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First generic dutasteride 0.5mg with amex hair loss cure by 2020, patient data buy 0.5 mg dutasteride visa hair loss in men rain, obtained during the normal course of clinical care, has proven to be a valid source for replicating genome-phenome associations that previously had been reported only in carefully qualified research cohorts. Second, although the individual institutions initially thought that they had large enough effect sizes and odds ratios to be adequately powered, in most cases, the entire network was needed to determine genome-wide association. The ability to extract high-quality phenotypes from narrative text is essential along with codes, laboratory results, and medication histories to get high predictive values. Fourth, although the five electronic medical systems have widely varying structures, coding systems, user interfaces, and users, once validated at one site, the information transported across the network with almost no degradation of its specificity and precision. For instance, a particular challenge has been to achieve both meaningful data sharing and respect for patient privacy concerns, while adhering to applicable regulations and laws (Kho et al. Evidence is already accumulating that these alternative and “informal” sources of health care data, including information shared by individuals from ubiquitous technologies such as smart phones and social networks, can contribute significantly to collecting disease and health data (Brownstein et al. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease 29 Many data sources exist outside of traditional health-care records that could be extremely useful in biomedical research and medical practice. Informal reports from large groups of people (also known as ‘crowd sourcing’), when properly filtered and refined, can produce data complementary to information from traditional sources. One example is the use of information from the web to detect the spread of disease in a population. In one instance, a system called HealthMap, which crawls about 50,000 websites each hour using a fully automated process, was able to detect an unusual respiratory illness in Veracruz, Mexico, weeks before traditional public-health agencies (Brownstein et al. It also was able to track the progression and spread of H1N1 on a global scale when no particular public-health agency or health-care resource could produce that kind of a picture. The use of mobile phones also has tremendous potential, especially with developers building apps that engage patient populations. For example, a recent app called Outbreaks Near Me allows people to use their cell phones to learn about all the disease events in their neighborhood. People also can report back to the system, putting their own health information into the system. Many of the social networking sites built around medical conditions are patient specific and allow individuals to share unstructured information about health outcomes. Mining that information within proper ethical guidelines provides a novel opportunity to monitor health outcomes. For example, Google has mined de-identified search data to build a picture of flu trends. The advent of these inexpensive ways of collecting health information creates new opportunities to integrate information that will enhance the diagnosis and treatment of disease. Integrating Clinical Medicine and Basic Science Traditionally, a physician’s office or clinic has had few direct connections with academic research laboratories. In this environment, patient-oriented research—particularly if it involved studying patients or patient-derived samples with state-of-the-art scientific techniques and experimental designs—required a major division of labor between the research and clinical settings. Typically, researchers have used informal referral networks to make contact with physicians caring for patients with diseases of special interest to the researchers. This approach often yielded descriptive and anecdotal results of uncertain relevance to larger (and more diverse) patient populations. Moreover, the patients who contributed are unlikely to remain connected to the 6 research process or be aware of outcomes. This research model is ill suited to long-term follow- up of patients since it was never designed for this purpose. Although remarkably successful in addressing its original goals of testing clearly defined hypotheses, this traditional approach to clinical research is poorly suited to answering current questions about human health that are often more open-ended and larger in scope than those typically addressed in the past. Based on committee experience and the input from multiple stakeholders during the course of this study, including the two-day workshop, the Committee 6 There are notable exceptions such as the Framingham Heart Study and Nurses’ Health study, which were designed from the outset to follow a cohort of patients over an extended period of time. Toward Precision Medicine: Building a Knowledge Network for Biomedical Research and a New Taxonomy of Disease 30 identified several reasons that current study designs are mismatched to current needs. Traditional designs: x Require very large sample sizes —hence most studies are inevitably under-powered. As emphasized above, the number and complexity of questions inherent in genotype- phenotype correlations is virtually unbounded. Patients with particularly informative genotypes and phenotypes—often difficult or impossible to recognize in advance—will typically be rare. Identification and recruitment of such patients in sufficient numbers to acquire clinically actionable information about their diseases will be possible only if molecular and clinical information can be combined in huge patient cohorts. Indeed, the suite of obstacles that a young investigator must overcome to penetrate this system are a major disincentive for involvement in patient-oriented research. In addition, the many talented biomedical researchers who choose to focus their work on model organisms (such as flies, worms, and mice) have little opportunity to share insights or collaborate with clinical researchers.

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Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www dutasteride 0.5mg for sale hair loss in men magazine. State screening laws do not necessarily translate into higher testing rates generic 0.5 mg dutasteride with mastercard hair loss in men questions, because they often do not include an enforcement mechanism or sanctions for noncompliance (Euler et al. In a study of family physicians in New Jersey, a state with a maternal screening law, Ferrante et al. At the 2009 International Symposium on Viral Hepatitis and Liver Disease, Chao et al. Hepatitis C Health-care providers’ knowledge about hepatitis C appears to be similarly insuffcient, although there is far less published research on this topic (Ascione et al. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. One-fourth incorrectly indicated that blood transfusion continues to be a risk factor, and 19% erroneously be- lieved that casual household contact is a major risk factor. A previous study by the same researchers had also found substantial gaps in primary care providers’ knowledge about hepatitis C (Shehab et al. The gaps persisted even though 95% of the respondents in the 2001 study reported having used at least one educational tool about hepatitis C in the preceding 2 years; this suggests that primary care providers misreport their Copyright © National Academy of Sciences. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Recommendation Many providers are not aware of the high prevalence of chronic hepa- titis B and hepatitis C in some populations. On the basis of the evidence described above, the committee concludes that insuffcient provider knowledge leads to critical missed opportunities for providers to educate patients about prevention of hepatitis B and hepa- Copyright © National Academy of Sciences. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. To address that issue, the committee offers the following recommendation: Recommendation 3-1. The Centers for Disease Control and Prevention should work with key stakeholders (other federal agencies, state and local governments, professional organizations, health-care organiza- tions, and educational institutions) to develop hepatitis B and hepatitis C educational programs for health-care and social-service providers. Educational programs and materials for health-care and social-service providers should focus on improving provider awareness and adherence to practice guidelines for hepatitis B and hepatitis C. The educational programs should be targeted to primary care providers, appropriate social-service providers (such as staff of drug-treatment facilities and immigrant-services centers), and licensed and unlicensed alternative-medicine professionals (such as acupuncturists and traditional Chinese medicine practitioners) that serve at-risk populations. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Educational Institutions Schools of medicine, nursing, physician assistants, complementary and alternative medicine, and public health should develop improved curricula to ensure that their graduates are knowledgeable about chronic hepatitis B and hepatitis C. The curricula should include information on disease preva- lence, risk factors, preventive actions, appropriate diagnostics, selection of persons for testing, and appropriate followup for chronically infected patients and those susceptible to infection. Drug-treatment counselors’ education and certif- cation examinations should also include hepatitis B and hepatitis C. Although there has been no systematic effort to determine whether continuing-medical-education courses and certifcation examina- tions include questions about hepatitis B and hepatitis C, the shortcomings in knowledge among health-care providers suggest that current efforts are insuffcient, and that new approaches are needed to improve knowledge. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Hospitals and nonhospital health-care facilities (such as di- alysis units, endoscopy clinics, and long-term-care facilities) should develop educational programs to reinforce the importance of adhering to recom- mended standard precautions and procedures to prevent the transmission of bloodborne infections in both inpatient and outpatient health-care settings (Thompson et al. Health-care workers should be routinely vac- cinated to protect them from hepatitis B. Successful interventions to prevent exposures known to transmit bloodborne infections have included general safety train- ing; training specifc to prevention of needle-stick injuries; modifcation of practice, staffng, and workload adjustments; and use of protective devices, such as needles that automatically retract (Clarke et al. Substance-Abuse–Related Service Providers Staff of drug-treatment programs, needle-exchange programs, and cor- rectional facilities should be participants in viral-hepatitis educational pro- grams. Over the period during which a person may inject illicit drugs, the likelihood that he or she has been in a drug-treatment program rises (Galai et al. Thus, the committee believes that providing standardized education to staff of drug-treatment and needle-exchange programs and correctional Copyright © National Academy of Sciences. Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C http://www. Alternative-Care Providers Alternative-care providers would also beneft from participating in educational programs about viral hepatitis. Lack of knowledge and awareness about hepatitis B and hepatitis C in the community often leads to misinformation, missing of opportunities for prevention and treatment, and stigmatization of infected populations. Once infected, they frequently are unaware of their infection and so run the risk of unknowingly infecting others and of not receiving appropriate medical management.

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Interplay between different polyunsaturated fatty acids and risk of coronary heart disease in men buy 0.5 mg dutasteride mastercard hair loss name. Dietary fat intake and risk of coronary heart disease in women: 20 years of follow-up of the nurses’ health study quality 0.5mg dutasteride japanese hair loss cure. Accumulated evidence on fish consumption and coronary heart disease mortality: a meta-analy- sis of cohort studies. Fish and long-chain omega–3 fatty acid intake and risk of coronary heart disease and total mortality in diabetic women. Dietary n–3 polyunsaturated fatty acids and coronary heart disease-related mortal- ity: a possible mechanism of action. Omega-3 fatty acids and cardiovas- cular disease: new recommendations from the American Heart Association. N-3 polyunsaturated fatty acids in coronary heart disease: a meta-analysis of randomized controlled trials. Dietetic guidelines: diet in secondary prevention of cardiovascular disease (first update, June 2003). Lack of benefit of dietary advice to men with angina: results of a controlled trial. Urinary sodium excretion and cardiovascular mortality in Finland: a prospective study. Effects of weight loss and sodium reduction intervention on blood pressure and hypertension incidence in overweight people with high-normal blood pressure. Effect of modest salt reduction on blood pressure: a meta-analysis of randomized trials. Guidelines for management of hypertension: report of the third working party of the British Hypertension Society. Vegetable and fruit intake and stroke mortality in the Hiroshima/Nagasaki Life Span Study. Dietary fiber and risk of coronary heart disease: a pooled analysis of cohort studies. The public health burdens of sedentary living habits: theoretical but realistic estimates. Physical activity in older middle-aged men and reduced risk of stroke: the Honolulu Heart Program. A prospective study of walking as compared with vigorous exercise in the prevention of coronary heart disease in women. Changes in physical activity, mortality, and incidence of coronary heart disease in older men. Physical activity in the prevention of cardiovascular disease: an epidemiologi- cal perspective. Physical activity decreases cardiovascular disease risk in women: review and meta-analysis. Effects of endurance training on blood pressure, blood pressure-regulating mechanisms, and cardiovascular risk factors. Effect of resistance training on resting blood pressure: a meta-analysis of ran- domized controlled trials. Ten-year experience with an exercise-based outpatient life-style modification program in the treatment of diabetes mellitus. Effect of aerobic exercise on blood pressure: a meta-analysis of randomized, controlled trials. Aerobic exercise, lipids and lipoproteins in overweight and obese adults: a meta-analysis of randomized controlled trials. Low cardiorespiratory fitness and physical inactivity as predictors of mortality in men with type 2 diabetes. The effectiveness of public health interventions for increas- ing physical activity among adults. Review of primary care-based physical activity intervention studies: effec- tiveness and implications for practice and future research. Body mass index and mortality: a meta-analysis based on person-level data from twenty-six observational studies. Effect of body mass index on all-cause mortality and incidence of cardiovascular diseases – report for meta-analysis of prospective studies open optimal cut-off points of body mass index in Chinese adults. Overweight and obesity as determinants of cardiovascular risk: the Framingham experi- ence. Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.

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Multi-tasking is • mentored in a supportive buy dutasteride 0.5 mg overnight delivery hair loss graves disease, non-judgmental fashion to often viewed with disdain by Boomers generic dutasteride 0.5 mg on line hair loss cure 3 plus, 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’. The nurse looks at her and The advantages of good relationships among members of a leaves the room without responding. The nurse returns the benefts are improved care to patients and improved patient with the fellow and starts to explain the patient’s situation. The open sharing of information, and the attitude that The fellow notes that she is in the appropriate position and questioning and checking is expected, leads to safer care. The resident is astonished that the nurse ignored error or a nurse, acting on previous experience with a patient, her request and yet is willing to run to obtain things for the to question an order for a medication to which she believes fellow. Patients also report improved satisfaction in her relationship with the nurse and feels angry that her with care when members of the team work together. Both physicians and nurses who work on well-functioning Introduction teams report improved work satisfaction, less burnout, im- The culture of health care has changed over the past few proved morale, increased motivation and reduced confict. Well-functioning teams have great professional relationships and good communication with con- potential in delivering excellent patient care and improving sultants and other members of the multidisciplinary team, as patient safety. Poorly functioning teams, particularly those one of the most signifcant factors in improving the resilience with communication problems, can present signifcant risks of physicians. The ability to establish collegial relationships with members of the health care team is essential. Given the many benefts of collegiality, it is important to ad- Physicians must not only work with other health professionals dress potential barriers to good working relationships. Bulgar in a collegial fashion but must also establish good relation- and Bulgar highlight problems that subspecialists encounter in ships with clinicians and faculty members in other specialties. For their part, family phy- Collegiality enables academic interchange and collaboration at sicians frequently point to disparaging comments made about the level of the individual case, in the development of new them by specialist colleagues. We forget that it is impossible if techniques for medical care, and in research activities, improv- not futile to expect one physician to acquire a good working ing outcomes in all of these spheres. It can also be diffcult to be respectful of others when service demands are high, time is short, and we are fatigued from being on call. We accept differences, take risks, function indepen- are often ignorant of the knowledge and skill in other disciplines dently, articulate roles, and tolerate reviews and because we are not educated or trained together.

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