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Article review: Internal Medicine team redesign
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The Institute of viagra cialis online pharmacy pharmacy has re-sparked discussions about limiting and further reducing resident duty hours in the United States (IOM's Duty Hours Report from Dec 2008). In response to this, the Brigham and Women's Internal Medicine residency program created an innovative inpatient team model, which was published in this month's New England Journal of Medicine.


Study Design

Setting:
  • Faulkner Hospital, an affiliated community hospital with 72 inpatient medicine beds
Control team = General Medical Service (GMS) team
  • A single attending drawn from a "faculty pool"
  • 1 resident, 2 interns
  • A different attending drawn from a "faculty pool" to teach 3 times weekly
  • Intern call was every 4th night until 10 pm
  • Resident stays until 7 pm and then night float resident
Experimental team = Integrated Teaching Unit (ITU)
  • 2 attendings with each covering half of patients on team
  • One attending is hospitalist and the other is an internist or specialist
  • Attendings were selected based on excellent teaching evaluations.
  • Addition of multidisciplinary team members
  • 2 residents, 3 interns
  • Both attendings participated in daily morning rounds for 2 hours
  • One attending was available all day for teaching and clinical care
  • Intern call was every 6th night and leaving by noon next day
  • Resident supervised all interns every 4th night until 10 pm, and then night float resident
  • Team census cap = 15 patients
Methodology
Patients were randomized onto one of 4 teams over a 12-month period. There were 2 GMS and 2 ITU teams each month. An independent observer recorded intern activity on these 4 teams.

Results
Results for the GMS team are shown in blue and ITU team in red.
  • Average patient census per intern = 6.6 patients vs 3.5 patients
  • Overall trainee satisfaction (83% response rate) = 55% vs 78%
  • Intern time spent with learning activities = 10% of total time vs 20% (p=0.01)
  • Intern time spent with teaching activities = 2% of total time vs 8% (p=0.006)
  • Duration of patient hospital stay = 4.61 days vs 4.10 days (p=0.002)
  • There was no difference in time spent with patient care, patient outcome, and patient satisfaction.
The authors noted through qualitative responses, that having a dual-attending team was an important factor in greater trainee and attending satisfaction with the ITU team model. Trainees and attendings on the ITU teams enjoyed the increased exchange of ideas and debate, feedback, and different teach styles.

Bottom Line
The ITU team is a novel pro-education model which promotes greater attending supervision, a lower patient census, and more time for both self-reflective and structure learning on inpatient Medicine services. This study demonstrates that changes which prioritize education can be implemented without negatively impacting on the quality of clinical care.

How is this relevant for Emergency Medicine?
There are some fascinating findings from this study which are directly relevant to the field of EM. To me, this study seems to suggest:
  • There should be greater resident and attending staffing in the ED so that the ratio of providers-to-patients is lower. This is especially relevant given that our ED's are so often crowded and overwhelmed with clinical demands. This may help move education up on the priority list for residents and attendings on shift.
  • For residency programs with ED teaching attending shifts, where an attending physician's sole responsibility is to teach without clinical responsibilities, preference should be given to attendings who are stellar educators. This was the model used in this study.
  • Future studies should look at the ideal patient load in balanced learning for EM residents.

Reference McMahon, G., Katz, J., Thorndike, M., Levy, B., & Loscalzo, J. (2010). Evaluation of a Redesign Initiative in an Internal-Medicine Residency New England Journal of Medicine, 362 (14), 1304-1311 DOI: 10.1056/NEJMsa0908136


Capecitabine (Xeloda®)
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Capecitabine (Xeloda®)

Capecitabine (pronounced ka-pe-sight-a-been) is a chemotherapy drug that is given as a treatment for some types of cancer, including advanced bowel cancer or breast cancer. This information describes capecitabine, how it is given and some of its possible side effects. It should ideally be read with our general information about chemotherapy and about your type of cancer, which give more advice.

If you have any further questions you can ask your doctor or nurse at the hospital where you are having your treatment, or speak to one of our cancer support service nurses.

  • What capecitabine looks like
  • How it is given
  • Possible side effects
  • Less common side effects
  • Additional information
  • Things to remember about capecitabine tablets

What capecitabine looks like

Capecitabine is available as peach‑coloured online pharmacy of 500mg, and light peach-coloured tablets of 150mg.

How it is given

Your doctor may want you to take a combination of 500mg and 150mg tablets. You need to make sure that you are taking the right dose. The tablets should be swallowed whole with a glass of water, within half an hour of the end of a meal. You should take them in the morning after breakfast, and then again after your evening meal, so that the doses are spaced at least eight hours apart.

If you have trouble swallowing capecitabine tablets, they can be dissolved in a 200ml glass of warm water. The mixture should be stirred with a spoon until the tablets are completely dissolved and drunk immediately. The glass and spoon should be washed and kept separate from your other crockery and cooking utensils.

Capecitabine tablets are usually taken for a number of days, followed by a rest period in which no tablets are taken. This can vary depending upon the type of cancer you have. It is important to follow the instructions carefully and take the tablets as directed by your doctor.

You should only get the tablets from your hospital doctor. Do not get a repeat prescription from your GP.

Possible side effects

Each person’s reaction to chemotherapy is different. Some people have very few side effects, while others may experience more. The side effects described in this information will not affect everyone who is given capecitabine, and may be different if you are having more than one chemotherapy drug.

We have outlined the most common side effects and those which are less common, so that you can be aware of them if they occur. However, we have not included those that are very rare and therefore extremely unlikely to affect you. If you notice any effects which you think may be due to the drug but which are not listed in this information, please discuss them with your doctor or chemotherapy nurse.

Feeling sick (nausea) and vomiting This is usually mild. There are now very effective anti-sickness (anti-emetic) drugs to prevent or reduce nausea and vomiting. If you do feel sick, tell your doctor, who can prescribe other anti-sickness drugs which may be more effective.

Sore mouth and ulcers Your mouth may become sore or you may notice small ulcers during this treatment. Drinking plenty of fluids and cleaning your teeth regularly and gently with a soft toothbrush can help to reduce the risk of this happening. Tell your nurse or doctor if you have any of these problems, as special mouthwashes and medicines, which prevent or clear any mouth infection, can be prescribed.

Taste changes You may notice that your food tastes different. Normal taste will usually return when your treatment finishes.

Diarrhoea This can be quite severe but can usually be controlled with medicines. If you have diarrhoea more than 4–6 times a day, contact your hospital doctor for advice immediately. You may be advised to stop taking capecitabine, but it is often possible to restart the treatment at a lower dose. It is important to drink plenty of fluids if you have diarrhoea.

Abdominal pain and constipation It may help to drink plenty of fluids, eat a high-fibre diet and take gentle exercise. Sometimes you may need to take medicines to stimulate your bowel. These can be prescribed by your doctor.

Loss of appetite A dietitian or specialist nurse at your hospital can give advice and tips on boosting appetite, coping with eating difficulties and maintaining weight.

Skin changes Soreness and redness or darkening of the palms of the hands and soles of the feet (sometimes known as palmar plantar syndrome or hand-foot syndrome) can occur. You may be prescribed vitamin B6 (pyridoxine), which can help to reduce this. A rash and dry or itchy skin may also occur. If you notice this, let your specialist know.

Tiredness and feeling weak You may feel very tired. It is important to allow yourself plenty of time to rest.

Less common side effects

Lowered resistance to infection Capecitabine can reduce the production of white blood cells by the bone marrow, making you more prone to infection. This effect can begin seven days after treatment has been given, and your resistance to infection usually reaches its lowest point 10–14 days after chemotherapy. Your blood cells will then increase steadily, and will usually have returned to normal levels before your next course of chemotherapy.

Contact your doctor or the hospital straightaway if:

  • Your temperature goes above 38ºC (100.5ºF)
  • You suddenly feel unwell (even with a normal temperature)

You will have a blood test before having more chemotherapy to make sure that your cells have recovered. Occasionally it may be necessary to delay your treatment if the number of blood cells (the blood count) is still low.

Bruising or bleeding Capecitabine can reduce the production of platelets (which help the blood to clot). Let your doctor know if you have any unexplained bruising or bleeding, such as nosebleeds, blood spots or rashes on the skin, and bleeding gums.

Anaemia (low number of red blood cells) While having treatment with capecitabine you may become anaemic. This may make you feel tired and breathless. Let your doctor or nurse know if you develop these symptoms.

Hair loss Hair loss is rare but your hair may thin, or occasionally be lost completely. If this happens it usually begins about 3–4 weeks after starting treatment, although it may occur earlier. It is temporary and your hair will start to regrow once the treatment ends.

Headaches and dizziness Tell your doctor if you have headaches or feel dizzy and light-headed while taking capecitabine.

Changes in the way your heart works Capecitabine may affect the way your heart works. Some people can experience chest pain and tightening across the centre of the chest while taking capecitabine. This pain is called angina. Chest pain can be caused by many different things other than chemotherapy. If you develop any of these symptoms you should contact your doctor immediately.

Increased production of tears This may be caused by capecitabine and is temporary. You may also notice that your eyes become sore and inflamed (conjunctivitis). Your doctor can prescribe soothing eye drops if necessary.

Additional information

Other medicines Some other medicines can be harmful to take when you are having chemotherapy. Let your doctor know about any medications you are taking, including non-prescribed drugs such as complementary therapies and herbal drugs.

Fertility Your ability to become pregnant or father a child may be affected by taking this drug. It is important to discuss fertility with your doctor before starting treatment.

Contraception It is not advisable to become pregnant or father a child while taking capecitabine, as the developing foetus may be harmed. It is necessary to use effective contraception while taking this drug, and for at least a few months afterwards. Again, discuss this with your doctor.

Interaction with other drugs Capecitabine may affect the action of some medication given to thin the blood (anti-coagulants), such as warfarin. Let your doctor know if you take warfarin, as they may need to check more often how quickly your blood is clotting.

Folic acid Let your doctor know if you are taking folic acid because it might increase the side effects of capecitabine.

Things to remember about capecitabine tablets

  • It is important to take your tablets at the right times. You must take them as directed by your doctor, specialist nurse or pharmacist.
  • Keep the tablets in the original packaging and store them at room temperature, away from heat and direct sunlight.
  • Keep the tablets in a safe place where children cannot reach them, as capecitabine could harm them.
  • If your doctor decides to stop the treatment, return any remaining tablets to the pharmacist. Do not flush them down the toilet or throw them away.
  • If you are sick just after taking the tablets let your doctor know as you may need to take another dose. Do not take another tablet without first telling your doctor.
  • If you forget to take a tablet do not take a double dose. Inform your doctor and keep to your regular dose schedule.


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Himalayan Niagra - Sex Enhancement (for Women)
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Himalayan Niagra - Sex Enhancement (for Women)

Himalayan Niagra (Women) for Sex Enhancement

Recent studies show that 68% of women frequently experience problems reaching orgasm. Unfortunately many women tend to believe that there is something wrong with them or even that they are "frigid", if they can't climax on demand. This is not the case. Nearly all men can climax without difficulty, but women just aren't made that way. In the past, most doctors didn't rate the importance of the female orgasm very highly. Until recent years, doctors believed that only a tiny minority of women could have multiple orgasms; to the contrary, research now indicates that the vast majority of women are capable of having a series of climaxes one after the other.

Specially formulated to raise levels of progesterone in women, Himalayan Niagra (For Women) can help to enhance sexual sensitivity, increase sexual stamina, and improve your ability to achieve more frequent and more powerful orgasms.

Himalayan Niagra(For Women) is an all-natural alternative to prescription drugs made from the finest quality botanicals available. The all-natural proprietary blend of unique herbs found in Himalayan Niagra(For Women)is designed to increase blood flow and heighten sensation by activating the body's natural hormone production, while supplying vital nutrients necessary for peak sexual performance.

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Tricks of the Trade: Nursemaid elbow reduction
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We've all seen it before while working in the ED. A parent brings in their child because they pulled on their arm, and now the child is not using it. Parents are thoroughly convinced that the child's arm is either broken or dislocated. We all recognize this as radial head subluxation or "nursemaid's elbow" and immediately attempt to reduce it. The provider takes the injured arm, supinates at the wrist and flexes at the elbow. Does the child scream? Does the parent scream and threaten to sue? What if nothing happens?





Trick of the Trade: Hyperpronation technique

A 2009 paper by Bek et al. describes a method of pronation instead of supination. The proposed maneuver involves one hand holding the elbow at 90 degrees of flexion and the other hand holding the wrist. The wrist is then hyperpronated to complete the reduction.






Sixty-six patients were randomized to either a traditional reduction or the hyperpronation maneuver. If the initial attempt failed, a second attempt was performed. If the second attempt failed, then the alternate method was performed. Bottom line...hyperpronation was 94% successful on the first attempt compared to supination-flexion at 69%. Three patients failed supination-flexion (first and second attempt) but were successfully reduced with hyperpronation on the first attempt. Hyperpronation was also subjectively rated as significantly easier then supination-flexion by the practitioner.



I've been using hyperpronation for the past several years and love it. The maneuver appears less traumatic on the child (and parent).



Has anyone else tried it? I'd love to hear your experiences!



Reference

Bek D et al. Pronation versus supination maneuvers for the reduction of ‘pulled elbow’: a randomized clinical trial European Journal of Emergency cheap cialis. 2009, 16(3), 135-8. DOI: 10.1097/MEJ.0b013e32831d796a




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Tricks of the Trade: Nursemaid elbow reduction
widarole
See also: cheap cialis | 




We've all seen it before while working in the ED. A parent brings in their child because they pulled on their arm, and now the child is not using it. Parents are thoroughly convinced that the child's arm is either broken or dislocated. We all recognize this as radial head subluxation or "nursemaid's elbow" and immediately attempt to reduce it. The provider takes the injured arm, supinates at the wrist and flexes at the elbow. Does the child scream? Does the parent scream and threaten to sue? What if nothing happens?





Trick of the Trade: Hyperpronation technique

A 2009 paper by Bek et al. describes a method of pronation instead of supination. The proposed maneuver involves one hand holding the elbow at 90 degrees of flexion and the other hand holding the wrist. The wrist is then hyperpronated to complete the reduction.






Sixty-six patients were randomized to either a traditional reduction or the hyperpronation maneuver. If the initial attempt failed, a second attempt was performed. If the second attempt failed, then the alternate method was performed. Bottom line...hyperpronation was 94% successful on the first attempt compared to supination-flexion at 69%. Three patients failed supination-flexion (first and second attempt) but were successfully reduced with hyperpronation on the first attempt. Hyperpronation was also subjectively rated as significantly easier then supination-flexion by the practitioner.



I've been using hyperpronation for the past several years and love it. The maneuver appears less traumatic on the child (and parent).



Has anyone else tried it? I'd love to hear your experiences!



Reference

Bek D et al. Pronation versus supination maneuvers for the reduction of ‘pulled elbow’: a randomized clinical trial European Journal of Emergency purchase cialis. 2009, 16(3), 135-8. DOI: 10.1097/MEJ.0b013e32831d796a




Clip to Evernote