all patient information. Contemporary e-Prescription systems provide connectivity between general prac- titioners, pharmacists and healthcare agencies enabling secure and accurate transmis- sion of new and repeat prescriptions. At present, e-prescribing is being addressed at national levels with many systems already operational (Middleton, 2000) and others being piloted prior to uptake (Mundy & Chadwick, 2003). Copying or distributing in print or electronic forms without written permission of Idea Group Inc. Management and Analysis of Time-Related Data in Internet-Based Healthcare 37 Delivery and Support of Direct Care:The Internet has been comprehensively reported to support many home-based care models (Beolchi, 2003) supporting aspects such as medication management (Nugent, Finlay, & Black, 2001), vital signs assessment and cardiac monitoring to name but a few. Internet-based home care can be an efficient cost- effective means to reach distant groups of people. In Japan, where there are more than 200 islands with 80 of them having less than 300 people and 60 having no healthcare clinics, Internet-based healthcare plays an important role in preventive medicine and early diagnosis (Isechi, Oda, Shinkura, Akiba, Fujikawa, & Yamazaki, 2004). Decision Support and the Internet Many “intelligent” tools have made their way into medical applications. Indeed, medicine has always been one of the most important and sought-after application areas of decision support systems and artificial intelligence. Such systems have been helping healthcare professionals for more than four decades with the first instance of usage of computers in medicine considered to be the analysis of electrocardiogram data in the late 1950s (Stallman & Pipberger, 1961). Computerized approaches to decision support can provide intermediate patient assessments. In the most general case they are useful for the analysis of complex and large amounts of data quickly. This results in repeatable processing of clinical and patient data, and offers benefits of consistency and lower levels of observer variability (Willems, Abreu-Lima, Arnaud, Van Bemmel, et al. Successful approaches to medical decision support have varied from the application of decision trees and expert systems (van Bemmel & Musen, 1997) to Neural Networks and Genetic Programming.

More than 90 differ- abnormal and deficient Pi Z protein functions 1 200 mg red viagra fast delivery causes of erectile dysfunction in youth,000 ent forms of the gene have been identified safe red viagra 200mg how do erectile dysfunction pills work. Researcher Ronald Crystal states, “Cigarette smoking renders an already Demographics poorly defended lung completely defenseless. If people with two PI Z genes stop smoking before antitrypsin is less common in populations of Asian, they develop lung disease, their life expectancy increases African, and American Indian descent. These indi- Individuals who have one abnormal gene with very viduals account for 1% of all emphysema patients. It is possible that people with people at risk to have alpha-1 antitrypsin associated lung one Z gene and one normal gene are also at risk to disease is greater than one in 2,500. Approximately one develop chronic lung disease if they are exposed to harm- in 20 Caucasians has one Z gene and one normal gene. The The number of Caucasians with one S gene and one nor- age symptoms begin in this group would be later than mal gene is even higher. Some Caucasians of Northern European descent have two S researchers disagree, stating that people with PI SZ and genes (and no normal alpha-1 antitrypsin gene). Signs and symptoms Liver disease The main symptom of alpha-1 antitrypsin is a risk The risk of liver disease and liver cancer are for early-onset, rapidly progressive emphysema. Babies with alpha-1 antitrypsin who smoke tobacco are at espe- and children with alpha-1 antitrypsin may have abnormal cially high risk. The abnormal liver begins with breathlessness during exertion and pro- function they develop is called cholestasis, which is when gresses to shortness of breath at all times, caused by the liver stops secreting a digestive fluid called bile. The risk for liver build-up of bile causes cholestatic jaundice (yellowing of disease in adults is increased, as is the risk for hepatocel- the skin). Some children with liver disease and liver failure, which is fatal without a alpha-1 antitrypsin develop liver disease as well. In other babies and children, liver func- Individuals with alpha-1 antitrypsin are also at risk for tion returns to normal. Chronic obstructive lung disease is develop liver disease, and some develop liver cancer. The decreased breathing capacity, which may be caused by age at which the liver disease begins, the rate at which it emphysema but also has other underlying causes. Adults with alpha-1 antitrypsin who had liver abnormalities as children may be at increased KEY TERMS risk to develop liver disease or liver cancer. People with one normal PI gene and one PI Z gene may be at Autosomal—Relating to any chromosome besides increased risk for liver disease. Human cells con- The likelihood that a child or adult with alpha-1 tain 22 pairs of autosomes and one pair of sex antitrypsin will develop liver disease can be predicted to chromosomes. The risk with breathlessness during exertion and progresses that a baby with two Z genes will develop significant to shortness of breath at all times, caused by liver disease is approximately 10%. Males (both adult and chil- contains the instructions for the production of a dren) develop liver disease more often than females. The Protein—Important building blocks of the body, liver disease appears to be related to abnormal anti- composed of amino acids, involved in the forma- trypsin protein remaining in the liver instead of being tion of body structures and controlling the basic secreted. Diagnosis Alpha-1 antitrypsin may be suspected in a newborn with cholestatic jaundice, swollen abdomen, and poor Liver disease in children and adults with alpha-1 feeding. In later childhood or adulthood, fatigue, poor antitrypsin is diagnosed by the same methods used to appetite, swelling of the abdomen and legs, or abnormal diagnose liver disease in people who do not have alpha-1 liver tests may trigger the need for testing. Liver function studies include tests measur- of alpha-1 antitrypsin is based on measurement of antit- ing two liver proteins called serum glutamic oxaloacetic rypsin (Pi) in the blood. If levels of Pi are deficient, transaminase (SGOT) and serum glutamic pyruvic genetic studies may be performed to determine which transaminase (SGPT). The Pi protein tate transaminase (AST), and SGPT is sometimes called can also be studied to determine which type a person has. Studies may also be Prenatal diagnosis is available, however, it is recom- performed looking for deposits within the cells of the mended that parental genetic studies precede prenatal liver called inclusions. Once the diagnosis of alpha-1 antitrypsin has been Levels of antitrypsin protein in the blood may be made, it is important to share this information with rela- normal in individuals who have one PI Z gene and one tives related by blood, especially parents and children. Studying the Pi protein will more know that they have it before they develop lung disease, accurately diagnose these individuals. Some organi- Lung disease in people with alpha-1 antitrypsin is zations have recommended that individuals with asthma diagnosed by the same methods used to diagnose lung be tested for alpha-1 antitrypsin. These studies include breathing tests such as total lung capacity and pulmonary function tests.

Partial Membrane Cardio- Agonist Stabilizing -Blocker selective Activity Activity Mechanism of Action Propranolol No None Yes All of the -blockers exert equilibrium-competitive an- Acebutolol Yes Slight None tagonism of the actions of catecholamines and other Atenolol Yes None None adrenomimetics at -receptors red viagra 200mg fast delivery 2010 icd-9 code for erectile dysfunction. Probably the best- Betaxolol Yes None Slight Carteolol No Slight None recognized action of these compounds that is not medi- Esmolol Yes None None ated by a -receptor is depression of cellular membrane Levobunolol No None None excitability discount 200 mg red viagra with visa erectile dysfunction talk your doctor. This effect has been described as a mem- Metoprolol Yes None Slight brane-stabilizing action, a quinidinelike effect, or a local Nadolol No None None anesthetic effect. This action is not too surprising in Penbutolol No Slight None Pindolol No Yes Slight view of the structural similarities between -blockers Timolol No Slight None and local anesthetics. However, with the usual therapeu- 114 II DRUGS AFFECTING THE AUTONOMIC NERVOUS SYSTEM only 3 to 10% of an administered dose is recovered as short duration of action, esmolol is used by the intra- unchanged drug. The metabolites are essentially inactive venous route for the control of ventricular arrhythmias as -receptor blocking agents and are eliminated pri- in emergencies. Peak plasma levels occur metabolism does not seem to occur; nadolol is excreted 2 to 4 hours after oral administration; the plasma half- primarily unchanged in the urine and feces. The extensive half-life is quite long, approaching 24 hours, which per- tissue distribution of timolol into lung, liver, and kidney mits dosing once per day. Approximately Pindolol (Visken) is extensively absorbed from the 70% of the drug is excreted in the urine within 24 hours, gastrointestinal tract. Only at about 15%, and its plasma half-life is on the order of 6% of an administered dose is recovered in the feces. The binding of pindolol to plasma proteins Although timolol is approved for the topical treatment is approximately 50%. The metabolic fate of pindolol is of elevated intraocular pressure, there is limited infor- not completely understood, although 50% of an admin- mation about its pharmacokinetics following adminis- istered dose is recovered, primarily in the urine, as un- tration by this route. About half of an orally administered dose of acebu- The most important actions of the -blocking drugs are tolol (Sectral) is absorbed. These effects are most a metabolite with -blocking activity whose half-life is pronounced when sympathetic activity is high or when 10 hours. Roughly half of an orally administered dose of The actions of -blockers on blood pressure are atenolol (Tenormin) is absorbed. After acute administration, blood pressure is primarily by the kidney and unlike propranolol, under- only slightly altered. Its plasma half-life is ap- reflex increase in peripheral vascular resistance that re- proximately 6 hours, although if it is administered to a sults from a -blocker–induced decrease in cardiac out- patient with impaired renal function, its half-life can be put. The drug is subject to a results in a reduction of blood pressure, and this is the slight first-pass effect such that the absolute bioavail- reason for their use in primary hypertension (see ability of the drug is about 90%. The mechanism of this effect is not well un- administered betaxolol binds to plasma proteins, and its derstood, but it may include such actions as a reduction plasma half-life is about 20 hours; it is suitable for dos- in renin release, antagonism of -receptors in the central ing once per day. The primary route of elimination is by nervous system, or antagonism of presynaptic facilita- liver metabolism, with only 15% of unchanged drug be- tory -receptors on sympathetic nerves. Total coronary blood flow is reduced by the Carteolol (Cartrol) is a long-acting -blocker that is -blockers. It is almost completely posed -receptor–mediated vasoconstriction that fol- absorbed and exhibits about 30% binding to plasma lows -receptor blockade in the coronary arteries. Unlike many -blockers, carteolol is not ex- Additional contributing factors to the decrease in coro- tensively metabolized. Up to 70% of an administered nary blood flow are the negative chronotropic and in- dose is excreted unchanged. It is subject to hydrolysis by cytosolic es- blood pressure may also contribute to the reduced coro- terases in red blood cells to yield methanol and an acid nary blood flow. Only 2% of the administered esmolol is agents on coronary blood flow, it seems paradoxical that excreted unchanged. Because of its rapid onset and these drugs are useful for the prophylactic treatment of 11 Adrenoceptor Antagonists 115 angina pectoris, a condition characterized by inade- pathetic nerve activity to maintain sufficient cardiac quate myocardial perfusion. The chief benefit of the - output, the -blockers have been shown to be quite use- blockers in this condition derives from their ability to ful in the long-term management of patients with mild decrease cardiac work and oxygen demand. For this purpose, it is best if oxygen demand may also be responsible for the favor- -blocker therapy is instituted soon after the MI and able effects of these agents in the long-term manage- continued for the long term.