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By: Daniel James George, MD

  • Professor of Medicine
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  • Member of the Duke Cancer Institute

https://medicine.duke.edu/faculty/daniel-james-george-md

La inflamacion de la faringe puede ser de naturaleza infecciosa erectile dysfunction just before intercourse discount megalis 20mg online, alergica erectile dysfunction after zoloft 20mg megalis sale, quimica o traumatica erectile dysfunction protocol reviews generic megalis 20 mg. A su vez pueden ser circunscritas sudden erectile dysfunction causes generic megalis 20mg fast delivery, si quedan limitadas a una zona faringea (ejemplo: amigdalitis) o difusas si afectan a toda la faringe (ejemplo: faringitis). Es una via de entrada de infecciones al organismo en general; asi pues la faringitis aguda puede suele ser la primera manifestacion de enfermedades generales (viriasis), este hecho es especialmente frecuente en los ninos precediendo a las enfermedades infecciosas de la infancia. En otras ocasiones es una manifestacion unica, hablando en ese caso de faringitis como enfermedad. El cuadro mas frecuente es la llamada faringitis catarral aguda, que es una inflamacion superficial, difusa y suele estar ocasionada por virus (rhinovirus, coronavirus, adenovirus, influenzae, parainfluenzae) y en menor proporcion por bacterias (estreptococo fi hemolitico Capitulo 76 Patologia inflamatoria inespecifica de la faringe. Los virus representan el agente etiologico mas frecuente, cursando en brotes epidemicos. Entre los virus destacamos por orden de frecuencia a: rhinovirus y coronavirus (los mas frecuentes. Se suelen acompanar de lesiones cutaneas), adenovirus (afectan a ninos de entre 3 y 6 anos donde es tipica la afectacion conjuntival, las adenopatias y la fiebre), virus influenza (acompanado de mialgias y cefalea, cuadro tipico gripal), coxsackie (mano-boca-pie) y herpes virus (enantema). Las faringitis bacterianas van a representar aproximadamente el 30% del total y el agente mas prevalente va a ser el estreptococo pyogenes, responsable de la mitad de los cuadros bacterianos y cuya importancia radica en la posibilidad de producir complicaciones tanto supuradas como no supuradas. Es discutida y se postulan varias hipotesis, podemos afirmar que existen factores predisponentes, a la inflamacion del tejido faringeo como son el frio, la humedad, la polucion, el ambiente seco y el estres. La infeccion se puede producir por inoculacion directa de los agentes patogenos a traves de gotitas de pflugge, objetos o alimentos; en ocasiones se piensa en que puedan estar en relacion con infecciones bacterianas vecinas (fundamentalmente cavidad oral); tambien por obstrucciones de alguna cripta amigdalina que llevaria al sobrecrecimiento microbiano y la posterior invasion del resto del tejido amigdalar. En casos recurrentes, es probable que exista una funcion inmunologica comprometida, caracterizada por una produccion disminuida de inmunoglobulinas locales, un menor numero de celulas presentadoras del antigeno y un cambio en los valores relativos de los linfocitos T. Comienza con una vasoconstriccion pasajera, continuando con una vasodilatacion debida a mediadores de la inflamacion tipo bradicinina y factor C5a del complemento, que ademas actuan como quimiotactico para los leucocitos. Actuan mas mediadores celulares como la histamina, heparina, leucotrienos, prostaglandinas, tromboxanos, etc que son responsables de la vasodilatacion y quimiotaxis de elementos formes sanguineos. Mas tarde se produce una exudacion plasmatica con un edema submucoso que eleva el epitelio y a su vez una infiltracion por celulas redondas y leucocitos. Finalmente se produce un aumento de excrecion de las glandulas y una descamacion del epitelio. La clinica va a depender del agente causal, inmunidad del individuo, agentes externos como alcohol y tabaco, factores alergicos, respiracion bucal constante, carencias nutricionales, etc. En las formas menos graves y mas frecuentes existe un predominio de los sintomas locales con sequedad y constriccion faringea y a veces sensacion de quemazon. Es conveniente realizar un frotis faringeo para obtener un antibiograma y realizar un tratamiento especifico si se sospecha origen bacteriano. Ante la sospecha de origen bacteriano se usara ademas un antibiotico empirico y posteriormente ajustar al antibiograma (como primera eleccion se usa la Penicilina, dejando los beta-lactamicos para fallos en el tratamiento o eritromicina en caso de alergia). Pueden estar indicados los corticoides con proteccion gastrica si existe edema importante asociado a la inflamacion. Es una entidad muy discutida por algunos autores y cuya causa no es solo local, ya que al ser la faringe zona de confluencia de las vias aereas y digestivas superiores, existen multiples sintomas referidos a esta zona y cuya etiologia es multiple y derivada fundamentalmente de factores irritativos de la mucosa. Puede deberse a una alteracion en cualquier parte de la faringe, de aparicion mas o menos progresiva y con evolucion larvada. En determinados momentos y dependiendo de estados inmunitarios o por factores irritantes externos, el estado de portador pasa a estado patogeno produciendo cuadros de faringitis agudas de repeticion en algunas ocasiones y de faringitis cronicas en otras. Factores agravantes son la contaminacion atmosferica, el polvo y el aire acondicionado. Existen otros toxicos industriales capaces de desencadenar irritaciones faringeas cronicas comos son el polvo de cemento, de cal, de algodon, de hierro, de cromo y la mayoria de herbicidas y productos quimicos. La obstruccion cronica de las fosas nasales favorece la respiracion bucal, que da lugar a la desecacion de la mucosa faringea. Las rinosinusitis cronicas con rinorrea mucopurulenta constante, provoca una irritacion faringea que predispone a la inflamacion cronica o recurrente de dicha mucosa. El reflujo faringo-laringeo o extraesofagico es cuando el contenido gastrico o del esofago llega hasta la faringe y laringe afectando a estos organos; y en otras ocasiones puede producirse una produccion de acido en faringe sin mediar intermediacion gastrica que produce un cuadro similar. Pirosis, regurgitaciones, gastralgias y sobre todo tos seca persistente nos ayudan al diagnostico de una enfermedad por reflujo gastroesofagico. Otras enfermedades como esofagitis, gastritis, hernias hiatales o ulceras gastroduodenales tambien pueden estar implicadas en la aparicion de faringitis por causas ascendentes. Fundamentalmente en este apartado se trata de amigdalitis cronicas, corresponde a la infeccion amigdalina cronica salpicada de procesos infecciosos agudos puntuales. La clinica suele consistir en dolores espontaneos con odinofagia y halitosis; y en la exploracion se aprecia retencion de caseum en criptas amigdalinas que deja salir un liquido turbio a la presion en el pilar anterior. Tratamiento definitivo mediante amigdalectomia en los casos en los que se produzcan un numero elevado de episodios agudos y en los que la limpieza de dichas criptas por el especialista o por el propio paciente sea infructuosa. Existen faringitis cronicas que son expresion de enfermedades generales, como es el caso de la diabetes, hiperuricemia, hipocalcemia y dislipemias, debido a las modificaciones vasculares generales y nerviosas que provocan. Destacar como en la hiperuricemia se provoca una verdadera gota faringea con una mucosa roja oscura con hipervascularizacion difusa. Las alergias, y en especial las de origen alimentario, motivan hiperreactividad mucosa local predisponiendo a los cuadros inflamatorios. Otras enfermedades como por ejemplo el sindrome de Sjogren y el sindrome de Plumier-Vinson se relacionan con un mayor numero de episodios inflamatorios faringeos que en la poblacion general. Las molestias cronicas faringeas son frecuentes con el consumo de determinados medicamentos, que provocan xerostomia, como anticolinergicos, betabloqueantes, psicotropos, pirazolonas y antihipertensivos centrales. Un hecho habitual es la mayor presencia de faringitis cronica en pacientes amigdalectomizados, esto es todavia controvertido, y se supone que es debido por tres mecanismos: persistencia de restos cripticos infectados en polo inferior; desarrollo de faringitis en los islotes posteriores que tienden a reepitelizar el lecho amigdalino; faringitis cicatrizal a nivel de pilares y velo, en pacientes habitualmente neuroartriticos que son sensibles a cualquier cambio de humedad o temperatura. Ademas se asocia la sensacion de cuerpo extrano a ese nivel por la hipertrofia de la amigdala lingual que en estos pacientes se provoca, lo que ademas tambien predispone a las infecciones de dicha zona. Suelen localizarse en orofaringe o hipofaringe y clasicamente aumentar con la deglucion y al hablar. Con frecuencia describen odinofagia matutina, rinorrea pegajosa posterior, carraspeo, sensacion de quemadura, picor y de cuerpo extrano en la garganta y repeticion de las degluciones. Puede asociar a su vez tos nocturna, sensacion matinal de faringe rasposa, tenesmo faringeo y regurgitaciones a distancia de las comidas. Todas estas molestias son mas o menos antiguas y se asocian a antecedentes repetidos de automedicacion. Se debe realizar un estudio analitico en busca de datos de inflamacion o de parametros que nos indiquen la posible asociacion con alguna de las enfermedades generales anteriormente descritas: diabetes, hiperuricemia. Tambien debemos realizar una toma de muestra mediante un frotis faringeo si se sospecha un origen bacteriano o para valorar la presencia de un germen “acantonado”, portador cronico de Streptococo. Las pruebas radiologicas son utiles si se sospecha patologia dentaria, sinusal o gastroesofagica con el fin de descubrir estos posibles focos infecciosos vecinos Ante cualquier lesion de la mucosa sospechosa, y mas si existe antecedente de consumo de alcohol o tabaco, se recomienda la endoscopia directa bajo anestesia y biopsia de la lesion para su estudio anatomopatologico. Distinguimos cuatro formas clinicas en funcion de los hallazgos de la exploracion fisica: 3. Mucosa engrosada recubierta por una capa opalescente que se organiza en regueros blanquecinos en los pliegues. Se comprueba la presencia por detras de los pilares posteriores de cordones posteriores o foliculos linfoides en pared posterior (Fig. Es importante diferenciar las faringitis cronicas de otras entidades nosologicas que en algun caso puede tratarse de enfermedades realmente graves. Predominan los sintomas dolorosos a veces asociados a otalgia, alteracion del estado general, disfagia, aparicion de adenopatias o lesiones mucosas (Fig. El tratamiento se debe plantear mas desde el punto de vista etiologico y preventivo que del sintomatico. Es un tratamiento complejo y a menudo ineficaz, donde la psicologia del paciente suele ser muy importante en la evolucion. Las terapias realizadas son: Normas higienicodieteticas: Suprimir factores irritativos externos, fundamentalmente tabaco y alcohol, asi como proteccion frente a los posibles irritantes ocupacionales. Se aconseja una restriccion de sal y realizar una dieta hipouricemica y abundante aporte hidrico. Se debe recomendar la realizacion de Capitulo 76 Patologia inflamatoria inespecifica de la faringe. Entre estos tratamientos se incluyen por supuesto tratamientos medicos y quirurgicos si estos son necesarios. El uso de lavados nasales y gargarismos alcalinos pueden ser utiles para aliviar el dolor y desprender lesiones costrosas de la faringe. En la patologia faringea cronica las aguas mas utilizadas son las sulfurosas, en especial las sulfurosas sodicas alcalinas, que se usan entre 35-60fi y con pH elevado.

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While wheezes are classically associated with asthma erectile dysfunction treatment boston medical group order genuine megalis line, they can be noted with any abnormality/disease that causes narrowing of the airway lumen such as infections/secretions erectile dysfunction types purchase cheap megalis, tumors erectile dysfunction pills new cost of megalis, foreign body or dynamic airway collapse erectile dysfunction pills uk order megalis australia. Proper technique and positioning is essential and will significantly help with interpretation. If the cardiac silhouette and pulmonary vasculature are normal, then a cardiac-related cough would be very unlikely. However, if there is an interstitial pattern noted in the perihilar or caudodorsal lung fields and cardiogenic-pulmonary edema is suspected, then left atrial enlargement and pulmonary venous dilation would be expected as concurrent findings. Caution should be used in assessment of the right side of the heart on thoracic radiographs and it should be noted that mild right-sided enlargement is not usually detectable with thoracic radiographs. Right-sided heart enlargement does not typically cause coughing, however enlargement of the left atrium can cause compression of the mainstem bronchi and contribute to coughing. Assessment of the pulmonary parenchyma should include characterization of any abnormal patterns and localization of the abnormality. Unfortunately intermittent shedding may cause a false negative, but this test will be more sensitive than routine fecal flotation. Lung ultrasonography has also recently shown some promise in diagnosing cardiogenic edema, and potentially even differentiating between pneumonia, neoplasia and pulmonary edema. Echocardiography can be used to evaluate cardiac structure and function, and to provide support for suspected cardiogenic pulmonary edema or pulmonary hypertension. More advanced diagnostics such as transtracheal wash and bronchoalveolar lavage can be helpful for obtaining samples for cytologic analysis and culture, and in particularly challenging cases, these tests are an essential part of the diagnostic work up. Sedated oral exams and/or fluoroscopy are indicated for patients with significant upper airway signs. Treatment Treatment ultimately depends on the underlying diagnosis/cause of the cough. Some can be readily improved with appropriate therapy, however cases of tracheal collapse, chronic bronchitis, and cough due to left atrial enlargement/mainstem bronchus compression can be difficult to control. It must be relayed to owners in these situations that the cough is unlikely to resolve completely, and instead the goal is to decrease the frequency and/or severity to a point where it is tolerable for the patient and family. Acute/Emergency Setting In patients with an acute exacerbation of their cough, sedation. In patients where bronchoconstriction is suspected, a puff of albuterol and fluticasone can be administered. Antibiotic therapy should be continued for 2 weeks beyond radiographic resolution of pneumonia. Coughing in chronic bronchitis cases can be challenging, and sometimes frustrating to treat. Lifestyle management can also be very helpful, including weight loss, use of a body harness rather than collar, avoid environmental triggers (such as smoke, scents etc). In cats, the most common systemic disorders that can cause cardiac abnormalities include hyperthyroidism, systemic hypertension, acromegaly in addition to nutritional deficiencies and toxic insults such as anthracyclines. The precise diagnosis of primary cardiomyopathies in cats can be challenging – echocardiography is the gold standard, but there can be overlap between the phenotypes of the various cardiomyopathies, particularly in patients with advanced and end-stage disease. In a clinical setting, the stage of the disease is often sufficient to determine treatment/therapy, even when a precise classification is unclear. More specifically, the A31P mutation has been identified in Maine Coons, and the R820W mutation has been identified in the Ragdoll breed. This is particularly important if M-mode is used for measurements, so 2D images should be inspected carefully to determine if false tendon(s) are present. Restrictive Cardiomyopathy Restrictive cardiomyopathy is the second most common form of cardiomyopathy in cats. Normally as the ventricles relax in diastole there is an early, passive phase of ventricular filling (E), followed by diastasis and finally an active (A) phase of diastole due to atrial contraction/atrial “kick”. Doppler can be used to measure the speed of blood flow from the atria to the ventricles during diastole. In advanced cases, the wall motion can appear overtly stiff with eventual decline in systolic function. Dilated Cardiomyopathy Dilated cardiomyopathy is a relatively uncommon type of heart disease in cats ever since the requirement for dietary taurine supplementation was discovered in 1987. Typically the left ventricle is affected with this condition, however both ventricles can be involved. As a result of the decreased systolic function, the ventricular filling pressures increase, resulting in enlargement of the atria. High-output states such as anemia, hyperthyroidism can also cause volume overload, but systolic function is usually preserved in such cases. Unclassified Cardiomyopathy Unclassified cardiomyopathy is a bit of a controversial category of feline heart disease. It’s used to describe cats with left or biatrial enlargement, which typically is indicative of underlying heart disease, but their ventricular changes do not fit into the criteria of the other forms of cardiomyopathy. Other considerations for this category could include atrial myopathies that cause primary atrial dilation without necessarily any ventricular abnormality. The cause is unclear, however the disease seems similar to that diagnosed in Boxers and human with replacement of the right atrial and right ventricular myocardium by fatty or fibrofatty tissue. Arrhythmias are common with this condition – most will have some form of ventricular arrhythmias (either ventricular premature complexes or ventricular tachycardia) and many can have atrial arrhythmias such as atrial fibrillation. Echocardiographic findings include severe right ventricular eccentric hypertrophy and right atrial dilation +/left atrial dilation. The thinning of the walls can be remarkable, with transillumination through the heart walls reported on post-mortem exam of these hearts. This test should not be used indiscriminately for screening purposes, but rather performed in cats that are suspected of having underlying heart disease (eg. Clinical Findings All forms of cardiomyopathy in cats can have a long asymptomatic (occult) phase. Auscultation of a heart murmur can be suggestive of, but does not necessarily indicate the presence of heart disease in cats, as physiologic murmurs are not uncommon in this species. A gallop sound can be more indicative of underlying heart disease as this typically occurs due to increased ventricular filling pressures, however even these can be associated with other causes. Cats are different from dogs in that left-sided congestive heart failure can result in pleural effusion, pulmonary edema or both. Treatment – Asymptomatic (Stage B1-B2) Treatment of asymptomatic cats with myocardial disease is controversial. There are no therapies that have been definitively proven to delay the onset of congestive heart failure in cats with cardiomyopathy. The dose of furosemide to be used in the acute setting depends on severity of signs, current dose at home (if applicable), and (to some degree) renal function. If there is no improvement within 30-60 minutes, this can be repeated (and reassessment of diagnosis should be considered as well). Handling should be kept to a strict minimum until patient is stable, however cats that have pleural effusion should have thoracocentesis performed as this can provide immediate improvement in dyspnea/tachypnea. Clopidogrel should also be started once oral medications can be safely administered. Renal values and electrolytes should be monitored q24 hours during hospitalization. Diet change or supplementation should be implemented if a nutritional deficiency is suspected to be contributing to the underlying heart disease. Once a patient is stabilized and ready for discharge, maintenance with furosemide, benazepril, clopidogrel and pimobendan is typically instituted. For recurrent/refractory patients, a dosage increase of 25-50% for furosemide is generally effective initially, however with advanced disease and diuretic resistance that occurs with longer-term therapy, additional diuretics can be used as follows: Hydrochlorothiazide/Spironolactone 6. In cats with concurrent small airway disease/asthma, sotalol should be used with caution as this medication includes non-specific beta-blockade. Prognosis the asymptomatic phase is typically quite long, but can be extremely variable for cats with cardiomyopathy. Contemporary definitions and classification of the cardiomyopathies: an American Heart Association Scientific Statement from the Council on Clinical Cardiology, Heart Failure and Transplantation Committee; Quality of Care and Outcomes Research and Functional Genomics and Translational Biology Interdisciplinary Working Groups; and Council on Epidemiology and Prevention. In order to be clinically useful, a biomarker must meet three criteria: (1) accurate test results can be obtained by a clinician in a short period of time and at a reasonable cost, (2) biomarker test result provides information that is not already available from a clinical assessment, and (3) should advance clinical assessment and decision making. Several cardiac biomarkers have been identified, however only a select few meet the criteria to be clinically relevant – these will be the focus of this lecture hour. Cardiac Troponin Cardiac troponin I (cTnI) is a well-established cardiac biomarker. The cardiac troponin complex is made up of cTnI, along with troponin T (cTnT) and troponin C (cTnC).

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He has rejected one hypothesis (that is impotence nitric oxide buy generic megalis pills, “nothing [the surgeons] were doing”) impotence causes and cures purchase megalis, though he does not elaborate erectile dysfunction treatment canada best purchase megalis. He then tells the attending about the hypotheses he has considered but discarded erectile dysfunction treatment washington dc purchase generic megalis pills, and his reasons for doing so. In reaction to this, the resident seems to re-evaluate the data that fed into his conclusion that it could not have been due to the surgeons. He “revisits” what was occurring during the important time-frame (as pointed out by the attending). By going over in detail what was occurring then, he comes to the conclusion that the surgeons were indeed engaged in an activity that could have given rise to the event. Well I can’t necessarily r: the only thing a: I can’t necessarily explain that states he has no explanation r: Yeah, neither can I. Just process variables mentioned, all of the sudden—boom—out action to be taken mentioned of the blue—her potassium is 3 point 3 and we’re getting ready offers a third hypothesis but to replace that and we have been voices lack of knowledge hyperventilating but I don’t know if low potassium can affect heart rate. In event based on past experience discussion my experience it’s usually been stimulation of the trachea, it’s something traction on the dura r: yeah (absolutely) A: you know things r: yeah, it may have been dura Remarks that one of these causes may have been cause in this case A: sort of a refex, provides another possible pressure on an eye cause based on past cases r: actually it was when Remarks that event occurred during Discounted they were sawing the dura open a time when one of the causes hypothesis mentioned by a could have occurred reconsidered a: well that’s r: putting tension on it a: you touch the dura you’ll get that states mechanism R: okay a: ’cause the dura is ennervated Describes mechanism whereby by the ffth I believe, and it hypothesized cause leads somehow makes its way back to to the signifcant event the (. For example, they draw attention to anomalies, events, and parameters of concern and they speak about them relative to expectations. Team members also provide informative responses, that is, with elaborations tailored to the information needs in the current context. When the common ground is built up among team members, it will be unusual for team members to ask “why” questions like: “why do you think thatfi Breakdowns in cooperative interaction between pilots and cockpit automation are marked by just these questions (Sarter and Woods 1995). The fndings of the study are consistent with those of other studies, particularly work on cockpit resource management, that indicates the importance of continual verbal interaction in keeping team members attentive and informed (Foushee and Manos 1981; Hutchins 1990; norman 1989). In general, team members invest heavily in communicating about the state of the monitored process and problem solving. One reason is that diagnosis entails disentangling the various potential infuences acting on the process, some of which may be due to the interventions of other team members. Hence, it is important for team members to keep one another aware of their interventions on the process. The same level of effort to keep someone updated is not warranted if they are not true team members. This is refected in an episode in which an update to a medical student was cut short in order to deal with what was perceived to be a more pressing task. This is consistent with Orasanu’s (1990) cockpit crew simulator study fndings concerning the temporal-sensitive nature of communication; she found that captains in high-performing crews talked less than captains in low-performing crews when workload was high; also, the captains of high-performing crews requested slightly less information during abnormal phases of fight, whereas captains of poorperforming crews requested more information during these phases. We observed an episode in which the attending puts off an explanation of his decision until a more opportune time. In this purpose, maintaining common ground is similar to anesthesiologists’ preparatory or anticipatory behaviors (Cook, Woods and McDonald 1991; Xiao 1994), that is, a task undertaken at the moment, so that things will be easier later on, when they can be expected to be more busy. Team Member Capabilities for Supporting Dynamic Management Based on this study and other research fndings discussed, we can summarize some key team member communication capabilities that are needed for effectively supporting dynamic fault management. This serves to keep other team members in the loop and engages them in joint problem solving. By providing unprompted information about activities or assessments, directing attention to anomalies and relevant events, context-sensitive elaborations to queries, team members are, in effect, helping one another fnd the right information at the right time. This is a key ability because cognitive demands increase with the tempo and criticality of operations (Woods 1994). This mutual knowledge or mutual potential knowledge can be viewed as different kinds of shared context within which communication occurs. The team members use these different contexts to know what is relevant to say when. It allows one to understand why the attending might say “let’s give him some dobutamine” and how to take this action, or what “Why don’t you put the a-line in” means, why it would need to be done, and how to do it. This refers to knowledge about the history of the process, including what interventions were taken, what the evolution of the state of the process has been and of problem solving. Pointing (deitic reference) makes for compact communication— 3 Interestingly, reference can be so compact that it involves neither words nor direct pointing. In one episode observed, a medical student elicits an explanation of the resident by “waving” towards the vital signs display. From the resident’s point of view, the fat waveform is expected because the blood pressure cuff was on the same arm as the pulse oximeter monitor; whenever the cuff infates it squeezes off blood fow, which leads to a spurious pulse reading. However, it is the atypical item—that which would be anomalous in another context. Building up the common ground in the fow of events and using the various shared contexts allows for concise communication, and prevents the need for explanations that might distract from the situation. Secondly, the subordinate must be able to provide some kind of reconstruction of the event that emphasizes relevant events, actions, and relationships in order to provide the supervisor with a coherent recounting of the events that led to the present state. Teasley (eds), Socially Shared Cognition (Washington, Dc: american psychological association). Cheaney (eds), Information Transfer Problems in the Aviation System, nasa technical paper 1875 (moffett Field, ca: nasa ames research center). Egido (eds), Intellectual Teamwork: Social and Technical Bases of Cooperative Work (Hillsdale, nJ: erlbaum). Calderwood (eds), Decision Making in Action: Models and Methods (new Jersey: ablex). For instance, in anesthesia 25 per cent of deaths are due to inadequate communication, which represents 39 per cent of reported medical errors (Arbous et al. But, surprisingly, communication has not received much attention from researchers. Better training, better techniques, and better standards of equipment have been recommended in order to improve the patient’s safety, but not much effort has been spent on communication training and tools, even though healthcare practitioners designate “improving communication” as an important corrective strategy (Kluger et al. During the past decade or so, there have been two important developments in medical care relevant to the study of communication in hospital: • the increased specialization of medical sciences, which has increased the division and distribution of tasks among experts from different disciplines and, thus, the need for coordination and communication between healthcare providers. This specialization requires more and more information to be exchanged between departments as well as between individual operators who work cooperatively in hospitals in order to coordinate interventions both in time and space. Hospitals themselves have even become specialized, so that a patient may have to go to several hospitals and institutions to be properly taken care of (nyssen 2007). During the past decade, the healthcare system has seen the introduction of more and more sophisticated technological devices and automated systems. It is largely due to the fact that the design is still completely cut off from the environment of use as we, and other researchers such as Woods, have shown in various complex systems (Nyssen 2004; Cook and Woods 1996; Woods and Hollnagel 2006). But some problems of communication obviously remain, as we can see with the case of the sharm-elSeikh accident (Egypt, January 4, 2004), in which the crew failed to share a proper understanding of the autopilot status. Unlike required by the standard procedure, no take-off briefng was conducted by the captain. A take-off briefng allows the crew to review and share data about the distinctive details of the intended fight in order to properly anticipate expected events. For instance, the aircraft, a B737-300, had a few (minor) equipment failures which had not been repaired (in accordance with the minimum equipment List tolerance). Because no briefng had been made, the crew was surprised and a bit confused after lift-off and the captain requested the autopilot engagement in a condition in which by design it could not engage, which further increased his perplexity about the aircraft behavior. These diffculties faced in addressing cooperation needs might be grounded in the dominant tendency to use an analytical approach to solve a complex, non-linear problem. What characterizes a system as complex is not the mere number of its component parts but the heterogeneity of the component parts and their relations among them, leading to a potentially unanticipated and autonomous outcome, namely an emergence. In this approach, communication fows are seen as a manifestation of the adaptation work (Piaget 1967; le moigne 1999; maturana and varela 1980 and 1987; constructivism). In most circumstances, the act of communication represents our best attempt to adapt to a specifc situation. The view taken in our research is that analyzing communication will reveal the adaptation strategies and the limits of the adaptation of the “system,” taken here as the interaction between the surgeon, the assistant, and the robot. In this sense, our work is in accordance with new approaches to the safety of social-complex systems that have recently been explored under the name of resilience that looks for adaptation capacity instead of breakdowns and accident models. We shall discuss this new approach in the light of the constructivism perspective, in particular, the increasing focus on the emergent adaptive capacity of socio-technical systems through continual interaction with their environment.

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Assistant Professor of Psychiatry [2001; 2000] erectile dysfunction pills with no side effects buy megalis 20mg online, Adjunct Assistant Professor of Neurology [2003] Assistant Professor of Neurology [2006] Marwan Riad Khalifeh erectile dysfunction holistic treatment cheap generic megalis canada, M impotent rage quotes cheap megalis 20 mg with visa. Assistant Professor of Plastic and Reconstructive Assistant Professor of Pediatrics [2009] Surgery [2008; 2006] Petros Constantine Karakousis erectile dysfunction jacksonville fl megalis 20mg without a prescription, M. Assistant Professor of Medicine [2005] Adjunct Assistant Professor of Oncology [2008; 1999] Baktiar O. Assistant Professor of Molecular and Comparative Assistant Professor of Medicine [2011] Pathobiology [2007; 2006] Ron Khazan, M. Assistant Professor of Radiology [1991; 1989] (on Assistant Professor of Pediatrics [2008] leave of absence) Matthew Lewis Kashima, M. Assistant Professor of Otolaryngology-Head and Assistant Professor of Physical Medicine and Neck Surgery [2001] Rehabilitation [2010] Elizabeth A. Assistant Professor of Psychiatry [2004; 2001] Assistant Professor of Gynecology and Obstetrics Wendy G. Assistant Professor of Neurology [1995] Assistant Professor of Radiology [2009; 2008], Earl D. Assistant Professor of Neurological Surgery [2009] Assistant Professor of Ophthalmology [1980; 1978] Yoshinori Kato, Ph. Assistant Professor of Radiology [2008; 2006], Assistant Professor of Radiology [1979; 1971] Assistant Professor of Oncology [2009] Young Jun Kim, M. Assistant Professor of Otolaryngology-Head Assistant Professor of Gynecology and Obstetrics and Neck Surgery [2005], Assistant Professor of [1979] Oncology [2009] Eugene Katz, M. Assistant Professor of Gynecology and Obstetrics Assistant Professor of Neurology [2010] [2006] Mark King, M. Assistant Professor of Emergency Medicine [2000] Assistant Professor of Dermatology [2005] Tracy Meicha King, M. Assistant Professor of Pediatrics [2005; 2004] Assistant Professor of Medicine [2011] Arnold S. Assistant Professor of Pediatrics [1990] Assistant Professor of Pediatrics [2005; 2003] Flora N. Assistant Professor of Medicine [2007; 2004] Assistant Professor of Pediatrics [2010] Dmitry Eugene Kiyatkin, M. Assistant Professor of Medicine [2011; 2007] Assistant Professor of Psychiatry [2010; 2008] Mitchell Klapper, M. Assistant Professor of Dermatology [1992] Assistant Professor of Gynecology and Obstetrics Jonathan Tzvi Klein, M. Assistant Professor of Medicine [1981; 1980] Assistant Professor of Psychiatry [1996; 1993] Amy M. Assistant Professor of Medicine [2003; 2000] Assistant Professor of Radiology [2005; 2003] Han Seok Ko, Ph. Assistant Professor of Neurology [2010; 2008] Assistant Professor of Medicine [2010] Thomas Wayne Koenig, M. Assistant Professor of Psychiatry [1996; 1994], Assistant Professor of Psychiatry [1997; 1996] Associate Dean for Student Affairs [2004] Scott Elliot LaBorwit, M. Assistant Professor of Ophthalmology [1999; 1998] Assistant Professor of Medicine [2010] Aaron Nicholas LacKamp, M. Assistant Professor of Anesthesiology and Critical Assistant Professor of Ophthalmology [1986; Care Medicine [2011; 2009] (from 08/16/2011) 2004] Delese E. Assistant Professor of Gynecology and Obstetrics Assistant Professor of Medicine [2007; 2004] (on [2011; 2008], Instructor in Pediatrics [2011] leave of absence to 11/30/2011) John Gregory Ladas, M. Assistant Professor of Ophthalmology [2001; Assistant Professor of Gynecology and Obstetrics 2000] [2001; 1999] Hong Lai, Ph. Assistant Professor of Radiology [2008], Assistant Assistant Professor of Orthopaedic Surgery Professor of Ophthalmology [2001] [2003], Assistant Professor of Oncology [2003] Janet Christine Lam, M. Assistant Professor of Neurology [2011] Assistant Professor of Otolaryngology-Head and Neck Surgery [1999; 1992] Gyanu Lamichhane, Ph. Meyerhoff Chair Assistant Professor of Psychiatry [2011] Kathleen Bechtold Kortte, Ph. Assistant Professor of Physical Medicine and Assistant Professor of Medicine [1997; 1994] Rehabilitation [2003] Michael Edward Lantz, M. Assistant Professor of Gynecology and Obstetrics Assistant Professor of Medicine [2004; 2003] [1995] Michael Kottgen, M. Adjunct Assistant Professor of Medicine [2009] Assistant Professor of Psychiatry [2007] Brian Gustav Kral, M. Assistant Professor of Medicine [2009] Assistant Professor of Anesthesiology and Critical Care Medicine [2008] Katherine Goodrich Kratz, M. Care Medicine [2011] (from 07/18/2011) Adjunct Assistant Professor of Radiology [2008] Robert Kimball Kritzler, M. Assistant Professor of Pediatrics [2007] Assistant Professor of Oncology [2008] Esther I. Assistant Professor of Medicine [2005] Assistant Professor of Neurology [1997] (to 09/30/2011) Geoffrey Y. Care Medicine [2011] Assistant Professor of Gynecology and Obstetrics [2006; 1994] Prakash Kulkarni, Ph. Professor of Oncology [2009] Assistant Professor of Gynecology and Obstetrics [2008] Kanupriya A. Assistant Professor of Oncology [2009; 2007] Assistant Professor of Emergency Medicine [2011; 2009] William Leahy, M. Professor of Neurology [2003] Assistant Professor of Pediatrics [1994] Benjamin H. Assistant Professor of Anesthesiology and Critical Adjunct Assistant Professor of Anesthesiology and Care Medicine [2002] Critical Care Medicine [2006] Gabsang Lee, Ph. Assistant Professor of Neurology [2011] (from Assistant Professor of Pathology [2006] 09/01/2011) Tong Li, Ph. Assistant Professor of Pathology [2008; 2002] Assistant Professor of Anesthesiology and Critical Xuhang Li, Ph. Care Medicine [2004] Assistant Professor of Medicine [2004; 2002] Judy Mon-Hwa Lee, M. Assistant Professor of Gynecology and Obstetrics Assistant Professor of Emergency Medicine [1990; [2003; 2000] 1987] Linda A. Assistant Professor of Medicine [1995; 1994] Assistant Professor of Pediatrics [1985; 1978] Melissa Ann Lee, M. Assistant Professor of Psychiatry [2005; 2000] Assistant Professor of Medical Psychology in the Jennifer Kim Lee-Summers, M. Department of Psychiatry [1970; 1968] Assistant Professor of Anesthesiology and Critical Anne O. Care Medicine [2010] Assistant Professor of Surgery [2004; 2003] Michelle Kim Leff, M. Adjunct Assistant Professor of Psychiatry [2005; Adjunct Assistant Professor of Oncology [2009], 1996] Adjunct Assistant Professor of Plastic and Susan W. Reconstructive Surgery [2009; 2007] Assistant Professor of Psychiatry [1992; 1989] Scott David Lifchez, M. Assistant Professor of Plastic and Reconstructive Assistant Professor of Medical Psychology in the Surgery [2006], Assistant Professor of Department of Psychiatry [1983] Orthopaedic Surgery [2011; 2011] (from 07/28/2011) Richard Leigh, M. Assistant Professor of Psychiatry [2010; 2009] Assistant Professor of Ophthalmology [2007] Mary L. Assistant Professor of Pediatrics [2000; 1995] Assistant Professor of Medicine [2006] Mark Lewis Lessne, M. Assistant Professor of Radiology [2011] Assistant Professor of Otolaryngology-Head and Eric Benjamin Levey, M. Adjunct Assistant Professor of Medicine [2000] Assistant Professor of Medicine [2010] Ming-Tseh Lin, M. Assistant Professor of Pathology [2010] Assistant Professor of Emergency Medicine [2008] Steven E. Assistant Professor of Psychiatry [2005] Assistant Professor of Medicine [2004; 2003] Nikeea Copeland Linder, Ph. Assistant Professor of Pediatrics [2007] Adjunct Assistant Professor of Art as Applied to Mark Evan Lindsay, M. Medicine [1999; 1976] Assistant Professor of Pediatrics [2010] Howard Philip Levy, M. Adjunct Assistant Professor of Art as Applied to Assistant Professor of Oncology [1998], Assistant Medicine [2010] Professor of Pediatrics [1998] John Timothy Little, M.