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Sometimes bizarre situations occur buy generic suhagra 100 mg line erectile dysfunction medicine list, when the viral genome caries the information about the regulation of the type of its reproduction cycle (as it is in bacteriophages) discount suhagra 100mg on-line erectile dysfunction in diabetes medscape, which they undergo inside the cell order 100 mg suhagra fast delivery erectile dysfunction doctor in kolkata. Considering that viruses don’t have their own metabolism and for their reproduction they use mechanisms present in cells, the only method (except interpherons) of destroying 86 them is specific immunity (specific antibodies, which are able to destroy the virions). The host organism survives, if its specific immunity is able to create a sufficient amount of specific antibodies. The treatment with antibiotics only has a preventive significance against superinfection – the spread of bacteria in the damaged (destroyed) tissue by viruses. When the right conditions arise, the change from the lysogenic cycle to the lytic cycle takes place and the virus starts to reproduce. The majority of the viruses cause inflammatory diseases and the lytic form of the cycle predominates, for example: flew, adenoviruses, virus of child poliomyelitis, encephalitis, chicken pox etc. Diseases caused by viruses with the lysogenic cycle belong to the most serious (e. From a medical point of view it is important to distinguish tropisms of viruses, according to the tissues (organs), which they primarily infect. Their nucleic acid can be arranged in different ways, single stranded or double stranded. The animal cells don’t have this enzyme, and therefore this replication is catalyzed by a different enzyme present in the virion. The cause are certain peculiarities in the life cycle of the flu virus: • A relatively large number of cells contain receptors on their membrane which distinguish the ligands (antigenes) on the surface of the capsid, this enable the entrance of the virion of the flew to the cell; • Penetration is simplified also by the fact that virions leave the cell, which multiplied them, by exocytosis (budding), so virions have a sac from the cytoplasmic membrane on the surface. Therefore when the virus binds to a membrane of another cell, both membranes merge and the virion is „shot“ right into the cell. In one sick person there are often from 4 to 6 variants of one virus which complicate the situation for the specific immunity; • Virus simple spreading by droplet infection, a large amount of cells which accept the virus, and a large degree of antigen drift cause periodic epidemy of the flu; • The risk of pandemy, as was mentioned, is increased as a result of possible recombination – mistakes during the packaging (reassembling) of different segments of the viral genome, when the cell is infected by two different types of influenza (e. This can induce major changes in the virus properties (formation of a new subtype) with a new combination of antigens (antigen shift). Besides others it contains enzymes (in two copies) important for the lysogenic cycle of the virus – reverse transcriptase, integrase and protease. The virus is surrounded by a lipid layer (the remains of the cytoplasmic membrane of the previous host cell), to which the gp120 and gp45 proteins are embedded. Gp45 serves as a ligand for the coreceptor on the cytoplasmic membrane of the cell, which causes the tilt of the virion, the contact and fusion of the cytoplasmic membrane of the cell and the capsule of the virus, which causes the „shooting“ of the contents of the capsid into the cell. Possible side effects for the degree of expression of the consecutive gene (proto-oncogene) are mentioned in the 2. As a result of the absence of this kind of T lymphocytes, the patient usually dies as because of a rapidly evolving tumorous disease (sarcoma) or the flare-up of long-date present disease (e. This is because one of the main taks of the T lymphocytes is the destruction of alien eukaryotic cells, which they recognize according to their antigens – for example tumorous cells and parasitic protozoa. The details of the mentioned phenomena will be discussed on lectures and seminars. Capsids of herpesviruses, formed inside the nucleus, get their covering on the nuclear membrane or on the membranes of vacuoles in the cytoplasm. Poxviruses code such a substantial amount of their own enzymes, that their replication takes place in the cytoplasm independently from the nucleus of the host cell. To this group of viruses belong for examples: herpesviruses, adenoviruses, and poxviruses. However from a medical point of view, these phenomena are often a source of problems, since not only small changes (result of mutations), but mostly the serious changes in their properties (result of recombination) can significantly higher the pathogenity of viruses. Eventough mutations in viruses appear not more common then in other organisms, but they need not to be detected and to repaired. Primarily it concerns viruses with a single stranded genome, with which it is not possible to repair a mutation, since reparation mechanisms (check 2. A typical example is the flu virus, which as a result of the mentioned errors has a slight deviation in the structure of antigenes - allready during the replication process in one sick individual. This helps the mass propagation of the disease between susceptible population, with the occurence of periodical epidemy. It is not uncommon to see that a virion with a mutated genome also looses the ability to infiltrate a host cell (loss of host specificity). This means that the number of mutations is much higher then the number of clinically detected variants of mutated viruses. Recombinations in viruses arise as a consequence of new genetic information entering the genome of the virus. The most known situation is when reassortment of parts of the genome occurs between two familiar types which infect the cell (organism). A typical example is the virus of A-flew, in which the exchange of segments of its genome between human and animal (bird or pig) type (during packaging of virions) leads to a significant change in its properties – the formation of a new subtype. This is how the great flu (Spanish flu) arose, which 90 years ago killed 20 million people worldwide. Recombination has very serious consequences because it causes acute transformation of retroviruses (see part 2). If a virus proto-oncogene arises, the retrovirus becomes capable of an acute malignant transformation of a cell it infected (after reverse transcriptase, integration and expression of this gene). The Collaborative serves as a broad-based national advocacy organization for the primary care patient-centered medical home, providing timely information and networking opportunities to support transformation of the us health system. Too often patients simply do not understand what their medications are for or how to take them. Health literacy is the capacity to understand basic health information and make appropriate health decisions. Information from health professionals is one of the most important sources of infor- mation for patients on health topics, regardless of their respective health literacy level. This guide outlines the rationale for including comprehensive medication management services in integrated patient-centered care. It also delineates the key steps necessary to promote best practices and achieve meaningful quality improvements for patients while reducing costs associated with poor-quality outcomes. The two most commonly identifed drug therapy problems in patients receiving comprehensive medication management ser- vices are: (1) the patient requires additional drug thera- py for prevention, synergistic, or palliative care; and (2) the drug dosages need to be titrated to achieve thera- peutic levels that reach the intended therapy goals. Drug-related Introduction morbidity and mortality costs exceed $200 billion annually in the u. The care is based on an impact overall cost, morbidity, and productivity— effective, sustained relationship between patients and when appropriately used—is enormous. When consumers or intervention, and their potential for both help and patients have this type of relationship and coordination harm is enormous. This document presents the to include payment for comprehensive medication rationale for including comprehensive medication management as an essential professional activity for management services in integrated patient-centered effective integrated care. While the processes of writing and flling a prescription the need for Comprehensive are important components of using medications, the technical aspects of these activities are not addressed Medication Management services in this document. The service (medication management) needs to the medical condition, safe given the comorbidities and be delivered directly to a specifc patient.

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In addition to Moustakas’s (1994) view of phenomenology best purchase for suhagra impotence diagnosis code, my understanding of phenomenology has been enriched by Van Manen (1997) 100mg suhagra overnight delivery erectile dysfunction nitric oxide, who developed five principles that contribute to good phenomenological research: lived thoroughness generic 100mg suhagra with mastercard erectile dysfunction pills at gnc, evocativeness, intensity, tone, and epiphany. Lived thoroughness means that the phenomenon of interest is concretely situated in the real world such that those reading the research document recognize it as being rooted in true experience (Van Manen, 1997). Evocativeness refers to language that enables the reader to understand the phenomenon through the senses, so that it is part of their own experience. This is valuable because it gives the reader the 89 feeling of being close to the research participants and helps bring them to life (Van Manen, 1997). Intensity refers to an emphasis on key terms or expressions within the research document. Intensity makes it possible for the reader to trace how the research participant creates meaning out of the phenomenon. Intensification is the use of repetition, but it also involves the use of evocative language to communicate fully (Van Manen, 1997). Tone is the way a statement sounds, such as serious, funny, and so on (Van Manen, 1997). Van Manen’s approach (1997) is consistent with the university’s mission to effect positive social change, as it emphasizes understanding lived experience in order to change practice, whether in health care or teaching. Research and reflection focus on the improvement of professional practice, so that change is built on reflectivity and is a product of reflective engagement with the world. Thus, the nature of the researcher- participant relationship gives rise to an improved doctor-patient relationship, in which the doctor reflectively deals with patients, rather than treating them automatically or prejudicially. Research Design Using online chat, I individually interviewed 16 female thyroid patients (including myself) who were members of The Thyroid Support Group, an international online support group for individuals with thyroid disorders. The recommended sample size of a minimum of 10 participants for phenomenological research corresponds to the traditional quantitative research designs based on statistical power analyses conducted by Onwuegbuzie and Johnson (2004). The recommended sample size of a minimum of 10 participants for phenomenological research corresponds to the traditional quantitative research designs based on statistical power analyses conducted by Onwuegbuzie and Johnson (2004). By aiming for at least 10 participants, I was able to interview until data saturation occurred. Data are considered saturated when interviewees introduce no new information or perspectives on the topic being examined (Moustakas, 1994). Selection of Participants Criterion sampling was used in this study, as all participants were required to meet specific criteria to be eligible for participation. According to Creswell (2007), criterion sampling works well with phenomenological studies and helps with quality assurance. The criteria for inclusion were as follows: (a) female, (b) age 18 years and older, (c) with a self-proclaimed diagnosis of thyroid disease, and (d) a member of The Thyroid Support Group. Since the prevalence of thyroid disease is much higher in women than men (Canaris et al. Due to the vulnerable nature of children, individuals who were under 18 years of age were also excluded. The following are descriptions of vulnerable populations and explanations for their potential inclusion in this study: (a) Elderly individuals: Because the prevalence of thyroid disease in women increases with age (about 20% in women over age 60; Godfrey, 2007), eliminating participants over age 60 would have precluded those individuals who experienced thyroid disease late in life due to an age-related decline in thyroid hormones. In addition, verification was impossible due to the nature of the Internet; (d) Mentally/emotionally disabled individuals: Affective disorders commonly co-occur with thyroid disease. The experience of an affective disorder in conjunction with thyroid disease is vital to understanding the overall treatment experiences of women with thyroid disease; (e) Individuals who might be less than fluent in English: The online support group from which participants were obtained is international. Obtaining information from women who have thyroid disease from various parts of the world may help to provide a universal understanding of women with thyroid disease. However, because I do not speak any languages other than English, the interviews were conducted in English. Therefore, individuals who are not fluent in English were not included in the study; (f) Traumatized 92 individuals: Determining whether or not an individual is traumatized would have required asking invasive questions unrelated to the study; and (g) Economically disadvantaged individuals: Some of the individuals in the online support group are low income and/or have poor health insurance coverage. As such, some group members obtain much of their treatment advice, medications, or both via the Internet. Recruitment of Participants Although I utilized the services of a colleague in data analysis and interpretation (as discussed in the section “Qualitative Trustworthiness”), I was the only person to recruit and interact with the group owner, group members, and study participants. Permission was sought and obtained from the group owner-moderator of The Thyroid Support Group via a letter of cooperation (see Appendix B), after which members of The Thyroid Support Group were invited via an on-list e-mail to participate in the study (see Appendix C). If more than 16 equally qualified individuals had offered to volunteer, I would have selected the participants in the order in which their off-list e-mails were received. All participants were informed that they had the right to leave the study at any time for any reason, without explanation. Context of the Study Data were obtained via individual interviews with members of The Thyroid Support Group, an international online support group for individuals with thyroid disorders (see http://health. Although permission to solicit group members to participate in research was not required from the group owner-moderator, I believed that requesting permission was perceived by the owner-moderator as a gesture of respect and good will. To help ensure data trustworthiness and quality, I utilized the services of a colleague (on a voluntary basis) to assist me with data analysis and interpretation. My colleague’s qualifications included a PhD in English Literature, a Master’s degree in Counseling Psychology, and two decades of teaching. As the sole interviewer, I gathered data as a participant-observer, that is, as someone who already held a position in the community before acting as an observer (Creswell, 2007). As mentioned previously, the method of this study was phenomenological because the research was inspired by my personal interest in and experience with the phenomenon. Thus, my consciousness was the primary data analysis tool (Creswell, 2007; Moustakas, 1994; Willig & Rogers, 2008). Because of my role as designer of the study and collector and interpreter of data, it behooved me to discuss my 94 role as the researcher in the study and to state any latent biases that might have affected the study’s process and results. The researcher’s self-examination process, termed reflexivity, involves “confronting, and often challenging your own assumptions, and recognizing the extent to which your thoughts, actions and decisions shape how you research and what you see” (Mason, 2002, p. Reflexivity allowed me, as a researcher, to discern and clarify how my position shaped the research process and its interpretations (Willig & Rogers, 2008). Willig and Rogers (2008) distinguished between personal and epistemological reflexivity. Personal reflexivity has to do with the researcher’s own principles, beliefs, and social roles that have an impact on the research. Epistemological reflexivity refers to the way decisions and assumptions about the nature of knowledge have shaped the research, and foregrounds the framing of the research question and how that places limits on what can be learned about the phenomenon of interest (Willig & Rogers, 2008). This section includes a personal reflexive account in which I considered my social identity, principles and beliefs, technical ability, and research background as these related to the research. I looked at three major features of Willig and Rogers’ (2008) definition of personal reflexivity: (a) my identity as a person, (b) how I was related to the research topic, and (c) my identity as a researcher. I am a Caucasian female and an American citizen, and have lived in the United States all my life. As a student in psychology, I have learned much about mental illness, its diagnosis, and manifestations.

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Increasingly purchase cheap suhagra line impotence blood pressure, patients are turning to an emerging model of health care: the retail clinic order suhagra 100mg erectile dysfunction statistics worldwide. Retail clinics have emerged as a low-cost and convenient alternative to the traditional model of ambulatory care buy suhagra in united states online erectile dysfunction medication online pharmacy, providing a discrete set of acute care and preventive services, on an as-needed basis. Patient response to this type of service has been overall quite positive, driving the proliferation of such clinics, and the accreditation of the two largest retailers by the Joint Commission has helped to ensure practices that are consistent with national quality standards (Kaissi and Charland, 2013; Zamosky, 2014; Cassel, 2012). Hospitals, clinics, and ambulatory practices are increasingly expanding hours and evaluating processes to achieve scheduling flexibility. Yet, the current model remains a one-size-fits-all appointment system, whether the patient is a healthy child or a complex, chronically ill adult. Although social workers, patient navigators, nurse practitioners, and other health care professionals have redesigned their roles to 7 proactively accommodate this gap, the persisting scheduling delays in both private and public health care indicate that further change is needed. There is an increasing call for the redesign of office practices to reduce inefficiency and improve capacity through better use of existing office staff, retooling of office processes, increased previsit work, and non-face-to-face visits (Shipman and Sinsky, 2013; Kanter et al. In the private sector, their development frequently includes little systematic assessment or improvement. Many scheduling processes have not been designed intentionally and have merely grown in response to internal constraints, resulting in wait time standards and capacities that vary significantly across care facilities. Underlying these problems is the use of a one-size-fits-all standard to wait times and scheduling, the lack of data-driven practices, and the reliance on behavior change to accommodate changes in patient flow. The result is typically a set of scheduling practices that are idiosyncratic down to the provider level and unworkable for the staff charged with following them. The capacity to provide care is often driven by the supply of physicians and health professions at a particular institution and is unevenly distributed across the country. Because facilities in urban centers tend to house more specialty and subspecialty physicians than those in rural settings, patient influx and wait times can often be exacerbated at larger hospital centers. In a survey of 4,000 emergency rooms, the wait at public hospitals or major teaching hospitals tended to be longer than those at other care centers (Hsia et al. These challenges have led to the exploration of systems engineering strategies and processes for optimizing resource use. While these concepts have been introduced as strategic solutions, the spread and depth of their implementation is still lagging. Scheduling and Wait Time Metrics A noted opportunity lies in the metrics used to assess wait times that measure the key components of access, scheduling, and outcomes. This standard was designed for primary care yet has also been adopted by many subspecialty practices. Although no specific numeric standard exists in the public or private sector, third next available appointment represents a nationally reported measure against which organizations can monitor their performance with a goal of seeing patients when clinically indicated and when they desire (Murray and Berwick, 2003). This standard was designed for use in outpatient primary care yet has also been adopted by many subspecialty practices. Other measures of access are less common, with few systems reliably tracking the travel distance to an appointment or actively managing schedules to coordinate appointments for those coming from afar. In the acute care setting, within emergency rooms and hospitals, metrics are increasingly reflecting aspects of access that are relevant to patients and families such as parking availability, the registration experience, and the discharge process, while other measurement activities reflect system function such as availability of a test result, time to obtain a procedure, and operating room turnover. In the postacute care environment of a rehabilitation facility, a full census is a priority with few incentives to speed discharge processes. While financial incentives are commonly used at the leadership level, some organizations are now using direct incentives for frontline staff, which offers the opportunity to have additional data and work on process challenges that get in the way of day-to-day high-quality, patient-centered care. For example, the incentives of emergency rooms to shorten wait times have resulted in an increase in unnecessary admissions (Hsia et al. The recent use of bonuses tied to appointment wait times while potentially successful in other settings, resulted in falsifying data when combined with an intolerant management style (Kizer and Jha, 2014). Exploring New Models of Scheduling The challenges noted have led some health care leaders to explore new methods to improve scheduling and patient access, including methods of systems engineering and operations management, used successfully in other industries including aerospace, power distribution, and manufacturing. These techniques include Lean, six sigma, and the use of modeling and prediction tools to analyze, improve, and optimize the performance of complex systems, including health care (Litvak and Bisognano, 2011; Toussaint and Berry, 2013; Pocha, 2010; DelliFrane et al. The methods developed by operations research and systems engineering to match supply and demand has led to substantial improvements in cost, efficiency, and patient satisfaction in select hospitals, patient populations, and clinics (Litvak and Fineberg, 2014; Rohleder et al. Yet, these efforts are nascent, localized, and not necessarily scalable (Watts et al. Commitment to creating a high-value patient experience is required in order to affect real change in institutional practices and outcomes. Although leaders are well meaning, too often they lack simple awareness of alternative approaches, or, if known, there is a lack of commitment to do the hard work of system redesign. Our organizations include a pediatric hospital, a safety net health care system, local and national integrated health care systems, an integrated community-owned health system, and a managed care health care system. Although our organizations differ in size, populations served, and institutional constructs, these themes and the strategies described are broadly applicable to all of U. Accordingly, while examples are given from some institutions, each of our institutions employed these strategies, and they are broadly applicable in health care. Attention to the barriers to flow and removing waste will increase capacity, enable timely care delivery, and improve care. It must be noted that these approaches were part of a larger, comprehensive effort to redesign care delivery. It should be underscored that efforts to improve access within our organizations are ongoing. Our organizations are committed to continuous process improvement and recognize that improvement is not static but rather an iterative process. As such, the examples contained within this discussion paper often reflect efforts within a single service line, practice, or geographic location. It is widely recognized that much more remains to be done before effective scheduling and access is a systemwide characteristic. That being said, and recognizing the unique constraints of each organization, three overarching principles are common throughout all of our efforts: the application of a systems-thinking approach, the use of a disciplined methodology for system redesign, and a foundation of respect for people. A common strategy of our organizations was the consideration of our institutions as complex systems. Tantamount to determining how to best implement change and mitigate unanticipated outcomes was recognizing that, rather than discrete environments or services, our organizations are complex groups of interdependent processes, personnel, and incentives. For example, looking beyond the immediate problem of delayed clinic visits enabled us to see problems with referrals for subspecialty appointments, difficulties with weekend discharges, or inadequate communication during appointment requests. A systems-level approach ensures that all aspects of a complex system are considered, including how the system elements interact with one another over time. Our organizations used system-thinking strategies to tackle access challenges, and they all used a disciplined methodology, albeit different methods, to ensure that improvements would be effective, efficient, and provide value to patients and their families and the organization. The two best known approaches, Lean and six sigma, are management philosophies and tools successfully used in other industries that are now being adopted in health care.