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M. Aila, M.A., M.D., M.P.H.

Clinical Director, University of New Mexico School of Medicine

The bonus is usually relatively small (<5% of total income) and is paid in relation to absolute performance. This means that the bonus of an individual provider is independent from the performance of other providers, except in certain regions of Sweden (Lindgren, 2014), where relative achievement compared to peers is rewarded. Bonuses depend on achievements related to preventive and monitoring services in vulnerable populations (pregnant women, children, patients with diabetes or high blood-pressure) and in women of reproductive age (Almeida Simoes et al. The bonus comprises an up-front payment at the beginning of the year and achievement payments at the end. Initially, the scheme in England comprised 146 Pay for Quality: using financial incentives to improve quality of care 367 incentivized indicators from clinical, public health, organizational and patient experience domains (Doran et al. The scheme is comprised of basic and optional requirements, while the payment for each type of requirement consists of fixed and variable payment. The first P4Q programme in hospital care was introduced in Luxembourg in 1998 and the last of the included programmes was implemented in Norway in 2014 (see Table 14. Identified programmes are typically mandatory, implemented at the national level mainly in western European countries. The majority of programmes includes indicators that either target improved effectiveness of care (for example, performing surgery or initiating treatment within a pre-specified period of time) or patient safety (for example, avoidance of 30-day readmissions, wrong-side surgery and hospital-acquired conditions). Only P4Q programmes for hospitals in Croatia, Denmark, France and Luxembourg include indicators for structures. Indicators concern timely treatment (for example, surgical treatment of hip-fracture within 48 hours of admission, initiation of cancer treatment within 20 days), appropriate disease management (for example, medication at admission, discharge and during the stay, disease monitoring and diagnostic activities), and care coordination (for example, referrals to rehabilitation and primary care, plans for disease management, discharge summary sent within seven days). The size of bonus payments or penalties is usually relatively small (<2% of total hospital income) and the payment is almost always made in relation to absolute performance. Only in France, Norway and Portugal does the payment depend on relative performance of providers compared to their peers. In most countries the bonus Pay for Quality: using financial incentives to improve quality of care 371 or penalty amounts to less than 2% of the total hospital budget. In the first four years the programme targeted prevention of nosocomial infections, implementation of electronic health records, preventive care and pain management, as well as the technical quality of mammography. The reward depends on the number of achieved points on a scale of 0 to 100 and the corresponding percentage with respect to all the available points. While most indicators are measured on the hospital level, the five-year survival rates for cancer are measured on the regional level. The patient satisfaction results came from the National Patient Satisfaction Survey. The fulfilment of reporting requirements is the prerequisite for the possibility to generate indicator-based points. The aim of the programme is to improve management of myocardial infarction, acute stroke, renal failure, the prevention and management of postpartum haemorrhage, documentation and efficient medication prescription. Only the upper 20% of the providers with the highest performance receive a bonus between 0. The total remuneration of the 372 Improving healthcare quality in Europe scheme amounts to between 15 000 and 500 000 (Minister of Social Affairs and Health, 2016). Seven reviews were conducted in non-English-speaking countries, and one review was in Portuguese. Five reviews focused solely on preventive care, while another three focused only on chronic care. Three reviews evaluated the effectiveness of P4Q in comparison to other interventions, with one review focusing on audit and feedback (Ivers et al. The number of studies included in each review varies from two studies included by Giuffrida et al. The original studies (around 400) included in the 31 reviews were conducted between the "early 1980s" (Armour et al. Pay for Quality: using financial incentives to improve quality of care 373 With the exception of the reviews by Huang et al.

Phosphatidylcholine (lecithin) is the most abundant phospholipid in animal tissues but phosphatidylglycerols (glycosides) predominate in plant lipids. Various phospholipases can hydrolyze the acyl groups or head group during digestion or metabolism. One of the outstanding characteristics that make phospholipids suitable as major constituents of biological membranes is that, in water, they naturally aggregate into spherical or rod-like liposomes or vesicles, with the hydrophilic portion facing outwards and the hydrophobic portion facing inwards (Figure 6. Changing the constituent acyl groups from saturated to polyunsaturated changes the fluidity of these aggregates because of the greater amount of space Nutrition and Metabolism of Lipids 91 Outer surface Inner surface Trans-membrane protein/receptor Ion channel Carbohydrate unit Saturated phospholipid Unsaturated phospholipid Cholesterol Phospholipid head groups (asymmetrically distributed) Figure 6. The main components are proteins, free cholesterol, phospholipids, and carbohydrates. There are many different proteins with a myriad of shapes, membrane distribution, and functions, of which three are illustrated. The two fatty acids in phospholipids are mixtures of 16- to 22-carbon saturates, monounsaturates, and polyunsaturates in all combinations, with those rich in unsaturated fatty acids occupying more space; hence, their trapezoid shape compared with the narrower, rectangular shape of the more saturated phospholipids. At interfaces between non-miscible polar and non-polar solvents, phospholipids also form a film or monolayer. Cholesterol is found only in animal lipids, while a variety of other phytosterols occur in plants. The leafy and fruit components of plants contain phospholipids and sterols, whereas seeds contain triglycerides. With rare exceptions such as flaxseed (linseed), edible green leaves are proportionally much richer in -linolenate than are seeds. Foods enriched with esters of plant sterols are used widely to lower blood cholesterol via the inhibition of cholesterol absorption in the gut. Phospholipids and cholesterol constitute the majority of lipids in tissues (gut, kidney, brain, a vital component of biological membranes a precursor to bile salts used in fat digestion a precursor to steroid hormones. Sterols are secondary alcohols belonging to the polyisoprenoids or terpinoids (terpenes), which have a common precursor, isopentenyl diphosphate. Sterols have a common cyclopentano(a)perhydrophenanthrene skeleton with different substitutions giving rise to the multiple sterols and steroids. Partial hydrogenation is a common feature of unsaturated fatty acids in processed foods. Complete hydrogenation makes fats very hard and is more expensive than partial hydrogenation. Depending on the applications and the source of the original oil or fat, partial hydrogenation is an economical way to control the properties of fats or oils used in food production. Dietary diacylglycerols and monoacylglycerols are used by the food industry for emulsification of water- and oil-based components in foods such as ice cream and mayonnaise. The physical properties of dietary fat, such as their hardness at room temperature (melting point) and subsequent metabolic properties once in the body, are determined by the number of double bonds in their constituent fatty acids (degree of saturation or unsaturation) and length of the fatty acid carbon chain (see Tables 6. It has become conventional to refer to dietary fats as "lipids" once they have been absorbed into the body via the small intestine, although it is not incorrect to refer to dietary fat as "dietary lipid. These involve crude emulsification in the stomach, lipolytic breakdown by lipases and solubilization with bile salts in the duodenum and, finally, absorption into the epithelial cells or enterocytes lining the walls of the small intestine or ileum. Digestion may actually be initiated in the mouth under the influence of a lingual lipase skeletal muscle, etc. Animal meat lipids are the main dietary source of arachidonate (20:4n-6), although it can also be obtained from tropical marine fish. Cold-water marine fish are the main dietary source of the long-chain n-3 (omega-3) polyunsaturates eicosapentaenoate (20:5n3), and docosahexaenoate (22:6n-3), but the former Nutrition and Metabolism of Lipids 93 secreted by the palate, although its contribution to lipolysis in adults is questionable and thought to be more important in young suckling infants, in which its release is stimulated by suckling and the presence of milk. The stomach serves mainly as an organ of mechanical digestion and, by churning its contents, produces a coarse creamy emulsion known as chyme. The circular pyloric sphincter muscle that separates the stomach from the duodenum and, with other factors, controls the rate of gastric emptying opens twice a minute to release approximately 3 ml of chyme. Since emulsified fat in chyme is less dense than the aqueous material, the two fractions separate with the fat collecting above the aqueous layer. The duodenal phase involves the breakdown of the emulsified fat by a process known as lipolysis and the solubilization of the products of lipolysis. Solubilization of emulsified fat With the notable exceptions mentioned previously (Section 6. In each of these situations, this is achieved by the hydrophobic fat or lipid associating with molecules that are capable of interfacing with both hydrophobic and hydrophilic environments. Molecules with these characteristics are called amphipathic molecules, examples of which are phospholipids, bile salts, and specialized proteins known as apoproteins (Figure 6.

The applicant should indicate whether near vision contact lens(es) is/are used while flying. If the applicant answers "yes," the Examiner must counsel the applicant that use of contact lens(es) for monovision correction is not allowed. Examples of unacceptable use include: the use of a contact lens in one eye for near vision and in the other eye for distant vision (for example: pilots with myopia plus presbyopia). The use of a contact lens in one eye for near vision and the use of no contact lens in the other eye (for example: pilots with presbyopia but no myopia). Binocular bifocal or binocular multifocal contact lenses are also acceptable under the Protocol for Binocular Multifocal and Accommodating Devices. The Examiner should provide in Item 60 an explanation of the nature of items checked "yes" in items 18. The responsibility for providing such supplementary reports rests with the applicant. Affirmative answers alone in Item 18 do not constitute a basis for denial of a medical certificate. A decision concerning issuance or denial should be made by applying the medical standards pertinent to the conditions uncovered by the history. Experience has shown that, when asked direct questions by a physician, applicants are likely to be candid and willing to discuss medical problems. The Examiner should attempt to establish rapport with the applicant and to develop a complete medical history. The applicant should report frequency, duration, characteristics, severity of symptoms, neurologic manifestations, whether they have been incapacitating, treatment, and side effects, if any. The applicant should describe the event(s) to determine the primary organ system responsible for the episode, witness statements, initial treatment, and evidence of recurrence or prior episode. Although the regulation states, "an unexplained disturbance of consciousness is disqualifying," it does not mean to imply that the applicant can be certificated if the etiology is identified, because the etiology may also be disqualifying in and of itself. Is there a history of serious eye disease such as glaucoma or other disease commonly associated with secondary eye changes, such as diabetes? Under all circumstances, please advise the examining eye specialist to explain why the airman is unable to correct to Snellen visual acuity of 20/20. The applicant should report frequency and duration of symptoms, any incapacitation by the condition, treatment, and side effects. The Examiner should inquire whether the applicant has ever experienced any barotitis ("ear block"), barosinusitis, alternobaric vertigo, or any other symptoms that could interfere with aviation safety. The applicant should provide frequency and severity of asthma attacks, medications, and number of visits to the hospital and/or emergency room. For other lung conditions, a detailed description of symptoms/diagnosis, surgical intervention, and medications should be provided. The applicant should describe the condition to include, dates, symptoms, and treatment, and provide medical reports to assist in the certification decision-making process. These reports should include: operative reports of coronary intervention to include the original cardiac catheterization report, stress tests, worksheets, and original tracings (or a legible copy). Part 67 provides that, for all classes of medical certificates, an established medical history or clinical diagnosis of myocardial infarction, angina pectoris, cardiac valve replacement, permanent cardiac pacemaker implantation, heart replacement, or coronary heart disease that has required treatment or, if untreated, that has been symptomatic or clinically significant, is cause for denial. Issuance of a medical certificate to an applicant with high blood pressure may depend on the current blood pressure levels and whether the applicant is taking anti-hypertensive medication. The Examiner should also determine if the applicant has a history of complications, adverse reactions to therapy, hospitalization, etc. If a surgical procedure was done, the applicant must provide operative and pathology reports. The applicant should provide history and treatment, pertinent medical records, current status report and medication. If a 36 Guide for Aviation Medical Examiners procedure was done, the applicant must provide the report and pathology reports. A medical history or clinical diagnosis of diabetes mellitus requiring insulin or other hypoglycemic drugs for control are disqualifying. An established diagnosis of epilepsy, a transient loss of control of nervous system function(s), or a disturbance of consciousness is a basis for denial no matter how remote the history. Like all other conditions of aeromedical concern, the history surrounding the event is crucial. An applicant with an established history of a personality disorder that is severe enough to have repeatedly manifested itself by overt acts, a psychosis disorder, or a bipolar disorder must be denied or deferred by the Examiner.

The Australian artist, Justine Cooper, invented a hilarious hoax,27 which can be seen on YouTube. The ad says that Havidol should be taken indefinitely, and that side effects include extraordinary thinking, dermal gloss, markedly delayed sexual climax, inter-species communication and terminal smile. An even more hilarious video on YouTube29 featured Ray Moynihan as the victim,27 the journalist who wrote Selling Sickness with Alan Cassels. In its mild form, people cannot get off the beach, or out of bed in the morning, and in its most severe form it can be lethal as the sufferer may lose the motivation to breathe. I bring it in its entirety:31 McCartney makes several disparate claims about the drug industry. Secondly, medical representatives do seek to engage with clinicians to educate them on the latest available treatments. I think it is important that clinicians are offered the chance to learn about new and innovative drugs and make their own decisions about their suitability for patients. Finally, cooperation and partnership between the drug industry and the wider health community are valuable, despite negative preconceptions. This drive towards closer working has not been pushed by the drug industry but by all healthcare stakeholders. Earlier this year a range of signatories, including the Department of Health and the medical royal colleges, approved principles for working in partnership with the life sciences sector for the good of patients. Talking about codes of practice, strict rules and strict guidelines as the panacea solution for an industry that is the worst of all industries in routinely breaking the law to such an extent that it is organised crime that results in the deaths of innocent people in huge numbers! After I had lectured at a Prescrire meeting in Paris in January 2013 about the pervasive crime in the drug industry,32 I had a chat with Alain Braillon who inspired me to finish my book with a cartoon. General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis. Ethical dilemmas arising from implementation of the European guidelines on cardiovascular disease prevention in clinical practice. Oral bisphosphonates are associated with increased risk of subtrochanteric and diaphyseal fractures in elderly women: a nested casecontrol study. Cumulative alendronate dose and the long-term absolute risk of subtrochanteric and diaphyseal femur fractures: a register-based national cohort analysis. High Yield Internal Medicine Shelf Exam Review Emma Holliday Ramahi Cardiology A patient comes in with chest pain. Most common cancer is broncogenic carcinoma, but incr risk lower lobes w/ pleural for mesothelioma plaques. Exudative with high hyaluronidase Patient with kidney stones, Squamous cell carcinoma. Patient with ptosis better after 1 Lambert Eaton Syndrome from small minute of upward gaze? Roommate of the kid High protein and low glucose support bacterial in the dorms who has bacterial meningitis Rifampin!!