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This com bination converts into cocaethylene in the body which lasts longer in the brain and is m ore toxic than either drug alone kamagra gold 100mg generic. Desired Effects The desired effects of cocaine use include: y Feelings of euphoria order 100 mg kamagra gold with visa, increased self-worth and emotional disinhibition y Increased energy y Increased mental activity and alertness y Lack of appetite y A heightened sense of pleasure112 Sm oking crack produces sim ilar effects buy 100 mg kamagra gold fast delivery. However buy generic kamagra gold 100mg on-line, the m ode of adm inistration ensures a m ore intense high but one which is shorter in duration than intranasal use. This practise considerably increases the risks of developing habitual patterns of use. Signs and Symptoms of Use The following are associated with cocaine use: y Unusual confidence y Hyperactivity and insomnia y Being very talkative y Nose irritation – it may be runny or itchy due to “snorting”. Risks Cocaine use can vary from sporadic recreational use to binge use over a period of days which may result in bizarre, aggressive and violent behaviour. These include: y Insomnia y Agitation, anxiety and panic attacks y Hallucinations y Blood vessel constriction Excessive doses can cause death through heart failure or lung damage. After discontinuing regular use of any form of cocaine, the user will experience a ‘crash’ – severe depression and tiredness, along with excessive eating and sleeping. The experience of the ‘crash’ brings about its own risks with some cocaine users becoming so depressed that they may attempt suicide. Some will attempt to counteract the ‘crash’ through a self-medication approach using tranquillisers, alcohol, or injecting heroin and cocaine “speedballs”. However, it is difficult to predict who will m aintain control of their cocaine use and who will becom e chronic dependent users. Whilst it can be prescribed and dispensed, it is illegal to produce, possess or supply (except on prescription). It is also illegal to allow one’s premises to be used for producing or supplying cocaine. Administration Amphetamine can be taken: y By mouth y By sniffing/snorting y By smoking y By dissolving in water and injecting 57 Drug Facts Desired Effects The intensity of effects depend on the mode of administration. A small dose of around 30mgs taken orally will have a similar effect to the natural release of adrenaline, preparing the body for ‘fight or flight’ in response to stress or an emergency. Higher doses see: y Users become overactive, boastful and they may indulge in repetitive behaviour. Duration of Effects The duration of effects will depend on the purity of the drug, the mode of administration and the tolerance of the user. Signs and Symptoms of Use Signs and symptoms are similar to cocaine as both drugs are stimulants, including: y Unusual confidence y Hyperactivity and insomnia y Being very talkative y Nose irritation – it may be runny or itchy due to “snorting”. Short Term Risks Repeated use of small doses may see some users experience: 58 Drug Facts y Irritability y Confusion y Dizziness121 Given the way that am phetam ines stim ulate the body in a sim ilar fashion to adrenaline, its use, particularly when bingeing or after m ore sustained use, m ay contribute to feelings of deep depression, exhaustion, sleepiness and extrem e hunger as the body addresses postponed fatigue and the depletion of energy. Those who use high doses of am phetam ines on a regular basis are likely to develop ‘am phetam ine psychosis’. This drug-induced condition is sim ilar to schizophrenia and includes: y Thought disorders y Hallucinations y Feelings of being persecuted, which in turn may lead to hostility, aggression and violence towards others, as the user defends themselves against their imagined persecutors. This condition will usually disappear when drug use ceases but for some people will persist for a considerable period of time. Given the intensity of the mood-altering effects experienced, particularly in relation to the rush associated with higher doses and more efficient administration, “… severe psychological dependence can develop …”. Various amphetamines are also controlled by the 1970 Medical Preparations (Control of Amphetamines) Regulations which equally prohibits their manufacture, preparation, importation, sale and distribution. Where amphetamines are needed for treatment of a patient, the Minister of Health & Children can grant a licence to allow their supply; however, they are not available for normal prescription by doctors or pharmacies. However, the use of naturally occurring hallucinogenics such as mescaline found in the Peyote cactus and psilocybin found in magic mushrooms (referred to as teonanacatl ‘flesh of the gods’ by the Aztecs124) have a considerable history. In a wide range of cultural and geographic settings, there is evidence of hallucinogenics being utilised as an aspect of religious ritual to prom ote detachm ent from reality and to induce ‘m ystical’ visions; this particular deploym ent of psychoactive substances was renewed in the late 1950s and throughout the 1960s whereby users sought to expand their m inds and raise their consciousness through the use of hallucinogenics as part of hippie counter-culture. A tiny am ount (30 m icrogram s) is needed to produce hallucinations which m ay last for up to 12 hours. It peaks 2 to 3 hours later and the effects usually wear off after 12 to 15 hours. An increase in pulse, blood pressure and temperature, in addition to widening of the pupils can be experienced by the user. However, effects are difficult to predict as they depend upon the experience and expectations of the individual, the potency of the tab ingested and there environment within which the drug is taken. A bad trip may include: y Frightening mood changes and severe terrifying thoughts y Anxiety and feelings of loss control y Depersonalisation (a feeling of floating outside one’s own body) y Disorientation and panic y Fear of going mad or dying 61 Drug Facts For the distressed user, reassurance plays a significant role in addressing serious panic, anxiety or even psychotic reactions. Unpleasant reactions are likely if the user is mentally unstable, anxious or depressed. Users are at risk of being injured due to delusions, particularly in relation to the perceived ability to fly or walk on water. There are no exact figures for fatalities arising from accidents or suicide in relation to acid but death due to over-doses is non-existent. Flashbacks can be particularly dangerous if experienced when one is driving, working at heights or operating m achinery. Tolerance will develop with m ore sustained use which m ay, in som e instances, act to reduce habitual use. In an Irish context, it is thought that the Liberty Cap mushroom (Psilocybe semilanceata) which grows wild, is the one most commonly used. This mushroom is small, with a thin stem and a head which is said to resemble head gear worn during the French Revolution, hence its name. This “… is a com plicated task, requiring reference to relevant botanical texts and som e expertise in the classification of m ushroom s and is not a task to be perform ed while hallucinating. The number of mushrooms taken in any one episode of use will vary depending on the experience and expectations of the user; with anything from 8 to 300 mushrooms being reported. There are reports of users having the heightened awareness of sound and colour and the sensation of objects changing shape. Users have reported: y Nausea, vomiting and abdominal pain This may occur because of ingesting poisonous mushrooms. Users have also referred to the experience of bad trips which may include: y Feelings of depersonalisation y Panic and anxiety y Psychotic reactions y Aggression and hyperactivity y Tingling limbs and flushing The duration of a bad trip is normally around 12 hours, with no long-term effects and the negative experiences listed above can be dealt with through friendly reassurance. There are also reports of users engaging in rash behaviour such as running in and out of traffic or along railway lines, which obviously increases the likelihood of fatal or non-fatal accidents. Recurrence of panic/anxiety attacks often triggered by alcohol use are experienced by some users. Long Terms Risks There is little evidence as to the long-term effects of frequent use of magic mushrooms, however, tolerance develops rapidly. There are no major withdrawal symptoms when use ceases and whilst a user may develop a psychological dependence, physical dependence is not a feature. Opiates are strong, sleep inducing painkillers and are found in over the counter painkillers containing codeine, cough m edicines, anti-diarrhoea preparations, dihydrococaine and buprenorphine (used to treat m oderate to severe pain), and m ethadone (prescribed as a substitute for dependent heroin users in either m aintenance or detoxification program m es). It has been recognised as one of the country’s m ost pressing drug problem s, given the im pact not just on the individual user but also on their fam ily and com m unity (and typically Dublin com m unities “… characterised by poverty and generalised deprivation … ”140). Physical Description Heroin, at the time of production, is a white, odourless powder which over time darkens to varying shades of brown and develops a vinegar like smell. As with other substances, injecting into a vein maximises the effects of the drug.

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Another aspect of scientific medicine that the public takes for granted is the testing of new drugs 100 mg kamagra gold mastercard. Drugs generally are tested on individuals who are fairly healthy and not on other medications that could interfere with findings kamagra gold 100mg line. But when these new drugs are declared “safe” and enter the drug prescription books kamagra gold 100 mg on line, they are naturally going to be used by people who are on a variety of other medications and have a lot of other health problems cheap kamagra gold 100 mg amex. Then a new phase of drug testing called “post-approval” comes into play, which is the documentation of side effects once drugs hit the market. Agger reminds us that low concentrations of antibiotics are measurable in many of our foods and in various waterways around the world, much of it seeping in from animal farms. Agger contends that overuse of antibiotics results in food-borne infections resistant to antibiotics. Salmonella is found in 20% of ground meat, but the constant exposure of cattle to antibiotics has made 84% of salmonella resistant to at least one anti-salmonella antibiotic. The conventional approach to countering this epidemic is to radiate food to try to kill all organisms while continuing to use the antibiotics that created the problem in the first place. Approximately 20% of chickens are contaminated with Campylobacter jejuni, an organism that causes 2. Fifty-four percent of these organisms are resistant to at least one anti-campylobacter antimicrobial agent. Denmark banned growth-promoting antibiotics beginning in 1999, which cut their use by more than half within a year, from 453,200 to 195,800 pounds. A report from Scandinavia found that removing antibiotic growth promoters had no or minimal effect on food production costs. With a population of 284 million Americans, this amount is enough to give every man, woman, and child 10 teaspoons of pure antibiotics per year. Agger says that exposure to a steady stream of antibiotics has altered pathogens such as Streptococcus pneumoniae, Staplococcus aureus, and entercocci, to name a few. In Germany, the prevalence of systemic antibiotic use in children aged 0-6 years was 42. Antibiotic use in children aged three months to under 3 years decreased 24%, from 2. Group A beta-hemolytic streptococci is the only common cause of sore throat that requires antibiotics, with penicillin and erythromycin the only recommended treatment. Furthermore, patients treated with antibiotics were prescribed non-recommended broad-spectrum antibiotics in 68% of visits. This period saw a significant increase in the use of newer, more expensive broad-spectrum antibiotics and a decrease in use of the recommended antibiotics penicillin and erythromycin. Most people involved with alternative medicine have known about the dangers of antibiotic overuse for decades. Finally the government is focusing on the problem, yet it is spending only a miniscule amount of money on an iatrogenic epidemic that is costing billions of dollars and thousands of lives. Richard Besser, head of “Get Smart”: "Programs that have just targeted physicians have not worked. Hopefully, as a result of this campaign, patients will feel more comfortable asking their doctors for the best care for their illnesses, rather than asking for antibiotics. Will doctors recommend vitamin C, echinacea, elderberry, vitamin A, zinc, or homeopathic oscillococcinum? Drugs Pollute Our Water Supply We have reached the point of saturation with prescription drugs. The tons of antibiotics used in animal farming, which run off into the water table and surrounding bodies of water, are conferring antibiotic resistance to germs in sewage, and these germs also are found in our water supply. Flushed down our toilets are tons of drugs and drug metabolites that also find their way into our water supply. We have no way to know the long-term health consequences of ingesting a mixture of drugs and drug-breakdown products. These drugs represent another level of iatrogenic disease that we are unable to completely measure. Epithelial cancer is the type of cancer with which we are most familiar, arising from epithelium found in the lining of body organs such as the breast, prostate, lung, stomach, and bowel. From these sites, cancer usually infiltrates adjacent tissue and spreads to the bone, liver, lung, or brain. With his exhaustive review, Abel concluded there is no direct evidence that chemotherapy prolongs survival in patients with advanced carcinoma; in small-cell lung cancer and perhaps ovarian cancer, the therapeutic benefit is only slight. According to Abel, “Many oncologists take it for granted that response to therapy prolongs survival, an opinion which is based on a fallacy and which is not supported by clinical studies. The women in this trial were highly selected as having the best chance to respond. In fact, research should be conducted to determine whether chemotherapy itself is responsible for secondary cancers instead of progression of the original disease. We continue to question why well-researched alternative cancer treatments are not used. Sidney Wolfe, called for a criminal investigation of Schering-Plough, charging that the company distributed albuterol asthma inhalers even though it knew the units were missing the active ingredient. Besides paying the fine, the company was forced to halt the manufacture of 73 drugs or suffer another $175 million fine. In 1989, Leape wrote that perhaps 30% of controversial surgeries—which include cesarean section, tonsillectomy, appendectomy, hysterectomy, gastrectomy for obesity, breast implants, and elective breast implants(74)— are unnecessary. In 1974, the Congressional Committee on Interstate and Foreign Commerce held hearings on unnecessary surgery. The House Subcommittee on Oversight and Investigations extrapolated these figures and estimated that, on a nationwide basis, there were 2. In 1995, researchers conducted a similar analysis of back surgery procedures, using the 1974 “unnecessary surgery percentage” of 17. Media-driven surgery such as gastric bypass for obesity “modeled” by Hollywood celebrities seduces obese people to think this route is safe and sexy. The study notes that the large increase in the number of surgeons was not accompanied by a parallel increase in the number of surgeries performed, and expressed concern about an excess of surgeons to handle the surgical caseload. By 1994, cataract surgery was the most common procedure with more than 2 million operations, followed by cesarean section (858,000 procedures) and inguinal hernia operations (689,000 procedures). One study examined catheters that were inserted to deliver anesthetic into the epidural space around the spinal nerves for lower cesarean section, abdominal surgery, or prostate surgery. In some cases, non-sterile technique during catheter insertion resulted in serious infections, even leading to limb paralysis. Although we must sign release forms when we undergo any procedure, many of us are in denial about the true risks involved; because medical and surgical procedures are so commonplace, they often are seen as both necessary and safe. Unfortunately, allopathic medicine itself is a leading cause of death, as well as the most expensive way to die.

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Until the advent of the Apple Macintosh and discount 100 mg kamagra gold with mastercard, later buy kamagra gold 100mg lowest price, the Windows operating system in the mid-1980s buy 100mg kamagra gold amex, physicians who wanted to undertake computerized physician order entry had to learn an awkward language of computer commands and type those commands into the computer to manage their patients or to retrieve or use clinical information buy 100 mg kamagra gold free shipping. As will be seen in Chapter 3, these efforts were also hampered by the highly fragmented record structure of hospitals. Hospitals 32 Digital Medicine have historically maintained separate record systems in each clinical department (for the laboratory, the operating room, the radiology department, the emergency room, etc. These so-called “legacy” systems were constructed primarily for billing purposes, not for care management. Legacy clinical systems are like a gigantic tangle of weedy undergrowth that strangles the care process as well as the efforts of those nurses, physicians, and other caregivers who use them. Even small hospitals may have as many as two dozen legacy clin- ical information systems. Unbelievably, large health systems with multiple hospitals may have as many as 500 legacy systems, pur- chased from different vendors, written in different software lan- guages, and operating on different, often incompatible hardware. As a consequence of this tangle, slightly different versions of our clinical reality exist in as many as 15 different places inside the hospital. The fact that there is no unified picture of an individual’s health status is a hazard to that person’s health. Creating a unified repository of all information requires a common format for clinical information, a single patient identifier applied across departments, and an agreement by all those who provide care to contribute what they know to the digital record. Clinical Decision Support Clinical decision support played an increasingly prominent role in emerging clinical systems. In the mid-1980s, intensive care special- ists at George Washington University led by Dr. Altogether, these tools may be the most complex commercial software products ever built, considering that they are automating what may be the most complex process in the economy—health service. Clinical systems are becoming “context aware,” meaning that they will be wired to diagnostic devices and patient monitoring equipment. They can track real-time changes in the patient’s health and will follow patients as they move through different levels of care—from an ambulatory diagnosis through surgery, into recov- ery, or even into home healthcare. These new systems now alert care providers when the patient’s condition changes, prompting the clinical team to take specific actions to deal with an emerging problem. Most importantly, however, clinical systems are reaching a suf- ficient level of intelligence to bring up-to-date medical knowledge to the physician’s office, exam room, or hospital bed. As medical science better defines how to treat patients, that knowledge will flow through computer systems to the point of care. The clinical system will prompt physicians, nurses, and others involved in patient care to follow the care pathway that holds the most promise for improving the patient’s health. The Clinician’s Role These systems do not relieve physicians and the care team of their professional and moral obligation in making patient care decisions. Just as those who use a navigational system in an airplane have Digital Medicine 35 the ultimate responsibility for reaching the destination safely, the clinical team is going to remain accountable—to patients, family members, colleagues, the courts, and society—for making the right decisions. However, clinical decision support is transforming the electronic medical record into a powerful advocate for patient safety, as well as a research tool for recording and investigating what works in medicine (Figure 2. Physicians who want to understand the basis for the system’s rec- ommendations will be able to look behind the recommendations to the research studies and clinical drug trial results and even review the outcomes of care for the last several hundred patients who received a particular treatment in the hospital to see what clinical strategies have worked best. The traditional medical record documents a patient’s health his- tory and any treatments provided. The clinical information systems presented here will be more like navigational systems in an airliner. It will locate the patient in the sphere of medical risk, constantly update the clinical team on his or her condition, and indicate a trajectory based on the latest scientific knowledge to help the care team negotiate the patient through an episode of care. The system will present a clinical “dashboard” to the physician each morning, in whatever form and venue he or she chooses (home or office desktop, portable laptop or tablet computer, or personal digital assistant). Clinical systems will be intelligent enough to rec- ognize their users by their past inquiries and even their different cognitive styles. This latter capability is especially helpful, because physicians do not all think about a medical problem the same way. Most physicians will bridle against a rigid, prepackaged approach to making care decisions. As clinical systems evolve, they will be able to recognize those cognitive differences and enable physicians or other caregivers to acquire and process information in a way with which they are comfortable. Clinical software will enable physicians to stratify their pa- tients, active and inactive, into risk groups and will both orga- nize and maintain communication with them to ensure not only that their inquiries are answered, but also that they are comply- ing with treatment recommendations. It will “remember” prescrip- tions and communicate with patients or family members about whether the therapy is producing the desired results. Clinical soft- ware will automatically schedule follow-up appointments and send patients information electronically on their illness and treatment options. Information systems will also link them automatically to disease management programs, managed by voice-response tools such as Eliza, to interact with patients to ensure that they are taking their medications as prescribed and managing their own health effectively. The remote patient monitoring systems discussed earlier, whether they are wearable devices like the wireless cardiac monitor, passive sensors like those used in the smart house, or implantable devices like Medtronic’s intelligent pacemakers, will connect “pa- tients” to physicians or the care team through their clinical infor- mation systems. We need a new term for people at medical risk that does not imply that they are institu- tionalized or under active care. Until very recently, medical science has been remark- ably incurious about what treatments actually improve the patient’s health. Safety, not efficacy, has been the principal focus both of research and of regulation. With the advent of what is now known as the Agency for Health Research and Quality in the Department of Health and Human Services, the federal government in 1989 began funding research into clinical outcomes. Additionally, more than 180 organizations, including medical and surgical specialty societies, academic health centers, and commercial companies, are developing scientifically based clinical guidelines. Natural Language Processing Another important constraint is the interface with the clinician. Although moving from typing to pointing and clicking helped make clinical software more accessible, the ability of clinicians to enter new information and interact with the system still depends more than it ought to on a mouse or keypad. Physicians do not like to type; they are used to dictating (and correcting, and reviewing, and correcting again). Removing typing or pointing and clicking from the process of interacting with the clinical system will require advances not in speech recognition, which is surprisingly powerful today, but in something called “natural language processing. Prying common meanings loose from the stream of words recognized by a computer system is the technical challenge that stands between today’s clinical systems that rely on typing or point-and-click interfaces and a truly interactive voice- response capability. According to Gartner, a respected technology evaluation firm, this capability may still be a decade off. How to present clinical information and treatment options in a way that clinicians find accessible and easy to use is a less visible, but very significant, barrier to adoption by clinicians. The “desktop” may not be the best visual metaphor to use in organizing this information.

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