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Cell Biology 45 Degree, Preparation for Medical School, Requirements for Admission, Cellular and Molecular Medicine 45 Application for Admission, School Functional Anatomy and Evolution 46 of Medicine Technical Standards for History of Science, Medicine, and Admission, Course Requirements Technology 47 for M. Applicants, Human Genetics and Early Decision, Deferred Admission, Combined Study-M. Clinical Curriculum in Clinical Investigation 65 Graduate Student Honor Code 66 Institute of Genetic Medicine 157 Graduate Student Policy Gynecology and Obstetrics 160 Statements 66 Health Sciences Informatics 164 History of Medicine 167 the Training of Medicine 169 Medical Scientists: Molecular and Comparative M. Students are expected to master basic principles and theories as well as to obtain suffcient knowledge and experience to practice medicine. The education must convey the continually expanding body of medical science and prepare students for a lifetime of competent and thoughtful interactions with patients at a time of rapid change in technology and societal needs. To meet these educational goals, schools of medicine must be at once conservative and creative. Yet the great advances in medicine, the need to reasonably limit the number of years of formal education, the increasing number and complexity of special felds, and the diversity of interests and talents among students all demand continual examination of our educational aims and process. Old traditions and new methods are characteristics of the Johns Hopkins University School of Medicine, which to a large degree was founded in response to the highly variable standards of medical education at the time. Hopkins was the frst medical school in the United States to require a college degree for admission, quite a radical idea when the frst class entered over one hundred years ago. A college degree is still required, and current admission policies encourage a broad undergraduate education and permit successful applicants to select from a number of options prior to matriculation. The relative fexibility of the original curriculum foreshadowed the even greater number of choices available today. The wide variety of elective courses in the current curriculum allows students to extend their knowledge in special felds of interest and to schedule elective and required clinical courses in a fexible manner. Also, selected students are given the opportunity to work simultaneously towards both the M. The University was incorporated in 1867 nately, what was ample in 1867 was no longer under the terms of his bequest, and instrucso twenty years later. Garrett was the principal sity of California, was elected frst president of donor. In his inaugural address cational foundation of the School of Medicine in 1876, Gilman elaborated his philosophy of soon after his investiture. He was duly coneducation, in terms both prophetic and praccerned with the lack of fundamental knowltical, which was to become the guiding prinedge of biology, chemistry, physics, and ciple of the University. Students should be modern languages in students undertaking free to select under guidance their courses the study of medicine. This was a great so much to impart knowledge to the pupils, departure from the then accepted requireas to whet the appetite, exhibit methods, ments for admission (see Appendix). It was in this environment Welch began to organize courses in patholof the frst true university in America that the ogy and bacteriology for practicing physiSchool of Medicine was evolved. Part of this delay was occasioned by the research were established even before the desire to have a fully equipped hospital before School was offcially in existence. The Johns Hopkins In 1888 William Osler was called from the Hospital was completed in 1889, and from the University of Pennsylvania to be Physicianoutset its destiny has been inextricably woven In-Chief to the Hospital and Professor of the with that of the School of Medicine. This policy Theory and Practice of Medicine in the Univerwas established in a letter from Mr. Also called from many parts of 7 the country to serve on the faculty when the clinics a new approach to surgery based on school opened in 1893 were Henry M. He also, with Superintendent of the Johns Hopkins HospiWelch, championed the system of full-time tal and subsequently Professor of Psychiatry, clinical departments. Welch served as Professor of Patholsible instructors in Medicine, Surgery, Pediatogy and Dean of the Medical Faculty. The endowments of sity School of Medicine marked a new departhe Henry Phipps Psychiatric Clinic and the ture in medical education in America because William Holland Wilmer Ophthalmological it was the frst time that all professors in the Institute accomplished the same ends for the preclinical branches served on a full-time Departments of Psychiatry and Ophthalmolor university basis. Of all over the country would follow the lead, and comparable signifcance, perhaps, was the medical education, instead of being largely development of the graduate school concept a proprietary business conducted for proft, in medical education. Students in their clinical would become a major concern of university years at the Johns Hopkins School of Mediendeavor. They were also encouraged to the development in America of exact diagnoparticipate in research activities in the labosis, with the assistance of the laboratory, and ratories and clinics under the supervision of detailed description of disease. Graduates of the the foundations for intern and residency trainSchool introduced the Hopkins practices ing in American hospitals. Halsted and his elsewhere when called to fll posts at other colleagues developed in the laboratories and institutions. Johns Hopkins Medicine the Johns Hopkins Hospital are often referred and School of Medicine administrative offces to as the Johns Hopkins Medical Institutions. The preclinical curInstruction in the School of Medicine is riculum for medical students is taught in the under the supervision of the Advisory Board Anne and Michael Armstrong Building, a four of the Medical Faculty, composed of the story, 100,000 square foot structure which President of the University, the Dean and the opened in the Fall of 2009. Today, it is the largest school of public cal Chemistry, Biophysics and Biophysical health and provides opportunities for graduate Chemistry, Cell Biology, Functional Anateducation to individuals from a wide variety of omy and Evolution, Molecular Biology and backgrounds and experience. Programs of study embrace Basic Science, Preclinical Teaching Building, research and service in diverse felds: Biophysics, Physiology, and the Broadway professional practice, basic and applied Research buildings. The Wood Basic Sciresearch; social policy; planning, manageence Building and the Preclinical Teaching ment and evaluation of the delivery of health Building contain teaching laboratories, conservices; and the biological and environmenference rooms, and lecture halls for gradutal health sciences. Graduate training proate student teaching, as well as research grams in clinical investigation, postdoctoral laboratories. The Department of Pathology training programs, certifcate programs, and occupies a building across Monument Street other continuing education opportunities are from the other preclinical departments and also offered. The Richard Starr Ross ment Streets, directly opposite the Welch Research Building houses the research laboMedical Library. Its mission is to improve the health rium Building contains a 750 seat auditorium, of individuals and diverse communities locally a 150 seat auditorium, and conference and and globally through leadership and excelseminar rooms. The Broadway Research lence in nursing education, research, pracBuilding is home to the Department of Molectice, and service. Email delivery is used whenever posthe School of Nursing offers an individusible. The School began offering a Docproviding services at the point of use, a numtor of Nursing Practice program in January ber of Welch spaces have been created for 2008. This practice-focused doctoral program Hopkins communities in Hampton House, the is designed to prepare expert nurse cliniSchool of Nursing and the Hopkins Populacians, administrators, and executive leaders tion Center. Epidemiology, and Clinical Research Wolfe Street, directly across the street from infosuite. This ten year the Hopkins Population Center infoold structure, named in honor of Anne M. Authors Pinkard, is the frst building dedicated solely at the Medical Institutions can fnd open to nursing education at Johns Hopkins. Online tutorials its affliates with information services that on information resources and tools are made advance research, teaching, and patient available on Welch Web as they are develcare. Classes are offered to advance skills in ing library services around the all-digital colsearching online databases, managing inforlection of the future, creating state-of-the-art mation, fnding funding for research, and the interfaces to these collections and redefning use of various tools to promote scholarship. Rubenstein Child Health Building and a community hospital care, home health care, basic biomedical sciences laboratory and and long-term care for the elderly as well as offce building also known as the Broadway sophisticated treatment centers in virtually Research Building. Located on a these facilities offer care in a variety of medifve-acre site, the new clinical buildings will cal and surgical sub-specialties.

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Tenth Anniversary Advances in Pediatric NutriJohns Hopkins Faculty Development Program: tion. Education activities for 2011-2012 write to: Offce Celebrating 100 Years: Teaching Excellence in of Continuing Medical Education, Johns Hopkins Medical Illustration. The secprofessionalism and humanism with a trusted ond foor of the Armstrong Education Buildadvisor and small group of peers, as well as ing is dedicated to this learning communities build valued student-faculty connections. The range of issues that connections within the Hopkins medical may be addressed is broad, and additional community to meet their emerging goals resources will be found when needed. It also assists in Students and faculty are organized into arrangements for special funding of student four colleges, named after legendary Johns projects and works in liaison with the Johns Hopkins faculty: Sabin, Nathans, Thomas, Hopkins Medical Student Society and other and Taussing. Notices conulated by 120 students (30 from each class) taining new or more current information on a and 6 core faculty. Incoming students meet variety of topics are sent to each student at their core faculty advisors at Orientation. University and divisional regulations, as well as performance and conduct meeting bona Students with Disabilities fde expectations of faculty. No member of the the School is prepared to furnish reasonable faculty is obliged to provide students or graduaccommodations to students with disabilities. The national or ethnic origin, disability, marital staSchool retains the right to refer a student for tus or veteran status to all of the rights, privian independent evaluation of disability. Policy for Students Statement Regarding the Privacy the University, in keeping with its basic mission, recognizes that its primary response to Rights of Students issues of alcohol and drug abuse must be Notice is hereby given that the School of through educational programs, as well as Medicine of the Johns Hopkins University through intervention and treatment efforts. Eligible students, as programs as part of its orientation for new defned in the regulations, have the right 1) to students. The possession, use, or distribuis responsible for fostering civility, for being tion of illegal drugs and controlled substancfamiliar with this policy, and for refraining es, as defned by federal, state, and local from conduct that violates this policy. The distribution, possession and disability, religion, sexual orientation, genunprescribed use of narcotics and other conder identity or expression, veteran status, trolled dangerous substances by students that is unlawful and strictly forbidden on Univerb)is so severe or pervasive that it intersity premises. Students are also advised that because of sex, gender, marital status, the University may decline to furnish and may pregnancy, race, color, ethnicity, national withdraw letters of recommendation for those origin, age, disability, religion, sexual oriwho have engaged in the illegal distribution, entation, gender identity or expression, possession and use of controlled dangerous personal appearance, veteran status, or substances. The Johns Hopkins University is committed 4) Sexual harassment, whether between to providing its staff, faculty and students people of different sexes or the same sex, the opportunity to pursue excellence in their is defned to include, but is not limited to , academic and professional endeavors. This unwelcome sexual advances, requests for opportunity can exist only when each memsexual favors, sexual violence and other ber of our community is assured an atmobehavior of a sexual nature when: sphere of mutual respect. The University is particularly conplains of discriminatory harassment under cerned about the increase in reports of sexthis policy, is strictly prohibited. Individuals who are found to involved in an incident of sexual violence, and have violated this policy will be subject to the of the services available to victims of sexual full range of sanctions, up to and including violence. University community, including, but not lim3) Individuals who witness what they believe ited to students, faculty and staff, and also may be discriminatory harassment of applies in certain instances, to certain third another are encouraged to report their parties. Sexual harassment, Institutional Equity for assistance in inveswhich is a form of discrimination, violates tigating and resolving the issue. A person may be unable to give consent to 7) the University administration is responsia sexual act for a number of reasons, includble for ensuring the consistent application ing, but not limited to: if he or she is physiof this policy. Physical classes or housing if necessary to allay conresistance need not occur to fulfll the defnicerns about security. Examples of sexual to accommodate the request if such classes violence include, but are not limited to: and housing are reasonably available. Both a complainant and the person Campus security will arrange for transporaccused of a sexual violence will be afforded tation to the nearest hospital. In cases alleging a Police Sexual Assault Evidence Collection sex offense, both the complainant and the Kit. Persons who are victims of sexual viorespect to the alleged sex offense and any lence will also be advised by campus secusanctions imposed against the accused. The rity of their option to fle criminal charges University will, upon written request, disclose with local police of the jurisdiction where the to the alleged victim of any crime of violence offense occurred. Information on vary according to the severity of the conduct, local and state law enforcement units and and may include expulsion of a student from databases maintained by them is available on the University and termination of the employthe Homewood Campus Safety and Security ment of a member of the staff or faculty. This can university considers fling intentionally false only exist when each member of our comreports of sexual harassment a violation of munity is assured an atmosphere of mutual this policy. The university is committed to providessary, the university will institute disciplinary ing such an environment, free from all forms proceedings against the offending individual, of harassment and discrimination. Each which may result in a range of sanctions, member of the community is responsible for up to and including termination of university fostering mutual respect, for being familiar affliation. All academic and admincreates an intimidating, hostile or offensive istrative units of the University (including all working or educational environment. Complaints Brought Within the University the University is prepared to receive and B. Policy resolve complaints of discrimination and the University will not tolerate sexual harassment under the policies listed above harassment, a form of discrimination, a violathat are brought to the attention of any Unition of federal and state law and a serious vioversity administrative offcer by members of lation of university policy. The University its educational mission, the university works encourages any individual who has a comto educate its community regarding sexual plaint of discrimination or harassment where harassment. Agencies receiving such may be directed to the Vice Provost or the complaints notify the University that a charge Director. Information on local and state law complaints may allege that the University enforcement units and databases maintained has violated laws prohibiting discrimination by them is available on the website of Homeor harassment on the basis of gender, mariwood Campus Safety and Security. These legal obligations extend of Discrimination and Harassment to complaints received anonymously as well. Discrimination Complaints Filed With tion is the shared responsibility of the Offce Government Agencies of Institutional Equity, the offces of Human Present or former University faculty memResources and the department or program bers, staff members, students, or applicants within which the charge arose, and in cases to University education programs or employof sexual violence (including sexual assault), ment who believe that they have been disthe campus law enforcement offcers. A and the respondent will be afforded similar complainant may end an informal process at and timely access to any information used in any time for any reason and begin the formal connection with that hearing, consistent with stage of the complaint process. An investigation conducted with respect to fndings and/or sanctions, by the Offce of Institutional Equity generally such right to appeal shall be available equally consists of two main phases: (a) a prelimito the complainant and the respondent. In nary assessment of the complaint; and (b) the cases of sexual harassment (including sexual issuance of factual fndings and a recommenviolence and sexual assault), subject to the dation. This notice will be provided resolution of the complaint to the appropriate to the complainant and the respondent in the administrative offcial at the school, division same manner and in the same time frame. While report on the results of any disciplinary proevery effort is made to adhere to these genceeding conducted by the University against eral time frames, these may vary depending a student who is the alleged perpetrator of on the complexity of the investigation and the such crime or offense with respect to such severity and extent of the alleged discriminacrime or offense. When advised of circumstances warrantthe University will take steps to prevent the ing intervention, the University will render recurrence of any discrimination or harassassistance by contacting local or federal law ment, including sexual harassment and sexenforcement agencies as appropriate. Indiual violence, and to correct its discriminatory vidual members of the University community effects on the complainant and others, as who receive threats of bodily harm or who are necessary. Note that local, state, and federal the targets of harassing or stalking behaviors law and University policy prohibit any form are urged to contact Campus Security and to of retaliation against a person who fles or avail themselves of the services offered by bears witness to a discrimination or harassstudent counseling offces and the Faculty ment complaint. Every effort will be made to respect the Complainants are urged to contact the Offce privacy of all individuals involved in the matof Institutional Equity promptly, with any conter. However, the necessity to investigate the cerns or claims regarding retaliation and the matter and to cooperate with law enforceUniversity will take steps to address such ment authorities may require the disclosure retaliation. Individuals accused of engaging in inciPolicy Addressing Campus dents of campus violence may seek legal counsel at their own expense. Individuals and Violence their attorneys are reminded that attorneys the Johns Hopkins University is committed do not participate in any internal University to providing a learning and working environhearing. The University will not employees who conduct business on Univertolerate violent acts on its campuses, at offsity premises must conform their conduct to campus locations administered by the Unithe requirements of this policy. Photography and Film Rights the University urges individuals who have experienced or witnessed incidents of vioPolicy lence to report them to Campus Security. The Johns Hopkins University reserves the Alternatively, students are urged to report right from time to time to flm or take photoconcerns about violence to the divisional graphs of faculty, staff, and students engaged offce responsible for student matters, faculty in teaching, research, clinical practices, and to the divisional offce responsible for faculty other activities, as well as casual and portrait matters, and staff to the applicable human photography or flm. Classes will Enforcement be photographed only with the permission of Information regarding incidents of violent the faculty member. The University will notify law will remain available for use by the univerenforcement authorities of criminal conduct. In addition, the University may refer individuFaculty, students, and staff are made aware als accused of violations of this policy for an by virtue of this policy that the university assessment of the likelihood that they will reserves the right to alter photography and carry out violent acts. Faculty, students, ence of an individual on campus threatens or and staff who do not want their photographs disrupts the conduct of University business, used in the manner(s) described in this polthe individual may be suspended from paricy statement should contact the Offce of ticipation in University programs or activities Communications. The faculty, students, and staff are considered Center also provides specialty care including public places for the purpose of this policy. Mental health services are proover the use of photographs or flm taken by vided by faculty and staff of the Department third parties, including without limitation the of Psychiatry. Pediatric care is provided by a news media covering university activities pediatrician of your choice. Information concerning clinic hours, referrals to specialty clinics and other Medical Student Teaching arrangements is contained in a brochure disAll animal use at the University, including use tributed at the time of registration. Additional in training, must be reviewed and approved information is available at Hopkins Medical Campus to assist students, housestaff, postdoctoral fellows, staff, and Policy on Firearms faculty for the School of Medicine, School of the possession, wearing, carrying, transPublic Health, School of Nursing, Johns Hopporting, or use of a frearm or pellet weapon kins Hospital, and Johns Hopkins Health Sysis strictly forbidden on University premises. Discihave about Baltimore, student life, entertainplinary action for violations of this regulation ment, shopping, daycare, school systems in will be the responsibility of the divisional stuthe city and surrounding counties, and other dent affairs offcer, Dean or Director, or the useful resources. Committee are presented in the appendix to Seminars, lectures, panel discussions, and this catalogue in connection with information flms are offered throughout the academic on the important gift to the University by Miss year. Stufrom each graduate program, and students dent representation on the governing comwho serve on various committees. We communicate the desires and needs of the student body to the faculty International Services and administration while representing institutional ideals and standards to the student International students may receive assisbody. Currently, we have representatives tance with visas and other documents in the for the M. In addition, we organize many social ety, open to all members of the medical comevents and lectures throughout the year and munity plans trips and social events during fund travel awards and recognized student the year of particular interest to international groups. Each media nationwide organization, run autonomously cal school class annually elects four represenby and for medical students. Medical students with Native American students through monthly exceptional records of clinical and preclinical meetings, faculty forums, community activiacademic performance as well as outstanding ties, and recruitment of prospective students.

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The results show the group; on the other hand impotence with blood pressure medication 40 mg levitra extra dosage otc, the risk of heart failure showed odds ratio expressing relative benefits of the two regimens a trend in favour of valsartan erectile dysfunction injection therapy video buy levitra extra dosage with a mastercard. Pooled data have shown to be close to unity and non-significant for total coronary that the benefit of angiotensin receptor antagonists for events erectile dysfunction drugs australia purchase genuine levitra extra dosage, cardiovascular mortality erectile dysfunction in young adults cheap levitra extra dosage 40mg on-line, total mortality as well as heart failure prevention are particularly large in diabetic coronary heart disease erectile dysfunction pills in pakistan discount levitra extra dosage online. Protection against stroke was over the counter erectile dysfunction pills uk order levitra extra dosage 60mg, on patients, but the number of observations is small [296]. However, this has not been confirmed by Five trials have compared angiotensin receptor comprehensive meta-analyses published recently, which antagonists with other antihypertensive agents. The show the incidence of myocardial infarction to be similar different comparators used make meta-analysis of these to that occurring with other drugs [337,338]. Comparative randomized trials in heart myocardial infarction, but a 25% difference in the failure or post-myocardial infarction patients with left incidence of stroke. During a mean follow-up of although the latter may exert a small blood pressure 2. These underline the important role of blood pressure lowering two large trials have strongly infiuenced a recent metafor all cause-specific events, with the exception of heart analysis [343] which concluded that b-blocker initiated failure: whenever systolic blood pressure is reduced by therapy is inferior to others in stroke prevention, but not 10mmHg, independent of the agent used, both stroke and in prevention of myocardial infarction and reduction in coronary events are markedly reduced [328,329]. On the other hand, individual majority of patients randomized to a b-blocker actually trials and their meta-analyses [292,296] are generally conreceived a b-blocker-thiazide combination. It has treatment strategy based on the initial administration of been remarked that new onset heart failure is often a a b-blocker followed by the addition, in most patients, of difficult diagnosis and, when calcium antagonistsare admia thiazide diuretic was accompanied by an incidence of all nistered, diagnosis may be confounded by ankle oedema cardiovascular and cause-specific events similar to that of dependent on vasodilatation. It is may be due to a lesser blood pressure reduction [330], reasonable to suppose that in prevention of heart failure particularly of central blood pressure [166], that occurred humoral effects, differently infiuenced by different antiin this trial with this therapeutic regimen. In randomized to slow-release nifedipine administration any case, the above quoted meta-analyses of b-blocker was associated with a 38% reduction in the incidence of initiated trials [297,343] well illustrate the difficulties hospitalized heart failure compared with placebo [304]. The possibility of clinically relevant differences in the beneficial effects of various classes of antihypertensive 4. Comparative randomized trials show that for similar blood Subclinical organ damage occurs much earlier than pressure reductions, differences in the incidence of events in the continuum of cardiovascular disease and cardiovascular morbidity and mortality between different may be more susceptible to specific, differential actions drug classes are small, thus strengthening the conclusion of the various antihypertensive compounds [274]. For this that their benefit largely depends on blood pressure reason, randomized trials using subclinical organ damage lowering per se. As studies in hypertensive receptorantagonistsandcalciumantagonists,andprobably patients with left ventricular hypertrophy cannot be by aldosterone antagonists, while at least angiotensin placebo controlled but must compare active treatments, receptor antagonists are superior to b-blockers. In two comparative studies, information is provided by two studies using magnetic natriuretic peptides decreased with losartan and increased resonance imaging to evaluate left ventricular mass. In a with atenolol [356,369], suggesting opposite effects on left relatively large-size study [361] the aldosterone blocker, ventricular compliance. Lower values of in-treatment electrocardiographic In conclusion, information from adequate trials shows hypertrophy were significantly associated with lower rates that blood pressure lowering by whatever agent or agent of cardiovascular morbidity and mortality [195]. Therefore, current evidence suggests that calcium antagonists may have a greater effect on hypertension Attention has recently been concentrated on echocardiorelated thickening (presumably hypertrophy) of the graphic measurement of left atrial size, as a frequent carotid artery than other antihypertensive agents. Smaller also found that lower progression of the composite carotid studies have addressed the effects of angiotensin receptor intima-media thickness is paralleled by lower progression antagonists on recurrent atrial fibrillation in patients with and greater regression of plaque number with lacidipine previous episodes of the arrhythmia. Composition of the carotid wall, favourable effects of either irbesartan versus placebo investigated by an echorefiectivity approach histologi[383] and losartan versus amlodipine [384], the drugs cally tested [396], did not show significantly different being in both cases added to amiodarone. Thus there changes with both lacidipine and atenolol, however is strong evidence concerning new atrial fibrillation [397]. In conclusion, sufficient evidence appears to be and less strong evidence concerning recurrent atrial available to conclude that progression of carotid atherofibrillation in favour of beneficial effects of angiotensin sclerosis can be delayed by lowering blood pressure, but receptor blockers as compared with b-blockers, calcium that calcium antagonists have a greater efficacy than antagonists or placebo. Although pulse wave velocity is acknowledged as a valid clinical method for assessing large artery distensibility, 4. Therefore there is no firm evidence on whether term (only a few weeks) studies suggests that several some antihypertensive agents are more beneficial than antihypertensive agents can indeed favourably affect others in preserving or improving cognition. However, it pulse wave velocity [398], but the observed decrease should be mentioned that the only placebo-controlled could well be due to blood pressure reduction. This study that reported a significant reduction in incident conclusion is strengthened by a recent study of more dementia used the calcium antagonist nitrendipine as an or less intense blood pressure lowering, in which a active agent [275,407]. A limited number of randomized trials of antihypertensive Because of the diversity of the clinical conditions, of the therapy have used brain lesions and cognitive dysfunction endpoint used, as well as of the size and statistical power asendpoints[404]. Probably the best approach is that of critical imaging) and shown a significant reduction in mean total and selective reviews of available data [418,419]. The three mended by all current guidelines [3,30,420], it must be studies on 13143 subjects that have used the Mini Mental recognized that evidence from trials having randomized State Evaluation Test for cognitive performance [283, renal patients to more versus less intensive blood pressure 407,408] found a small but significant improvement lowering is scanty. However, in other trials randomization on the immediate and the delayed task results. Therefore, it < 120/80mmHg by valsartan did not infiuence creatiappears that lowering blood pressure may improve nine clearance to a greater extent than less intense performance on screening tests for dementia and memory, treatment achieving blood pressures slightly above further supporting the benefits of antihypertensive 120/80mmHg, but urinary protein excretion was favourtherapy on cerebrovascular morbidity. It should be emphasized that trials showing end stage renal disease and proteinuria. Angiotensin receptorblocktrial [425] and of 11 trials in non-diabetic renal patients, ers were found to be more effective in reducing urinary showing that systolic blood pressure reduction down to protein excretion than a b-blocker [440], a calcium a least 120mmHg may be beneficial [426]. An antiproinhibitor dose was titrated to obtain the same blood teinuric effect versusplacebo hasbeen shownalsowith the pressure decrease as the combination, no difference in use of spironolactone [436]. Available all other placebo controlled studies the renal effects of studies have been included in a recent meta-analysis [450] the active drug were accompanied by a slightly greater which has confirmed the greater antiproteinuric action of blood pressure reduction, which may have been at least the combination, associated with a greater blood pressure partly responsible for the renal effects. These studies deserve to be Comparison of different active regimens has provided less confirmed by larger trials. Two trials, one in patients with proteinuric diabetic nephropathy [309] the other in non-diabetic 4. Itisdifficulttoconcludewhether [319,422], or a b-blocker [316] or an angiotensin receptor agents interfering with the renin-angiotensin system exert antagonist [439] or both a calcium antagonist and a diuretic a real antidiabetogenic action, or whether they simply lack [438]; equal effect of a calcium antagonist and a diuretic a diabetogenic action possessed by b-blockers and was also shown by another study [322]. Other placebo controlled trials in conditions different from hypertension (high cardiovascular risk, 5. A very recent network Evidence for the benefit of treating grade 1 hypertensives meta-analysis of 22 trials with more that 160,000 particiis admittedly more scant, as specific trials have not pants [460] has calculated that the association of addressed the issue. This claim is based In all grade 1 to 3 hypertensives, lifestyle instructions on the observation that during controlled trials patients should be given as soon as hypertension is diagnosed or developing diabetes have not had a greater morbidity than suspected, while promptness in the initiation of pharmapatients without new onset diabetes [322]. However, it is cological therapy depends on the level of total cardiovasknown that cardiovascular complications follow the onset cular risk. A limitation of the above long-term should be initiated promptly in grade 3 hypertension, as follow-up studies is that microvascular endpoints, i. Furthermore, in long-term studies followwith moderate total cardiovascular risk drug treatup cannot be done under controlled conditions and ment may be delayed for several weeks and in grade 1 confounding factors may be frequent and unknown. In case of bloodpressure who are at high risk because of thepresence diabetes, history of cerebrovascular, coronary or peripheral of three or more additional risk factors, the metabolic artery disease,randomized trials [283,300,302,305,319] syndrome or organ damage is uncertain. It should be have shown that antihypertensive treatment is associated emphasized that prospective observational studies have with a reduction in cardiovascular fatal and non-fatal demonstrated that subjects with high normal blood events, although in two other trials on coronary patients pressure have a greater incidence of cardiovascular disease no benefit of blood pressure lowering was reported [306] or compared to people with normal or optimal blood pressure a reduction of cardiovascular events was only seen when [7,11,33]. Furthermore, the risk of developing hyperteninitial blood pressure was in the hypertensive range [304]. In contrast with these potentially favourable of progression to more severe proteinuric states. This justifies the recommendation did not significantly delay onset of diabetes or reduced to start administration of blood pressure lowering drugs cardiovascular events despite blood pressure lowering. In addition and blood pressure should be closely monitored because of totheevidencereviewedinthe2003guidelines[3],further the relatively high chance these individuals have to indirect evidence supporting a blood pressure goal progress to hypertension [31,32], which will then require < 140mmHg has been provided by post-hoc analyses of drug treatment. All this isto achievethe maximum reduction in the long-term total is consistent with what has been reported in studies on risk of cardiovascular morbidity and mortality. This hypertensive patients followed in the setting of clinical requires treatment of all the reversible risk factors identpractice, those achieving blood pressure values <140/ ified, including smoking, dyslipidemia, abdominal obesity 90mmHgshowingacardiovascularmorbidityandmortality or diabetes, and the appropriate management of associated rate much less than those treated but uncontrolled [479]. In hypertensive patients, the primary goal of There are also arguments in favour of trying to achieve treatment is to achieve maximum reduction in values below 90 mmHg diastolic and 140 mmHg systolic, the long-term total risk of cardiovascular disease. A recent meta-analysis of available considered as a possible mechanism and often unreported, trials in diabetic patients has calculated a reduced although when mentioned it was lower in the actively incidence of cardiovascular events (particularly stroke) treatedthanintheplacebogroups. Yet,ithasbeennotedin with more versus less intense treatment, for a betweensection 5. Never305] have provided evidence of reduced incidence of theless, evidence on the benefit of the strict goal of < 130/ cardiovascular events by bringing blood pressure to rather 80 mmHg is more limited. For ambulatory blood Data favouring lower blood pressure targets in patients in pressure this approach is supported by the evidence that whom a high risk condition is due to factors other than for similar achieved office blood pressure values, lower diabetes are of variable strength. The most clear evidence achieved ambulatory blood pressures are associated with a concerns patients with previous stroke or transient lower rate of cardiovascular outcomes [88]. Home and ambulatory blood pressures to 138/82mmHg showed a 28% reduction in stroke are several mmHg lower than office blood pressures recurrence and 26% reduction in the incidence of major (Table 5), but these differences are proportional to the cardiovascular events compared with placebo in which the level of office blood pressure values [484], i. There were usually larger when office blood pressure is high and substantial cardiovascular benefits also in normotensive smaller at the lower office blood pressure values representpatients in whom on-treatment values were reduced to ing treatment goals [77]. Similartargetsshould beadoptedinindividuals with a of the trial duration,raising the possibility of a greater longhistory of cerebrovascular disease and can at least be term protective effect of blood pressure reductions; 3) In considered in patients with coronary disease. Although younger low risk hypertensives what appears to be as a differences between individual patients may exist, the risk relatively small benefit when calculated over a treatment of underperfusion of vital organs is very low, except in period of 5 years may translate into a more substantial episodes of postural hypotension that should be avoided, numberof addedlife years comparedwith elderly high risk particularly in the elderly and diabetic. This implies that in younger subjects of a J-shaped curve relating outcomes to achieved blood actuarial information may provide a better assessment of pressure has so far been suspected as a result of post-hoc the benefit than data obtained in trials [496]. This suggests that some of the major It should be mentioned that, despite large use of multicardiovascular risk changes may be difficult to reverse, drug treatment, in most trials the achieved average sysand that restricting antihypertensive therapy to patients at tolic blood pressure remained above 140 mmHg [492], high or very high risk may be far from an optimal strategy. Reaching the target blood pressures recommended above may thus be difficult and the 6. Trial evidence also shows that normal blood pressure and patients who require drug for the same or even a greater use of combination treattreatment. The purpose is to lower blood pressure, to ment achieved systolic blood pressure remains usually control other risk factors and clinical conditions, and to somewhat higher in diabetics than in non-diabetics reduce the number and doses of antihypertensive agents [249,428, 493]. Healthy eating habits islikely thatthebenefitiseven greater than that calculated should always be promoted. They substantial number of patients randomized to placebo should never delay unnecessarily the initiation of drug received treatment and a number of patients allocated treatment, especially in patients at higher levels of risk. Therefore, hyperLifestyle measures should be instituted, whenever tensive smokers should be counselled regarding smoking appropriate, in all patients, including those who cessation. Exposure to passive smoking may have smoking cessation declined in those countries where regulations have been weight reduction (and weight stabilization) introduced to protect the nonand ex-smokers from reduction of excessive alcohol intake environmental tobacco smoke. The relationship between alcohol consumption, variable, patients under non-pharmacological treatblood pressure levels and the prevalence of hypertension ment should be followed-up closely to start drug is linear in populations [524]. Alcohol attenuates the effects of antihypertensive drug smoking one cigarette [502]. Heavier drinkers (five or more standard drinks for an increase in plasma catecholamines parallel to the per day) may experience a rise in blood pressure after blood pressure increase [503,504]. Paradoxically, several acute alcohol withdrawal and be more likely to be diagepidemiological studies have found that blood pressure nosed as hypertensive at the beginning of the week if levels among cigarette smokers were the same as, or they have a weekend drinking pattern. However, studies reduction have shown a significant reduction in systolic using ambulatory blood pressure monitoring have and diastolic blood pressures [500]. They should be warned against the also been reported to predict a future rise in systolic increased risk of stroke associated with binge drinking. Sodium 2007 Guidelines for Management of Hypertension 1139 restriction may have a greater antihypertensive effect if predisposes to increased blood pressure and hypercombined with other dietary counselling [500] and may tension [552]. There is also conclusive evidence that allow reduction of doses and number of antihypertensive weight reduction lowers blood pressure in obese patients drugs employed to control blood pressure. The effect of and has beneficial effects on associated risk factors sodium restriction on blood pressure is greater in blacks, such as insulin resistance, diabetes, hyperlipidemia, left middle-aged and older people as well as in individuals ventricular hypertrophy, and obstructive sleep apnoea. In a further subgroup analysis, blood [535,536], may counteract the blood pressure lowering pressure reductions were similar for non-hypertensive effect of sodium restriction. In a restricted salt diet, and hypertensive individuals, but were greater in patients should be advised to avoid added salt, and those who lost more weight. Within trial dose-response obviously oversalted food (particularly processed food) analyses [554,555] and prospective observational and to eat more meals cooked directly from natural studies [556] also document that greater weight loss ingredients containing more potassium [537]. Modest sive intake of salt may be a cause of resistant hypertenweight loss, with or without sodium reduction, can sion. The recommended adequate daily sodium intake prevent hypertension in overweight individuals with has been recently reduced from 100 to 65 mmol/day high normal blood pressure [557], and can facilitate corresponding to 3. An achievable Because in middle aged individuals body weight recommendation is less than 5 g/day sodium chloride frequently shows a progressive increase (0. A recent meta-analysis of ransaturated and total fat) [539] have emerged as also having domized controlled trials [561] concluded that dynamic blood pressure lowering effects. Several small clinical aerobic endurance training reduces resting systolic and trials and their meta-analyses have documented diastolic blood pressures by 3. The reducsupplements (commonly called fish oil) can lower blood tion in resting blood pressure was more pronounced in the pressure in hypertensive individuals although the effect hypertensive group(A6. In hypertensive individuals, exercise lowered blood pressure [562], and this type of average systolic and diastolic blood pressure reductions training also reduced body weight, body fat and waist were 4. Dynamic resistance training insufficient to recommend it for blood pressure lowering.

Beyond this relative impotence judiciary purchase levitra extra dosage once a day, research has also shown measures of sa to be sensitive to differences between system or design characteristics that were not refected by performance measures icd 9 code for erectile dysfunction due to medication order cheap levitra extra dosage online. This is particularly interesting for complex felds where errors occur rarely but have high consequences erectile dysfunction doctor boca raton buy levitra extra dosage from india, such as both aviation and healthcare erectile dysfunction kidney cheap levitra extra dosage 100 mg. In healthcare erectile dysfunction treatment by homeopathy purchase levitra extra dosage online now, written communications such as patient charts erectile dysfunction 10 order 60 mg levitra extra dosage, physician orders, and lab results contain critical information for supporting shared sa. Wears and colleagues have studied the use and development of status boards in the emergency department (Wears et al. Features of the boards that are useful are initiated easily and adopted, while ineffective features are quickly dropped. In particular, the presence of shared or common mental models is believed to support shared sa. Cross-training team members on other team member tasks may support the development of common or shared mental models and has led to improved team performance and communication (travillian et al. Bolstad and endsley (1999; 2000) have explored the effect of shared displays on fostering shared mental models and shared situation awareness. At high levels of workload, the shared displays provide advantages by reducing communication requirements. Bolstad and endsley (2000) caution that shared displays should be designed carefully because excess information provided on shared displays can slow performance. Both of these processes have been adopted into practice within the Kaiser health system. Implications for Design and Training to Support Healthcare Team Communications Implications for Design there are a number of implications that a model of team sa has on the design of healthcare equipment and processes. Human factors methods such as cognitive task analyses may be used for eliciting these requirements (see, for example, endsley, Bolte and Jones 2003; crandall, Klein and Hoffman 2006). Clearly, however, these methods must focus attention on the sa requirements that must be shared between individuals or team member roles. In addition to processes such as these that directly involve the sharing of information, processes that promote an environment of information sharing are also benefcial. For example, displays that abstract small subsets of information from the domain of another team member could foster the development and maintenance of shared mental models that will support shared sa (Bolstad and endsley 2000). In addition, designers must also consider that displays that may primarily be used by one provider (for example, an anesthesia provider) may also be used by other providers (for example, a surgeon), and that the presentation of information should support both Nemeth Book. Implications for Healthcare Team Training and Assessment a model of team sa also has a number of implications for training and assessment of healthcare teams. First, training and assessment of teamwork should incorporate behaviors that serve to develop and maintain shared sa. Examples of specifc behaviors that enhance the development and maintenance of shared sa include: (1) communication skills such as the use of standard terminology, acknowledgement and repeat back of information received, the use of structured communication, and the use of critical language; and (2) the knowledge and practice of specifc processes such as planning, briefng, and time-outs that support the development and maintenance of shared sa. Behaviors such as the use of structured communication and the conduct of effective briefngs require not only the knowledge of these tools, but also practice or experience to attain skill in their use (Dreyfus 2004). Practice in these skills should be incorporated into the important and relatively common on-thejob healthcare provider training. In addition, practice in these skills should include multidisciplinary simulation-based training that can focus on critical scenarios that might otherwise be rarely encountered during training (Hamman 2004; Wilson et al. It is also possible to integrate the training of shared sa processes and communication skills into simulated clinical skills training. Helmreich, Merritt and Wilhelm (1999) describe how team training in aviation has evolved over the past 25 years into a more integrated approach, with teamwork skills being integrated into all fight training, rather than being presented as a stand-alone training module. For members of a team to have a shared understanding of the environment and their goals, it is critical that they have an understanding of the tasks, goals, and information requirements of other members of the team. Finally, a model of team sa also implies that assessment of team sa should be completed in realistic practice environments. Assessment in simulation or real world environments is essential for evaluating the success of both training and design approaches to enhancing team sa. Conclusions research focused on measuring individual and team sa provides insight into the effect of sa on both individual and team performance. Behaviors that support the development of shared sa such as planning and frequent situation assessment updates have been shown to be associated with more effective team performance. The efforts described in assessing the team skills of medical students were funded by grant #0304-101 of the edward J. The authors would like to thank Jeffrey Taekman, Robert Wears, and Christopher Nemeth for their valued reviews and input. Due to the serious nature of patient illnesses in the Icu, the outcomes of treatment interventions are often diffcult to predict. However, research investigating the management of Icus has shown that the organizational characteristics of an intensive care unit, and in particular the quality of communication amongst team members, have a considerable impact upon patient outcomes (carson et al. These fndings are consistent with patient safety research showing communication failures to be a key causal factor underlying adverse events (schaefer and Helmreich 1994). In order to improve communication within and between teams, it is necessary to understand exactly how teams in particular work environment exchange information and what factors affect the level of individual and shared understanding. For example, research has shown that patterns of communication (for example, closed-loop communications) are related to fight team performance (Bowers et al. Such research fndings are used to inform not only workplace design and operating procedures but also the specialised Crew Resource management (crm) training that is used to enhance crew performance, principally Nemeth Book. In order to design appropriate interventions (such as crm training) to enhance team communication in the Icu, it is necessary to examine empirically the communication skills associated with high levels of safety and patient care, and also to understand the factors that affect how team members normally communicate with one another. The properties of the tasks being performed by the team must also be considered (Kent and McGrath 1969). For example, the complexity and importance of tasks will likely affect how decisions are made during the task and the level of communication and coordination needed between team members for completing the task. It is notable that the various team inputs are interdependent, as the skills, abilities and personality of individual team members will affect the structure of the team (for example, the role and status of team members) depending on the type of task being performed. The team inputs affect the team processes (for example, complex tasks being performed with inexperienced trainee team members will likely result in increased emphasis on decisions being made by team leaders), with this in turn affecting both task performance and individual levels of job stress and satisfaction. Lastly, the performance of the team will feedback to affect the team inputs, with successful team performance likely increasing team cohesiveness and improving individual knowledge and skills. Team Communication and Patient Safety the importance of effective team communication for patient safety has been demonstrated in various medical domains (gaba 1989; de leval et al. These are social and cognitive skills that are crucial for maintaining safety, and are often taught and assessed in aviation and medical crm courses (Fletcher et al. For example, a reluctance of nursing staff to speak up on the observation of errors, and lack of communication and understanding regarding medication handovers between nurses and doctors, have been found to contribute directly to the occurrence of preventable adverse events (pronovost et al. Team Communication and Patient Outcomes Investigations examining communication in the Icu have also shown better communication to be associated with positive patient-related outcomes. In summary, research investigating the relationship between communication and quality of care in the Icu has shown communication failures as commonly causing errors, and good communication as being associated with positive patient outcomes. Status Differences and Communication Healthcare teams tend to be quite hierarchical in nature, with senior doctors usually having a higher status than other healthcare professionals. Group research has shown that group members of a higher status voice their thoughts and opinions more often than those of a lower status (Islam and Zyphur 2005), and individuals of a lower group status are less likely to (a) contribute to group tasks (Berger et al. However, although nurse with doctor communications were found to occur in just 2 per cent of all activities performed in the unit, these were associated with over a third of errors. It was concluded that this might be due to the informal and infrequent communications between nurses and doctors, alongside misperceptions and misunderstandings regarding the information communicated between them. If junior team members believe they cannot communicate openly, this can result in information critical to patient care not being shared, and can reduce the likelihood of concerns being expressed or of guidance being asked for aspects of patient treatment. In particular, perceptions were positive for open communication within professional groups (for example, between nurses) and the timelines of communication between Icu caregivers. However, there were some less favorable results, with just over half of the sample having positive perceptions of the accuracy of communication between members of the same professional group (for example, between doctors). Specifcally, the perceptions of doctors regarding communication openness between nurses and doctors were signifcantly more positive than the perceptions of nurses. Divergent perceptions due to seniority were also found relating to communication openness between doctors. Interestingly, Icu team members who reported open communication in the Icu also reported having a better understanding of their patient care duties. Furthermore, the quality of senior physician leadership (for example, making clear the behaviors required of Icu staff, emphasizing standards) in the unit was found to be particularly important for encouraging open communication in the Icu. Within healthcare, changing the structure of teams in order to develop the ability of junior and senior team members to communicate well together is seen as one of the key ways through which teamwork can be enhanced (Leonard, graham and Bonacum 2004). Furthermore, Icu nurses and doctors tend to be in agreement that junior team members should be able to question senior members, that decision making should Nemeth Book. Despite this, nurses still report fnding it diffcult to speak up, with fewer nurses than doctors feeling that disagreements in the Icu are properly resolved, that input from nurses about patient care is well received, and that teamwork between nurses and physicians is well coordinated (thomas, sexton and Helmreich 2003). Status, Communication and Decision Making the team processes featured in Figure 8. The team-based decision-making processes involved in diagnosing patients and developing patient treatment plans constitute a core activity in providing critical care medicine. Additionally, minority dissent in teams with a high level of cohesion and participation has been shown to lead to more creative decisions (De Dreu and West 2001). Furthermore, real-life research during trauma resuscitation has shown the decision-making process (that is, autocratic or democratic) to depend on the severity of patient injuries and team experience, with physicians showing a more directive leadership style when patient trauma is more severe or the trauma team is less experienced (Yun, Faraj and sims 2005). Within intensive care, studies have compared the effect of task diffculty upon team communication and decision-making processes. A distinction was found between the decision-making process in the medical Icu (where it is necessary for teams to identify and diagnose the condition of patients and to make decisions about the application of suitable treatments) and the surgical Icu (where teams manage the post-operative, and thus better understood, conditions of patients). In contrast, communication in the medical Icu appeared to be more linear, with senior doctors making all of the major decisions, and with nurses communicating after performing information-gathering tasks. This fnding indicated that the team communication processes leading up to decision making were partly dependent on the severity and transparency of patient conditions. The daily goals sheets formalized the rounds process, and required all team members to participate in the setting of patient care goals and the recording of patient-related information. In particular, nurses reported that the daily goals form helped them to feel they were an active part of the patient care team. This has been found to improve interdisciplinary communication, with large increases being found in the numbers of Icu staff reporting a better understanding of patient care plans as well as higher levels of satisfaction with the process and outcome of Icu rounds. Data were gathered during Icu rounds regarding individual team member anticipations for how the most critically ill patients would progress over the proceeding 48 hours (that is, whether patients would deteriorate, remain on ventilation, or be discharged from the unit), and perceptions of individual involvement during the patient care decision-making process. Physicians and senior nurses used handheld computers to individually record their judgments after the review of 105 patients during 35 Icu rounds. The reported involvement of trainee doctors was associated with the number of verbal contributions made during patient discussions. Furthermore, the analysis found that nurses reported feeling highly uninvolved in the patient review process. However, the costs of interruptions can be a loss of attention, forgetfulness, and ultimately error (reason 2000), and interruptive behavior is particularly disruptive during tasks such as shift handovers, patient reviews, and surgery (Healey, Sevdalis and vincent 2006; laxmisan et al. Investigations of interruptions during Icu physician rounds have shown a large proportion of the communication during the round to be of an interruptive nature (alvarez and coiera 2005). Such grounded theory research (the generation of theory from data) can be informative for understanding the nature and culture of communication. In particular the physician round was identifed as a key process for sensemaking, with the cases of individual patients being presented to the team, explicit care plans being developed, and summaries being used to recap the discussion and highlight the core duties of team members.

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