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Even without any changes to rush pain treatment center buy sulfasalazine 500 mg line the law kidney pain treatment natural buy sulfasalazine 500 mg without a prescription, there is increased scrutiny of death certification and patterns of mortality by local and national agencies as a result of the Shipman Inquiry pain research and treatment journal impact factor generic sulfasalazine 500mg visa. Suspicions may be raised if death certificates appear to pain treatment center dr mckellar buy sulfasalazine 500mg with mastercard give inadequate or vague causes of death. Similarly, it would be surprising if a patient was being treated in an acute hospital, but no significant disease or injury at all was mentioned on their death certificate. What to do, depending on the degree of certainty or uncertainty about the exact cause of death, is discussed below. You are asked to start with the immediate, direct cause of death on line Ia, then to go back through the sequence of events or conditions that led to death on subsequent lines, until you reach the one that started the fatal sequence. If the certificate has been completed properly, the condition on the lowest completed line of part I will have caused all of the conditions on the lines above it. From a public health point of view, preventing this first disease or injury will result in the greatest health gain. Underlying cause statistics are widely used to determine priorities for health service and public health programmes and for resource allocation. Remember that the underlying cause may be a longstanding, chronic disease or disorder that predisposed the patient to later fatal complications. You should also enter any other diseases, injuries, conditions, or events that contributed to the death, but were not part of the direct sequence, in part two of the certificate. The conditions mentioned in part two must be known or suspected to have contributed to the death, not merely be other conditions which were present at the time. Other significant conditions Contributing to death but not related to the disease or condition causing it Non-insulin dependent diabetes the colon cancer on line 1(c) led directly to the liver metastases on line 1(b), which ruptured, causing the fatal haemorrhage on 1(a). Meningococcal septicaemia Meningococcal septicaemia is the underlying cause of this death. If you want to include more than 3 steps in the sequence, you can do so by writing more than one condition on a line, indicating clearly that one is due to the next. Recurrent urinary tract infections Insulin dependent diabetes with renal complications is the underlying cause. They should be written on the same line and you can indicate that you think they contributed equally by writing joint causes of death in brackets. Multiple cause data provides useful additional information on the mortality burden associated with diseases that are not often selected as the main cause of death. For example, conditions that are very often complications of another disease or its treatment, such as deep vein thrombosis / pulmonary embolism or health care associated infections should rarely be the underlying cause of death. In contrast to the above, if you do not know that your patient actually had any specific disease compatible with the mode and circumstances of death, you must refer the death to the coroner. For example, if your patient died after the sudden onset of chest pain that lasted several hours and you have no way of knowing whether he or she may have had a myocardial infarct, a pulmonary embolus, a thoracic aortic dissection, or another pathology, it is up to the coroner to decide what investigations to pursue. For example, a death can be certified as bacterial meningitis once the diagnosis is firmly established, even though the organism may not yet have been identified. Similarly, a death from cancer can be certified as such while still awaiting detailed histopathology. It is important for public health surveillance to have this information on a national basis; for example, to know how many meningitis and septicaemia deaths are due to meningococcus, or to other bacterial infections. You have personally cared for the deceased over a long period (years, or many months). You are not aware of any identifiable disease or injury that contributed to the death. You are certain that there is no reason that the death should be reported to the coroner You may mention old age or frailty as a contributory cause, especially if it explains the severe effect of a condition that is not usually fatal. If the immediate cause of death was Covid-19 or its consequences, and the patient had no specific pre-existing health conditions, but appears to have been especially vulnerable to Covid-19 or its effects because of old age or frailty, it is appropriate to state old age or frailty as contributing to the death. You should also be aware that the patient’s family may not regard old age as an adequate explanation for their relative’s death and may request further investigation. It is unlikely that patients would be admitted to an acute hospital if they had no apparent disease or injury. It follows that deaths in acute hospitals are unlikely to fulfil the conditions above. You can specify old age as the underlying cause of death, but you should also mention in part one or part two, as appropriate, any medical or surgical conditions that may have contributed to the death. Non-insulin dependent diabetes mellitus, essential hypertension and diverticular disease Ia. While there is no statutory age limit or restriction on referring to ‘old age’, a death certified as due to old age or senility alone will usually be referred to the coroner, unless the deceased was 80 or older, all the conditions listed above are fulfilled and there is no other reason that the death should be referred. Failure of most organs can be due to unnatural causes, such as poisoning, injury or industrial disease. This means that the death will have to be referred to the coroner if no natural disease responsible for organ failure is specified. Congestive cardiac failure Essential hypertension Conditions such as renal failure may come to medical attention for the first time in frail, elderly patients in whom vigorous investigation and treatment may be contraindicated, even though the cause is not known. When such a patient dies, you are advised to discuss the case with the coroner before certifying. If such a condition is considered to be relevant, the more immediate mechanism(s) or train of events leading to death must be made clear. Example (1): A person with learning difficulties may develop aspiration pneumonia. Example (2): A congenital syndrome which causes learning difficulties may also cause an organ defect which can lead to premature death. A description such as ‘learning difficulties’ should not be the only cause of death. You may give a degenerative condition such as Alzheimer’s disease as the only cause of death if the mechanism by which it caused death is unclear but it is fully supported by the clinical history as the underlying cause. This includes terminal events, or modes of dying such as cardiac or respiratory arrest, syncope or shock. Very vague statements such as cardiovascular event or incident, debility or frailty are equally unacceptable. It could, however, also include cardiac arrest or fainting, or a surgical or radiological procedure. If no clear disease can be identified as the cause of death, referral to the coroner will be necessary. Their meaning may seem obvious to you in the context of your patient and their medical history, but it may not be clear to others. For example, specify whether the cause was haemorrhage, thrombosis or embolism, and the specific artery involved, if known. Remember to include any antecedent conditions or treatments, such as atrial fibrillation, artificial heart valves, or anticoagulants that may have led to cerebral emboli or haemorrhage. Avoid the term cerebrovascular accident and consider using terms such as stroke or cerebral infarction if no more specific description can be given. Accurate statistics are important for planning care and assessing the effects of changes in policy or practice. Where applicable, you should indicate whether a neoplasm was benign, malignant, or of uncertain behaviour. Please remember to specify the histological type and anatomical site of the cancer. You should make sure that there is no ambiguity about the primary site if both primary and secondary cancer sites are mentioned. Do not use the terms metastatic or metastases unless you specify whether you mean metastasis to, or metastasis from, the named site. If you mention two sites that are independent primary malignant neoplasms, make that clear. Primary adenocarcinoma of prostate If a patient has widespread metastases, but the primary site could not be determined, you should state this clearly. In the case of leukaemia, specify whether it is acute, sub-acute or chronic, and the cell type involved. If diabetes is the underlying cause of death, specify the complication or consequence that led to death, such as ketoacidosis. However, certification should not be delayed to await the availability of test results.

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In the next section arthritis pain treatment guidelines best order sulfasalazine, regulatory requirement regarding the role of sample size calculation in clinical research is discussed pain clinic treatment options order 500 mg sulfasalazine overnight delivery. These basic considerations include study objectives treatment pain from shingles sulfasalazine 500 mg online, design shoulder pain treatment youtube generic 500 mg sulfasalazine mastercard, hypotheses, primary study endpoint, and clinically meaningful difference. This lengthy and costly process is necessary not only to demonstrate the efficacy and safety of the drugproduct under investigation, but also to ensure the study drugproduct possesses good drug characteristics such as identity, strength, quality, purity, and stability after it is approved by the regulatory authority. This lengthy process includes drug discovery, formulation, animal study, laboratory development, clinical development, and regulatory submission. As a result, clinical development plays an important role in the process of drug research and development because all of the tests are conducted on humans. However, the followingscientific/statistical questions are raised: (i) what is the definition of an adequate and well-controlled clinical study? These characteristics include study objectives, methods of analysis, design, selection of subjects, assignment of subjects, participants of studies, assessment of responses, and assessment of the effect. For study objectives, it is required that the study objectives be clearly stated in the study protocol such that they can be formulated into statistical hypotheses. Under the hypotheses, appropriate statistical methods should be described in the study protocol. A clinical study is not considered adequate and well-controlled if the employed study design is not valid. A valid study design allows a quantitative assessment of drugeffect with a valid comparison with a control. The selection of a sufficient number of subjects with the disease or conditions under study is one of the keys to the integrity of an adequate and well-controlled study. Introduction teristics or prognostic factors such as medical history and disease severity. An adequate and well-controlled study requires that the primary study endpoint or response variable should be well-defined and assessed with a certain degree of accuracy and reliability. To achieve this goal, statistical inferences on the drugeffect should be obtained based on the responses of the primary study endpoint observed from the sufficient number of subjects usingappropriate statistical methods derived under the study design and objectives. Shao and Chow (2002) and Chow, Shao and Hu (2002) pointed out that the purpose of requiringat least two clinical studies is not only to assure the reproducibility but also to provide valuable information regarding generalizability. Reproducibility is referred to as whether the clinical results are reproducible from location. Regulatory Requirement 5 the same region or from region to region, while generalizability is referred to as whether the clinical results can be generalized to other similar patient populations within the same region or from region to region. When the sponsor of a newly developed or approved drugproduct is interested in getting the drug product into the marketplace from one region. In practice, it is often of interest to determine whether a clinical trial that produced positive clinical results provides substantial evidence to assure reproducibility and generalizability of the clinical results. In this chapter, the reproducibility of a positive clinical result is studied by evaluating the probability of observinga positive result in a future clinical study with the same study protocol, given that a positive clinical result has been observed. The generalizability of clinical results observed from a clinical trial will be evaluated by means of a sensitivity analysis with respect to changes in mean and standard deviation of the primary clinical endpoints of the study. Consequently, a single clinical trial is sufficient to provide substantial evidence for demonstration of efficacy and safety of the medication under study. In practice, hypotheses regardingmedical or scientific questions of the study drugare usually formulated based on the primary study objectives. The hypotheses are then evaluated usingappropriate statistical tests under a valid study design to ensure that the test results are accurate and reliable with certain statistical assurance. It is then suggested that the hypotheses be clearly stated when performing a sample size calculation. Each of the above hypotheses has different requirement for sample size in order to achieve a desired statistical assurance. Basically, sample size calculation can be classified into sample size estimation/determination, sample size justification, sample size adjustment, and sample size re-estimation. Basic Considerations 7 sample size, which is often a small number due to budget constraints and/or some medical considerations. In most clinical trials, sample size is necessarily adjusted for some factors such as dropouts or covariates in order to yield sufficient number of evaluable subjects for a valid statistical assessment of the study medicine. In many clinical trials, it may be desirable to conduct interim analyses (planned or unplanned) duringthe conduct of the trial. For clinical trials with planned or unplanned interim analyses, it is suggested that sample size be adjusted for controlling an overall type I error rate at the nominal significance level. In addition, when performinginterim analyses, it is also desirable to perform sample size reestimation based on cumulative information observed up to a specific time point to determine whether the selected sample size is sufficient to achieve a desired power at the end of the study. Sample size re-estimation may be performed in a blinded or unblinded fashion dependingupon whether the process of sample size re-estimation will introduce bias to clinical evaluation of subjects beyond the time point at which the interim analysis or sample size re-estimation is performed. In this book, however, our emphasis will be placed on sample size estimation/determination. The concept can be easily applied to (i) sample size justification for a selected sample size, (ii) sample size adjustment with respect to some factors such as dropouts or covariates, and (iii) sample size re-estimation in clinical trials with planned or unplanned interim analyses. To provide an accurate and reliable sample size calculation, it is suggested that an appropriate statistical test for the hypotheses of interest be derived under the study design. The hypotheses should be established to reflect the study objectives and should be able to address statistical/medical questions of interest under the study design. As a result, a typical procedure for sample size calculation is to determine or estimate sample size based on an appropriate statistical method or test, which is derived under the hypotheses and the study design, for testing the hypotheses in order to achieve a certain degree of statistical inference. As indicated earlier, in practice it is not uncommon to observe discrepancies amongstudy objective (hypotheses), study design, statistical analysis (test statistic), and sample size calculation. These discrepancies certainly have an impact on sample size calculation in clinical research. Introduction suggested that the following be carefully considered when performing sample size calculation: (i) the study objectives or the hypotheses of interest be clearly stated, (ii) a valid design with appropriate statistical tests be used, (iii) sample size be determined based on the test for the hypotheses of interest, and (iv) sample size be determined based on the primary study endpoint and (v) the clinically meaningful difference of the primary study endpoint that the clinical study is intended to detect. Since most clinical studies are conducted for clinical evaluation of efficacy and safety of drugproducts under investigation, it is suggested that the following study objectives related to efficacy and safety be clarified before choosingan appropriate design strategy for the intended trial. Safety Equivalence Non-inferiority Superiority Equivalence E/E E/N E/S Efficacy Non-inferiority N/E N/N N/S Superiority S/E S/N S/S For example, if the intent of the planned clinical study is to develop an alternative therapy to the standard therapy that is quite toxic, then we may consider the strategy of E/S, which is to show that the test drug has equal efficacy but less toxicity (superior safety). The study objectives will certainly have an impact on the sample size calculation. Sample size calculation provides required sample size for achievingthe study objectives. A valid study design is necessarily chosen to collect relevant clinical information for achievingthe study objectives by addressingsome statistical/medical hypotheses of interest, which are formulated to reflect the study objectives. The design strategy can certainly affect sample size calculation because statistical methods or tests are usually derived under the hypotheses and study design. As an example, Fleming (1990) discussed the following design strategies that are commonly used in clinical therapeutic equivalence/non-inferiority and superiority trials. Note that in practice, a more complicated study design, which may consist of a combination of the above designs, may be chosen to address more complicated statistical/medical questions regarding the study drug. In this case, standard procedure for sample size calculation may not be directly applicable and a modification will be necessary. For example, it may be of interest to show that the study drugis effective and safe as compared to a placebo for some intended indications. In some cases, it may be of interest to show that the study drugis as effective as, superior to, or equivalent to an active control agent or a standard therapy. In practice, hypotheses regarding medical or scientific questions of the study drug are usually formulated based on the primary study objectives. The hypotheses are then evaluated usingappropriate statistical tests under a valid study design. In clinical trials, a hypothesis is usually referred to as a postulation, assumption, or statement that is made about the population regarding the effectiveness and safety of a drugunder investigation. For testingthe hypotheses of interest, a random sample is usually drawn from the targeted population to evaluate hypotheses about the drugproduct. A statistical test is then performed to determine whether the null hypothesis would be rejected at a pre-specified significance level.

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Infusions of 1 powdered flowers are drunk in the treatment against jaundice and hypertension neuropathic pain treatment drugs cheap sulfasalazine uk. Toddalia asiatica is prepared mostly as decoctions or concoctions and administered orally neuropathic pain treatment guidelines iasp purchase sulfasalazine without prescription. Cough treatment pain ball of foot buy sulfasalazine 500mg online, 1 chest pain advanced pain treatment center purchase sulfasalazine 500 mg on line, and sore throat were also mentioned among other disease conditions treated. Harrisonia abyssinica has a multitude of uses, for example, to treat stomach problems, including diarrhea and dysentery, and as an antiemetic as well as a febrifuge for malaria 1 patients. Analysis of plant parts used in drug preparation (table 10) reveal that the roots are most commonly used (38 percent), followed by leaf (28 percent), and bark (22 percent). The frequency of combinations of plant parts was low: leaf or root (3 percent), bark or leaf (2 percent), and bark or root (2 percent). Plant Parts as Source of Medicinal Drugs Plant part Frequency Percent Root 688 38 Leaf 511 28 Bark 414 22 Seed 31 2 Fruit 14 na Stem 23 na Leaf/root 49 3 Bark/leaf 33 2 Bark/root 30 2 Whole plant 28 na While secondary metabolites may be present throughout a plant, the roots are an important location for storage of such medicinal products. They are easier to extract and utilize since their availability is direct (field collection), and they can be propagated. Many roots have low moisture content, a hard texture, and a shelf life of at least several years—ideal for storage in a dry location. The majority of plant products were stored in polyethylene bags (34 percent) in the home in a dry environment. The Traditional Medical Practitioner in Zimbabwe: His Principles of Practice and Pharmacopoeia. A Selected Bibliography of References on Indigenous Theory and Practice and Related Literature. Some Aspects of Traditional Medicine in Bendel State of Nigeria: An Exploratory Study. The fndings, interpretations, and conclusions expressed in this paper John Lambert, Kenneth Leonard with Geoffrey Mungai, Elizabeth Omindi-Ogaja, are entirely those of the author(s) and should not be attributed in any Gladys Gatheru, Tabitha Mirangi, Jennifer Owara, Christopher H. Ramana, Christophe Lemiere Citation and the use of material presented in this series should take into account this provisional character. For free copies of papers in this series please contact the individual authors whose name appears on the paper. The purpose of a negative pressure room is to confine pathogens to a single closed environment and to prevent the release of pathogens into other adjacent spaces. For contextual purposes, the occupancy rates do not reflect temporal or seasonal variations. Making facility changes on this scale can take significant time and cause serious operational disruption at a time when those beds are most needed. Beyond adjusting distribution and usage of existing hospital beds, there are a host of other options. Additionally, opening previously shuttered hospital facilities or medical wards and updating their supportive utilities (eg, power, data, air, oxygen, and suction) should be considered. These choices may be affected by a shortage of supportive medical devices and administrative and clinical staff. Each ship is equipped with a helicopter deck capable of landing large military helicopters. Their crew comprises 71 civilians and up to 1200 Navy medical and communications personnel when operating at full capacity. The United States has a significant number of critical care beds per capita as compared to other countries (Figure 1). Older models, which are not full featured but may provide basic functions, add an additional 98,738 ventilators to the U. Additionally, many modern anesthesia machines are capable of ventilating patients and can be used to increase hospitals’ surge capacity. Many of the additional and older ventilators, however, may not be capable of sustained use or of adequately supporting patients with severe acute respiratory failure. Also, supplies for these ventilators may be unavailable due to interruptions in the international supply chain. Alternatively, ventilator manufacturers could be encouraged to rapidly produce modern full-featured ventilators to allow experienced clinicians to use supplemental ventilators that are familiar to them and can be readily incorporated into the hospital ventilator fleet and informatics systems. Intensivists are physicians with training in one of several primary specialties (eg, internal medicine, anesthesiology, emergency medicine, surgery, pediatrics) and additional specialized critical care training. Hospitals with telemedicine capacity may also use the technology to connect with expert resources at other locations. As elective procedures are curtailed, experienced perioperative clinical staff (eg, anesthesiologists, certified registered nurse anesthetists, operating room and post-anesthesia care unit 5 U. This model recommends adding staff dedicated to the management of multiple ventilators, while other staff (experienced and additive) support the patient overall. While the ratios shown in the figure depict generally accepted models of critical care staffing augmentation, each hospital will need to adjust to its own demands for critical care while using its available supply of personnel. Resources may be overwhelmed: Hospitals and their critical care organizations must include in their pandemic resource planning an ethical and legal approach to triage and resource allocation that would be activated only if the pandemic is perceived to be overwhelming the hospital’s surge capacity strategies. Topics that must be considered are the potential for unfair allocation of treatment, use of experimental interventions, and the conduct of medical research at times of healthcare crisis. For example, if a hospital has mechanical ventilators but not appropriate staff to operate them, the ventilators are not useful for patient care. Of these, 2704 met our criteria for acute care hospitals that deliver critical care services. Rehabilitation, alcohol/drug abuse or dependency, psychiatric, skilled nursing facility, intermediate nursing, and other long-term beds are excluded. Metropolitan areas: > 50,000 population, micropolitan areas: 10,000-49,999 population, rural areas: < 10,000 population. Trends in critical care beds and use among population groups and Medicare and Medicaid beneficiaries in the United States: 2000-2010. Experimental studies on performance of ventilators stored in the Strategic National Stockpile. Assessing the capacity of the healthcare system to use additional mechanical ventilators during a large-scale public health emergency. Nurse practitioners and physician assistants in acute and critical care: a concise review of the literature and data 2008-2019. This facility shall not be available if the person or either of his / her parents or grand parents (paternal or maternal) was born in, or was permanently resident in Pakistan. List of countries whose nationals are presently eligible for e-visa is given in Appendix I. The applicant can apply 120 days in advance prior to expected date of arrival in India. A foreign national will also be permitted to club these activities provided he/she had clearly indicated the same in the application form along with requisite documents. Persons holding e-Visa can depart from any of the authorized Immigration Check Posts in India. Regarding conversion of e-visa to other categories of visa, please see the general policy guidelines relating to Indian visa on this website. This facility shall not be available to the citizens of Japan if the person or either of his / her parents or grandparents (paternal or maternal) was born in, or was permanently resident in Pakistan. After checking the eligibility criteria and payment of fee, the Immigration officer would then stamp Visa-on-Arrival on the passport. Regarding conversion of Visa-on-Arrival to other categories of visa, please see the general policy guidelines relating to Indian visa on this website. A person who desires to make two entries into India in transit in the course of the same journey can be granted a transit visa valid for two entries and for stay in transit for a period not exceeding 3 days for each journey. If the journey is not performed within this period, a fresh transit visa will be required. A transit visa is only valid for direct transit, which cannot be more than 3 days for each visit. This period is not extendable except in case of extreme emergency like strike, traffic disruption, inclement weather, illness, etc.

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Prevention: Behavior/Lifestyle/ Treatment intervention to pain treatment ulcerative colitis buy 500 mg sulfasalazine with visa prevent disease Detection: Early detection of disease Personalized Medicine Is Impacting Patient Care in at the molecular level Many Diseases treatment pain when urinating order sulfasalazine 500mg line. Today pain medication for dogs at petsmart order sulfasalazine from india, a genetic diagnostic test is performed on a blood sample pacific pain treatment center san francisco buy generic sulfasalazine 500 mg line, providing a non-invasive test to help manage the care of patients post-transplant. New research suggests that ongoing testing may be useful in longer-term patient management by predicting risk of rejection and guiding more tailored immunosuppressive drug regimes. The people and groups engaged in personalized medicine and helping to drive it forward the realization of personalized medicine relies on the input and contributions of a broad community of stakeholders, all working together toward a shared goal of harnessing breakthroughs in science and technology to improve patient care. The regulatory process must evolve in response to advances that are targeted to smaller patient populations based on genetic profles, and policies and legislation must be enacted that provide incentives for innovative research and adoption of new technologies. Together, progress in the research, clinical care, and policy enabling personalized medicine has great potential to improve the quality of patient care and to help contain health care costs. A Service of Personalized medicine is rapidly having an impact on how drugs are discovered and developed; how patients are diagnosed and treated; and how health care delivery is channeling its resources to maximize patient benefts. The Age of Personalized Medicine website is dedicated to highlighting the advances being made in the feld, the individuals working to enable those advances, and the implications for health and health care policy. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. Any opinions, fndings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily refect the view of the organizations or agencies that provided support for the project. Library of Congress Cataloging-in-Publication Data Confict of interest in medical research, education, and practice / Bernard Lo and Marilyn J. Field, editors ; Committee on Confict of Interest in Medical Research, Education, and Practice, Board on Health Sciences Policy. Printed in the United States of America the serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. The National Academy of Sciences is a private, nonproft, self-perpetuating society of distinguished scholars engaged in scientifc and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientifc and technical matters. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientifc and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Important information and insights came from four public meetings that the committee organized to collect information and perspectives from a range of academic, professional, consumer, patient, and other organizations and individuals. A number of speakers at these meetings also shared their knowledge at other times during the course of the study. Appendix A includes the agendas of the public meetings and a list of organizations that submitted written statements of views. The committee appreciates the contributions of the authors of the background papers that appear as Appendix C (Michael Davis at Illinois Institute of Technology and Josephine Johnston at the Hastings Center) and Appendix D (Jason Dana at University of Pennsylvania). Our project offcer at the National Institutes of Health, Walter Schaffer, was always helpful in getting our questions answered. We also called on Daniel Wolfson at the American Board of Internal Medicine Foundation for information. In addition, Ariel Winter of the Medicare Payment Advisory Commission helped by answering questions about the commission’s work. Mary Nix at the Agency for Healthcare Research and Quality provided data from the National Guidelines Clearinghouse that we could not obtain online. The committee and project staff also appreciate the work of copy editor Michael Hayes. Within the National Academies, we particularly acknowledge the assistance of Clyde Behney, Judy Estep, Robert Giffn, Janice Mehler, Abbey Meltzer, Amy Packman, Donna Randall, Bronwyn Schrecker, and Jackie Turner. Reviewers this report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published reports as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confdential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Claudia R. Adkison, Emory University School of Medicine Robert Baron, University of California, San Francisco School of Medicine Paul Citron, Medtronic, Inc. Sessions Cole, Washington University School of Medicine Peter Densen, University of Iowa Carver College of Medicine Thomas J. Furcht, University of Minnesota Linda Golodner, National Consumers League Henry T. Pizzo, Stanford University School of Medicine Richard Schilsky, University of Chicago Medical Center Larry J. Louis School of Medicine Harold Sox, Annals of Internal Medicine and American College of Physicians Jeremy Sugarman, Johns Hopkins Medical Institutions P. The review of this report was overseen by David Challoner, University of Florida, and Judith L. Appointed by the National Research Council and the Institute of Medicine, these individuals were responsible for making certain that an independent examination of this report was carried out in accordance with the institutional procedures and that all review comments were carefully considered. Responsibility for the fnal content of this report rests entirely with the authoring committee and the institution. Preface Hardly a week goes by without a news story about conficts of interest in medicine. While this committee met, colleagues and friends sent me many news reports and journal articles on the topic. These reports—even if one expects that initial news reports may not always have the stories quite straight—served as continual reminders that conficts of interest create deep concerns about the integrity of medicine and medical research and raise questions about the trustworthiness of physicians, researchers, and medical institutions. Although the committee members were aware of powerful anecdotes and had personal beliefs about the issues, we repeatedly asked whether the evidence supported our conclusions and recommendations. If it did not, we developed a reasoned case on the basis of the committee’s experience and the judgment of the committee members about the arguments for the use of different approaches presented in the literature or in statements submitted to the committee. Second, it is a challenge to craft policy recommendations that strike the right balance between addressing egregious cases and creating burdens that stife relationships that advance the goals of professionalism and generate knowledge to beneft society. The committee tried to consider the possibility that well-intentioned policies may have unintended adverse consequences. The committee considered how a variety of organizations—including those that accredit health care institutions and license health care professionals, publish the fndings of medical research, use practice guidelines, and pay for medical care—can buttress the confict of interest policies implemented by institutions that carry out medical research, provide education and patient care, and develop practice guidelines. This report cannot and did not attempt to resolve all issues related to conficts of interest in medicine. In view of our expansive charge, we tried to address central questions rather than the many details of this complex topic. For example, we focus on conficts that involve fnancial interests because they are at the heart of concerns and debates about conficts of interest. The committee expects that many of the recommendations and analyses in our report will also apply more generally to professional and institutional relationships with other commercial entities, such as insurers and vendors of nonmedical products. The committee could not resolve some important issues like harmonizing the different requirements for the disclosure of fnancial relationships because they would require much more time and additional expertise. Instead, to standardize aspects of disclosure policies and procedures, the committee recommended a focused consensus development process that would involve multiple stakeholders on the issue. Our committee was diverse, involving members with different professional backgrounds and areas of expertise.

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