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By N. Rasarus. Inter American University of Puerto Rico.

The quality of the interpersonal relationship is also important because of how it can affect technical performance (Donabedian 1988a) propranolol 80mg with amex blood vessels near surface of skin. A clini- cian who relates well to a patient is better able to elicit from that patient a more complete and accurate medical history (especially with respect to potentially sensitive topics such as use of illicit drugs); that purchase 80mg propranolol overnight delivery blood vessels of the brain, in turn, can result in a better diagnosis. Similarly, a good relationship with the patient is often crucial in motivating the patient to follow the prescribed regimen of care, such as taking medications or making lifestyle changes, for which noncompliance rates are alarmingly high despite their obvious importance to achieving the ultimate goals of healthcare (Haynes et al. Much like the interpersonal relationship, amenities are valued both in their own right and for their potential effect on the technical and interpersonal aspects of care. Amenities such as ample and convenient parking, good directional signs, comfortable waiting rooms, and tasty hospital food are all of direct value to patients. For exam- ple, in a setting that is comfortable and affords privacy and as a result puts the patient at ease, a good interpersonal relationship with the clinician is more easily established, leading to a potentially more complete patient his- tory and therefore a faster and more accurate diagnosis. Responsiveness to Patient Preferences Although taking into account the wishes and preferences of patients has long been recognized as important to achieving high quality of care, until recently this has not been singled out as a factor in its own right. Basic Concepts of Healthcare Quality 29 Efficiency Efficiency refers to how well resources are used in achieving a given result. Efficiency improves whenever the resources used to produce a given out- put are reduced. Although economists typically treat efficiency and qual- ity as separate concepts, it has been argued that separating the two in healthcare may not be easy or meaningful. Because inefficient care uses more resources than necessary, it is wasteful care, and care that involves waste is deficient—and therefore of lower quality—no matter how good it may be in other respects: Wasteful care is either directly harmful to health or is harmful by displacing more useful care (Donabedian 1988a). Cost Effectiveness The cost effectiveness of a given healthcare intervention is determined by how much benefit, typically measured in terms of improvements in health status, the intervention yields for a particular level of expenditure (Gold et al. In general, as the amounts spent on providing services for a par- ticular condition grow, diminishing returns set in; each unit of expendi- ture yields ever-smaller benefits, until a point is reached where no additional benefits accrue from adding more care (Donabedian, Wheeler, and Wyszewianski 1982). The idea that resources should be spent until no addi- tional benefits can be obtained has been termed the maximalist view of quality of care. In that view, resources should be expended as long as there is a positive benefit to be obtained, no matter how small it may be. An alternative to the maximalist view of quality is the optimalist view, which holds that spending ought to stop earlier, at the point where the added benefits are too small to be worth the added costs (Donabedian 1988a). The Different Definitions Although everyone values to some extent the attributes of quality just described, different groups tend to attach different levels of importance to individual attributes, leading to differences in how clinicians, patients, pay- ers, and society each define quality of care. Reference to current professional knowledge places the assessment of quality of care in the context of the state of the art in clinical care, which constantly changes. Clinicians want it recognized that, because medical knowledge advances rapidly, it is not fair to judge care provided in 2002 in terms of what has only been known since 2004. As a result, patients tend to defer to others on matters of technical quality. Patients therefore tend to form their opinions about quality of care based on their assessment of those aspects of care they are most readily able to evaluate: the interpersonal aspect of care and the ameni- ties of care (Cleary and McNeil 1988; Donabedian 1980). This often dismays clinicians, to whom this focus is a slight to the centrality of technical quality in the assessment of healthcare quality. Another aspect of care that has steadily grown in importance in how patients define quality of care is the extent to which their preferences are taken into account. Although not every patient will have definite prefer- ences in every clinical situation, patients increasingly value being consulted about their preferences, especially in situations in which different approaches to diagnosis and treatment involve potential tradeoffs, such as between the quality and quantity of life. Additionally, because payers typically manage a finite pool of resources, they often have to consider whether a potential outcome justifies the associated costs. Payers are therefore more likely to embrace an optimalist definition of care, which can put them at odds with individual physicians, who generally take the maximalist view of quality. Most physicians consider cost-effectiveness calculations as anti- thetical to providing high-quality care, believing instead that they are duty- bound to do everything possible to help their patients, including advocating for high-cost interventions even when such measures have a small, but pos- itive, probability of benefiting the patient (Donabedian 1988b). By contrast, third-party payers—especially governmental units that must make multiple tradeoffs when allocating resources—are more apt to take the view that spending large sums in instances where the odds of a positive result are small does not represent high quality of care, but rather a misuse of finite resources. In addition, however, society at large is often expected to focus on technical aspects of quality, which it is seen as better placed to safeguard than individuals are.

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A meta- pursue all of the possibilities in terms of esti- analysis of a series of trials that have naıvely¨ mating treatment effects buy discount propranolol 80mg on-line cardiovascular disease definition, the design offers ways discount propranolol 80 mg on-line blood vessels in spanish, ignored random therapist effects, for example, at least partially, of testing the validity of the or ignored the structure of a group therapy assumptions necessary for the above CACE esti- trial, simply summarises the faulty analyses of mator, or, equivalently, looking for a poor prog- the originals. Unfortunately, the consumers of nosis/demoralising effect in the potential com- meta-analyses (particularly if they are produced pliers of the control group. Getting preference under the auspices of such august bodies as the information prior to randomisation would also Cochrane Collaboration) seem to place far too improve the precision of the estimates of the much faith in their findings. Consumers need to CACE, but this is well beyond the scope of be aware that the authors of systematic reviews the present chapter – for further information, see are capable of missing subtle (or not so subtle) Fisher-Lapp and Goetghebeur. Con- will also provide a suitable entry to the literature sumers should resist taking the conclusions of the on adjustment for partial compliance (i. Reporting guidelines such as CONSORT46,47 are having a for the estimation of the effects of psychotherapy are difficult. It is not safe to simply assume that substantial impact on the quality of clinical trials, the theoretical and logistical problems are similar and on the appraisal methodologies of system- to those of the average drug trial. Psychotherapy (at least however, the CONSORT recommendations only in its individual form) involves the interaction cover a small part of the key components of the 310 TEXTBOOK OF CLINICAL TRIALS trial. I tute of Mental Health Treatment of Depression Collaborative Research Program (1989). Arch Gen hope the present chapter succeeds in stimulating Psychiat (1989) 46: 971–81. Clinical trials in psychiatry: should REFERENCES protocol deviation censor patient data? Statistical methods for measuring out- tocol deviation patient: characterization and impli- comes. In: Tansella M, Thornicroft G, eds, Men- cations for clinical trials research. In: Wykes T, Tarrier N, Lewis S, eds, Out- Design and Analysis of Clinical Trials. London: come and Innovation in Psychological Treatment Imperial College Press (1999). Estimating causal effects of treatments ucation for depression: a multicentre randomised in randomized and nonrandomized studies. Statistics and causal inference (with conceptual and statistical issues in analysis of discussion). Understand Psychological treatments for cocaine dependence: Stat (2002) 1: 19–29. Intention-to-treat and the cal considerations in group psychotherapy research: goals of clinical trials. Oxford: apist effects for the design and analysis of com- Oxford University Press (2000) 1411–20. Oxford: Oxford University Press come between health professionals for the design (2000) 1421–32. Oxford: Oxford University Press come research: disentangling therapists from ther- (2000) 1259–69. Contr Clin Tri- Institute of Mental Health Treatment of Depression als (1999) 20: 531–46. Br Med J (1989) 299: preferences in randomised trials: threat or opportu- 313–15. Diabet Care (1993) 16: holism treatments to client heterogeneity: Project 509–18. Randomized of causal effects using instrumental variables (with controlled trial of non-directive counselling, discussion). Statistical techniques for ana- practitioner care for patients with depression. Causal effects in clinical and ized controlled trial of non-directive counselling, epidemiological studies via potential outcomes: cognitive-behaviour therapy, and usual general concepts and analytical approaches. On estimating efficacy improving the quality of reports of parallel- from clinical trials. Ann ties of some structural mean analyses of the effect Int Med (2001) 134: 663–94. Green  2004 John Wiley & Sons, Ltd ISBN: 0-471-98787-5 20 C ontraception ∗ GILDA PIAGGIO Department of Reproductive Health and Research, World Health Organisation, Geneva, Switzerland ∗The views expressed in this paper are solely those of the author and do not necessarily reflect the views of the World Health Organization.

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In addition buy propranolol 80 mg on-line arteries that feed the heart, some fungi dermatophytes purchase 80mg propranolol amex blood vessels game, can grow only at the cooler temperatures of have characteristics that enhance their ability to cause disease. Other fungi, called dimorphic, can grow as Cryptococcus neoformans organisms, for example, can be- molds outside the body and as yeasts in the warm tempera- come encapsulated, which allows them to evade the normal tures of the body. As molds, these fungi produce spores that immune defense mechanism of phagocytosis. Aspergillus can persist indefinitely in the environment and be carried by organisms produce protease, an enzyme that allows them to the wind to distant locations. When these mold spores enter the destroy structural proteins and penetrate body tissues. They have a thick, rigid cell wall, of which one of the com- human pathogens such as those that cause blastomycosis, ponents is a polysaccharide called glucan. Fungi also 595 596 SECTION 6 DRUGS USED TO TREAT INFECTIONS have a cell membrane composed of lipids, glycoproteins, and tochrome P450 enzyme (14-alpha demethylase) that is re- sterols. One of the sterols is ergosterol, a lipid that is similar to quired for synthesis of ergosterol from lanosterol, a precursor. Within This action causes production of a defective cell membrane, the cell membrane, structures are essentially the same as those which also allows leakage of intracellular contents and de- in human cells (eg, a nucleus, mitochondria, Golgi apparatus, struction of the cell. Both types of drugs also affect cholesterol ribosomes attached to endoplasmic reticulum, and a cyto- in human cell membranes, and this characteristic is considered skeleton with microtubules and filaments). Echinocandins or glucan synthesis inhibitors (eg, caspo- fungin) are a new class of antifungal drugs that disrupt fun- FUNGAL INFECTIONS gal cell walls rather than fungal cell membranes. They act by inhibiting beta-(1,3)-D-glucan synthetase, an enzyme re- Fungal infections (mycoses) may be mild and superficial or quired for synthesis of glucan. Dermatophytes cause superfi- saccharide in the fungal cell wall; its depletion leads to cial infections of the skin, hair, and nails. Drugs for superficial fungal infections of skin and mucous Most fungal infections occur in healthy people but are more membranes are usually applied topically. Patients with HIV infections (eg, oral, intestinal, or vaginal candidiasis) with anti- infection need aggressive treatment of primary fungal infec- bacterial drug therapy. In immunocompromised hosts, candi- tions and prolonged or lifelong secondary prophylaxis. Patients dal infections are more likely to be deep, widespread, and with prolonged or severe neutropenia secondary to treatment caused by non-albicans species. Instead, they of fungal infections, because they are at high risk for acute, grow in soil and decaying organic matter. Most invasive fungal life-threatening, systemic mycoses such as candidiasis and as- infections are acquired by inhalation of airborne spores from pergillosis. Selected antifungal drugs are further described in contaminated soil and severity of disease increases with inten- the following sections. Infections such as histoplasmosis, coccid- teristics of selected drugs are listed in Table 40–1; clinical in- ioidomycosis, and blastomycosis usually occur as pulmonary dications for use and dosage ranges are listed in Drugs at a disease but may be systemic. Serious, systemic fungal infections commonly occur and Polyenes are increasing in incidence, largely because of human immuno- deficiency virus (HIV) infections, the use of immunosup- Amphotericin B is active against most types of pathogenic pressant drugs to treat clients with cancer or organ transplants, fungi, including those that cause aspergillosis, blastomyco- the use of indwelling intravenous (IV) catheters for prolonged sis, candidiasis, coccidioidomycosis, cryptococcosis, histo- drug therapy or parenteral nutrition, implantation of pros- plasmosis, and sporotrichosis. The drug is fungicidal or thetic devices, and widespread use of broad-spectrum anti- fungistatic depending on the concentration in body fluids and bacterial drugs. Characteristics of selected fungal infections on the susceptibility of the causative fungus. The drug is usually given Antifungal Drugs for 4 to 12 weeks but may be needed longer by some clients. Lipid formulations were developed to decrease adverse Development of drugs that are effective against fungal cells effects, especially nephrotoxicity. Compared to the original without being excessively toxic to human cells has been lim- deoxycholate formulation (Fungizone), these mixtures of ited because fungal cells are very similar to human cells. At the same time, tic effects by disrupting the structure and function of various lipid formulations do not penetrate normal tissues well and fungal cell components (Fig. This Polyenes (eg, amphotericin B) and azoles (eg, flucona- decreases adverse effects and also allows higher doses to be zole) act on ergosterol to disrupt fungal cell membranes. Although these products cause much less nephrotoxi- photericin B (and nystatin) binds to ergosterol and forms city, chills, and fever, they are much more expensive than the holes in the membrane, causing leakage of the fungal cell deoxycholate formulation.

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However quality 40 mg propranolol cardiovascular system location, additive cardiac depressant effects also may occur (brady- cardia buy propranolol 40 mg mastercard blood vessels from the heart, decreased force of myocardial contraction [negative inotropy], decreased cardiac output). Drugs that decrease effects of beta-adrenergic blocking agents: (1) Antacids Decrease absorption of several oral beta blockers (2) Atropine Increases heart rate and may be used to counteract excessive bradycardia caused by beta blockers (3) Isoproterenol Stimulates beta-adrenergic receptors and therefore antagonizes effects of beta-blocking agents. What are the main mechanisms by which beta blockers Nursing Notes: Apply Your Knowledge relieve angina pectoris? How are beta blockers thought to be cardioprotective Answer: Although she is probably not allergic to the Inderal, in preventing repeat myocardial infarctions? What are some noncardiovascular indications for the use Inderal is a nonselective beta blocker, which means that it blocks of propranolol? What are the main differences between cardioselective bronchial constriction. Why are cardioselective beta blockers preferred for clients with a history of asthma or chronic obstructive pulmonary dis- with asthma or diabetes mellitus? What signs, symptoms, or behaviors would lead you to How Can You Avoid This Medication Error? Do the same adverse effects occur with beta blocker eye by the first-pass effect, so the normal IV dose is significantly less drops that occur with systemic drugs? What information needs to be included in teaching clients push doses are usually 1 to 2 cc. What is the risk of abruptly stopping a beta blocker drug rather than tapering the dose and gradually discontinuing, as recommended? How can beta blockers be both therapeutic and non- therapeutic for heart failure? How do alpha2 agonists and alpha1-blocking agents de- crease blood pressure? What are safety factors in administering and monitoring the effects of alpha agonists and alpha -blocking agents? The cardiac insufficiency bisoprolol 2 1 study II (CIBIS-II): A randomised trial. Why should a client be cautioned against stopping alpha2 Drug facts and comparisons. Catecholamines, sympathomimetic drugs, and biologic basis for disease in adults and children, 4th ed. Critical Thinking Scenario Jamie, a 14-year-old, was diagnosed with myasthenia gravis 3 years ago and has been well managed on neostigmine (Prostigmin), an anticholinesterase agent. His mother calls the clinic and, clearly upset, reports the following symptoms that Jamie is experiencing: severe headache, drooling, and one fainting episode. Explain how Prostigmin alters neurotrans- mitters to manage this condition. What additional data would you collect to help arrive at a diagnosis before treatment? Myasthenia gravis is an autoimmune disorder in which auto- Cholinergic drugs, also called parasympathomimetics and antibodies are thought to destroy nicotinic receptors for acetyl- cholinomimetics, stimulate the parasympathetic nervous choline on skeletal muscle. As a result, acetylcholine is less able system in the same manner as acetylcholine (see Chap. Some drugs act directly to stimulate cholinergic receptors; In normal brain function, acetylcholine is an essential others act indirectly by slowing acetylcholine metabolism neurotransmitter and plays an important role in cognitive func- (by the enzyme acetylcholinesterase) at autonomic nerve tions, including memory storage and retrieval. In the cholinergic system, there is a substantial nary retention, respectively. Increased tone and contractility of smooth muscle promote normal secretory and motor activity. Cholinergic (detrusor) in the urinary bladder and relaxation of the stimulation results in increased peristalsis and relaxation of the sphincter smooth muscle in sphincters to facilitate movement of flatus 4. The secretory functions of the salivary and gastric muscle glands are also stimulated. Increased respiratory secretions Acetylcholine stimulates cholinergic receptors in the uri- 6. Constriction of pupils (miosis) and contraction of ciliary nary system to promote normal urination. Cholinergic stim- muscle, resulting in accommodation for near vision ulation results in contraction of the detrusor muscle and Indirect-acting cholinergic or anticholinesterase drugs relaxation of the urinary sphincter to facilitate emptying the decrease the inactivation of acetylcholine in the synapse by urinary bladder.

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