154. Anaesthesia, Pharmacology & Emergency

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154. Anaesthesia, Pharmacology & Emergency

154. Anaesthesia, Pharmacology & Emergency

 

 

CATEGORY: Medical & Medicine – 500 Courses

COURSE NUMBER: 154

FEES: 555/- INR only

CERTIFICATE VALIDITY: Lifetime

CERTIFICATES DELIVERY: In 48 hours

BOOKS/ MANUALS: Pages

Syllabus

Part I Continuing Medical Education
1 Can I Think what I Read? …………………………………………………………………….. 1
Philip D. Lumb
Part II Clinical Pharmacology
2 Pharmacological Manipulation in ICU ………………………………………………….. 9
Daniel De Backer, Katia Donadello and Sabino Scolletta
2.1 Effects of Fluids …………………………………………………………………………. 10
2.2 Effects of Red Blood Cell Transfusions …………………………………………. 11
2.3 Effects of Inotropic Agents …………………………………………………………… 11
2.4 Effects of Vasopressor Agents ………………………………………………………. 11
2.5 A Place for Vasodilatory Agents? ………………………………………………….. 12
2.6 Effects of Agents with Anticoagulant Properties ……………………………… 13
2.7 Conclusions ……………………………………………………………………………….. 13
References …………………………………………………………………………………………….. 13
Part III Kidney
3 Renal Injury ………………………………………………………………………………………… 19
Vladimir Gašparoviþ, Ivan Gornik
3.1 Introduction ……………………………………………………………………………….. 19
3.2 De nition …………………………………………………………………………………… 19
3.3 Epidemiology …………………………………………………………………………….. 20
3.4 Aetiology …………………………………………………………………………………… 20

3.5 Differences Between Acute and Chronic Kidney Injury …………………… 20
3.6 Prerenal Acute Kidney Injury ……………………………………………………….. 21
3.6.1 Aetiology of Prerenal AKI……………………………………………………………. 21
3.6.2 Pathophysiology of Prerenal AKI ………………………………………………….. 21
3.7 Intrinsic Acute Kidney Injury ……………………………………………………….. 22
3.7.1 Aetiology …………………………………………………………………………………… 22
3.8 Pathogenesis of Acute Intrinsic Kidney Injury ………………………………… 23
3.9 Postrenal Acute Kidney Injury ……………………………………………………… 23
3.10 Clinical Presentation of Acute Kidney Injury …………………………………. 23
3.11 Diagnostic Algorithm and Differential Diagnosis ……………………………. 25
3.11.1 Postrenal AKI …………………………………………………………………………….. 25
3.11.2 Prerenal or Intrinsic Renal AKI? …………………………………………………… 25
3.12 Treatment of Acute Kidney Injury …………………………………………………. 26
3.12.1 Fluid Balance ……………………………………………………………………………… 26
3.12.2 Hyperkalaemia ……………………………………………………………………………. 26
3.12.3 Metabolic Acidosis ……………………………………………………………………… 27
3.12.4 Diet …………………………………………………………………………………………… 27
3.12.5 Indications for Haemodialysis ………………………………………………………. 27
3.13 Prognosis …………………………………………………………………………………… 28
3.14 Prevention ………………………………………………………………………………….. 28
Further Reading …………………………………………………………………………………….. 29
Part IV Ventilation: Adult and Paediatric
4 Respiratory Mechanics: Principles, Utility and Advances ………………………. 33
Alysson R. Carvalho, Walter A. Zin
4.1 Introduction ……………………………………………………………………………….. 33
4.2 Principles …………………………………………………………………………………… 34
4.2.1 Pleural Pressure ………………………………………………………………………….. 34
4.2.2 Elastic Recoil of the Lungs…………………………………………………………… 35
4.2.3 Elastic Recoil of the Chest Wall ……………………………………………………. 38
4.2.4 Elastic Recoil of the Respiratory System ……………………………………….. 39
4.3 Resistive Properties …………………………………………………………………….. 40
4.3.1 Pulmonary Resistance …………………………………………………………………. 40
4.3.2 Chest-wall Resistance ………………………………………………………………….. 42
4.3.3 Respiratory System Resistance……………………………………………………… 42
4.4 Utility and Advances …………………………………………………………………… 42
References …………………………………………………………………………………………….. 44
5 Capnometry/capnography in Prehospital Cardiopulmonary Resuscitation 47
Štefek Grmec, Katia Lah and Štefan Mally
5.1 Introduction ……………………………………………………………………………….. 47
5.2 Physiology and Clinical Applications of Capnography…………………….. 47

5.3 Research of Capnometry/capnography in the Centre
for Emergency Medicine, Maribor ………………………………………………… 50
5.3.1 Capnography/capnometry and Veri cation of Endotracheal Tube
Placement ………………………………………………………………………………….. 50
5.4 Capnography in Cardiac Arrest and Cardiopulmonary Resuscitation …. 52
5.5 Conclusions ……………………………………………………………………………….. 54
References …………………………………………………………………………………………….. 54
6 Weaning from Mechanical Ventilation …………………………………………………… 57
Irene Cortés Puch, Andrés Esteban
6.1 Introduction ……………………………………………………………………………….. 57
6.2 Assessing Readiness for Weaning …………………………………………………. 58
6.2.1 Predictors of Adequate Spontaneous Breathing ………………………………. 59
6.3 Spontaneous Breathing Trials ……………………………………………………….. 60
6.3.1 Duration of the Spontaneous Breathing Trial ………………………………….. 60
6.3.2 Criteria to De ne SBT Tolerance/Success ……………………………………… 61
6.4 Failure of the Spontaneous Breathing Trial …………………………………….. 61
6.4.1 Causes of Weaning Failure …………………………………………………………… 61
6.4.2 Management of Patients who Fail Spontaneous Breathing Tests ……….. 62
6.4.3 Withdrawal of Ventilatory Support ………………………………………………… 63
6.5 Extubation………………………………………………………………………………….. 65
6.5.1 Risks Related to Reintubation ………………………………………………………. 66
6.6 The Role of Noninvasive Positive Pressure Ventilation ……………………. 66
6.6.1 Noninvasive Positive Pressure Ventilation as a Weaning Method ……… 67
6.6.2 Noninvasive Ventilation for Respiratory Failure after Extubation ……… 68
6.6.3 Noninvasive Positive-Pressure Ventilation for Preventing Respiratory
Failure after Extubation ……………………………………………………………….. 69
6.7 Management of Sedation and Weaning ………………………………………….. 70
6.8 Weaning in Special Populations ……………………………………………………. 71
6.8.1 Critical-Illness Polyneuropathy (CIP) and Weaning ………………………… 71
6.8.2 Neurological and Neurosurgical Patients ……………………………………….. 72
6.8.3 Chronic Obstructive Pulmonary Disease………………………………………… 72
References …………………………………………………………………………………………….. 73
7 Ventilatory Strategies in Acute Lung Injury ………………………………………….. 77
Edoardo Calderini, Sara Sher and Eleonora Allegritti
7.1 Introduction ……………………………………………………………………………….. 77
7.2 Ventilatory Support ……………………………………………………………………… 78
7.2.1 Ventilator-induced Lung Injury …………………………………………………….. 78
7.2.2 Prone Positioning ……………………………………………………………………….. 80
7.2.3 Noninvasive Respiratory Support………………………………………………….. 80
7.3 Conclusions ……………………………………………………………………………….. 84
References …………………………………………………………………………………………….. 84

8 Mechanical Ventilation Beyond the PICU ……………………………………………… 89
Giancarlo Ottonello, Alessia Franceschi
8.1 Introduction ……………………………………………………………………………….. 89
8.2 The Extent of the Problem ……………………………………………………………. 89
8.3 Patient Care: A Multisystemic Approach ……………………………………….. 90
8.3.1 Mechanical Ventilation ………………………………………………………………… 90
8.4 Prescribing Home Ventilation: Certi cation and Documentation ………. 94
8.4.1 Attribution of Disability ………………………………………………………………. 94
8.4.2 Handicapped Certi cation ……………………………………………………………. 94
8.4.3 Rare Disease Certi cation ……………………………………………………………. 94
8.4.4 School Attendance ………………………………………………………………………. 95
8.4.5 Worker Bene ts ………………………………………………………………………….. 95
8.5 Caregiver Training ………………………………………………………………………. 95
8.6 Follow-up and Emergency Admissions ………………………………………….. 96
8.7 Ethics ………………………………………………………………………………………… 96
8.8 Conclusions ……………………………………………………………………………….. 97
References …………………………………………………………………………………………….. 97
Part V Cardiovascular Monitoring
9 The Nex n Monitor – A Totally Non-Invasive Cardiac Output Monitor ……………… 103
Azriel Perel, Wilbert Wesselink and Jos Settels
9.1 Introduction ……………………………………………………………………………….. 103
9.2 Principles of CCO Measurement by the Nex n HD ………………………… 104
9.2.1 Continuous Measurement of Finger BP …………………………………………. 104
9.2.2 Transformation of the Finger BP Curve into a Brachial Artery Waveform 105
9.2.3 Calculating CCO from Brachial Arterial Pressure Waveform ……………. 105
9.3 Validation of the Nex n HD …………………………………………………………. 106
9.4 Clinical Applications …………………………………………………………………… 106
References …………………………………………………………………………………………….. 107
10 Doppler Echocardiography in ICU Patients: Does It Improve Outcome? .. 109
Jan Poelaert
10.1 Introduction ……………………………………………………………………………….. 109
10.2 Doppler Echocardiography …………………………………………………………… 109
10.3 Echo-Doppler Diagnostic Tools ……………………………………………………. 110
10.4 Immediate Bedside Haemodynamic Information …………………………….. 110
10.5 Right Ventricle ……………………………………………………………………………. 112
10.6 Preload and Fluid Responsiveness ………………………………………………… 113
10.7 Conclusions ……………………………………………………………………………….. 113
References …………………………………………………………………………………………….. 114

Part VI Management of Cardiac Arrest
11 Mild Therapeutic Hypothermia after Cardiac Arrest …………………………….. 119
Tommaso Pellis, Vincenzo Mione and Willy P. Mercante
11.1 Introduction ……………………………………………………………………………….. 119
11.2 Mechanisms of Neuroprotection …………………………………………………… 119
11.3 Clinical Relevance ………………………………………………………………………. 120
11.3.1 Randomised Clinical Trials ………………………………………………………….. 120
11.3.2 Nonrandomised Clinical Trials ……………………………………………………… 121
11.4 Complications of Mild Therapeutic Hypothermia …………………………… 121
11.4.1 Changes in the Immune System ……………………………………………………. 122
11.4.2 Effects on Coagulation ………………………………………………………………… 122
11.4.3 Cardiovascular and Haemodynamic Effects …………………………………… 122
11.4.4 Drug Metabolism ………………………………………………………………………… 123
11.5 Conclusions ……………………………………………………………………………….. 123
References …………………………………………………………………………………………….. 124
12 Nasopharyngeal Cooling During Cardiopulmonary Resuscitation …………. 129
Francesco Fumagalli, Giuseppe Ristagno
12.1 Introduction ……………………………………………………………………………….. 129
12.2 Therapeutic Hypothermia Following Resuscitation from Cardiac Arrest .. 129
12.3 Nasopharyngeal Cooling During CPR …………………………………………… 131
12.4 Conclusions ……………………………………………………………………………….. 135
References …………………………………………………………………………………………….. 135
13 Amplitude Spectrum Area as a Predictor of Successful De brillation …….. 141
Giuseppe Ristagno, Yongqin Li, Antonino Gullo and Joe Bisera
13.1 Introduction ……………………………………………………………………………….. 141
13.2 Monitoring Effectiveness of Chest Compression and Predicting
Return of Circulation …………………………………………………………………… 142
13.3 Analyses of ECG Features During Ventricular Fibrillation and CPR …. 143
13.4 Amplitude Spectrum Area (AMSA) as Predictor of Successful
De brillation ………………………………………………………………………………. 145
13.5 Applicability of AMSA to the Clinical Scenario ……………………………… 150
13.6 Conclusions ……………………………………………………………………………….. 153
References …………………………………………………………………………………………….. 154
Part VII Advances in Experimental and Clinical Research
14 Physiopathology and Severity of Post-Resuscitation Myocardial Dysfunction:
Effects of Sodium-Hydrogen Exchanger Isoform-1 (NHE-1) Inhibitors and
Erythropoietin ……………………………………………………………………………………… 163
Raúl J. Gazmuri, Iyad M. Ayoub and Jeejabai Radhakrishnan

14.1 Introduction ……………………………………………………………………………….. 163
14.2 Functional Manifestations ……………………………………………………………. 164
14.2.1 Reductions in Left Ventricular Myocardial Distensibility …………………. 164
14.2.2 Resistance to De brillation ………………………………………………………….. 165
14.2.3 Reperfusion Arrhythmias……………………………………………………………… 166
14.2.4 Postresuscitation Myocardial Dysfunction ……………………………………… 166
14.3 Novel Intervention Targeting the Pathophysiology of Myocardial Injury .. 166
14.3.1 NHE-1 Inhibitors ………………………………………………………………………… 167
14.3.2 Erythropoietin …………………………………………………………………………….. 170
14.4 Conclusions ……………………………………………………………………………….. 172
References …………………………………………………………………………………………….. 172
15 Experimental Treatment for Preservation of Mechanically Competent
Cardiac Activity Following Cardiac Arrest ……………………………………………. 179
Iyad M. Ayoub, Jeejabai Radhakrishnan and Raúl J. Gazmuri
15.1 Introduction ……………………………………………………………………………….. 179
15.1.1 Na+

Overload …………………………………………… 180
15.1.2 NHE-1 Inhibition during Ischaemia and Reperfusion ………………………. 181
15.2 NHE-1 Inhibition Promotes Return of Electrically Stable
and Mechanically Competent Cardiac Activity ……………………………….. 183
15.2.1 Clinical Implications of NHE-1 Inhibition Treatment during Cardiac Arrest 189
References …………………………………………………………………………………………….. 190
16 Erythropoietin Facilitates Return of Spontaneous Circulation and
Survival in Victims of Out-of-Hospital Cardiac Arrest …………………………… 195
Štefek Grmec, Matej Strand and Raúl J. Gazmuri
16.1 Introduction ……………………………………………………………………………….. 195
16.2 Effects on Resuscitation ………………………………………………………………. 197
16.2.1 Studies in Rats ……………………………………………………………………………. 197
16.2.2 Clinical Study …………………………………………………………………………….. 198
16.2.3 Results ………………………………………………………………………………………. 199
16.3 Erythropoietin in Cardiocerebral Resuscitation:
Potentially Neuroprotective Role of Erythropoietin? ……………………….. 201
References …………………………………………………………………………………………….. 201
Part VIII Infections, Sepsis and Organ Dysfunctions
17 Pathophysiology of Resistance amongst Aerobic Gram-negative
Bacilli in Particular Acinetobacter Species …………………………………………….. 207
Nia Taylor, Luciano Silvestri and Hendrick K.F. Van Saene
17.1 Introduction ……………………………………………………………………………….. 207
17.2 Philosophy: Carriage …………………………………………………………………… 207
17.2.1 Low- and High-grade Carriage ……………………………………………………… 207

17.2.2 Types of Infections ……………………………………………………………………… 208
17.3 Mechanisms of Action Explaining Ef cacy: Control of High-Grade
Carriage or Overgrowth ……………………………………………………………….. 209
17.3.1 Ef cacy ……………………………………………………………………………………… 211
17.3.2 Safety ………………………………………………………………………………………… 211
17.3.3 Meta-analysis of Resistance during SDD ……………………………………….. 213
17.3.4 Subgroup Analysis ………………………………………………………………………. 214
17.4 Conclusions ……………………………………………………………………………….. 214
References …………………………………………………………………………………………….. 216
18 What Have We Learned from the Surviving Sepsis Campaign? ……………… 219
Jean-Louis Vincent, Katia Donadello and Leonardo Gottin
18.1 Introduction ……………………………………………………………………………….. 219
18.2 What was the SSC? …………………………………………………………………….. 219
18.3 Clinical Trials Using the SSC Bundles …………………………………………… 221
18.4 Limitations of the SSC Bundles ……………………………………………………. 223
18.5 Conclusion: So What Have We Learned? ………………………………………. 223
References …………………………………………………………………………………………….. 224
19 Source Control ……………………………………………………………………………………… 227
Gabriele Sganga, Valerio Cozza
19.1 Introduction ……………………………………………………………………………….. 227
19.2 Concepts ……………………………………………………………………………………. 227
19.3 Drainage ……………………………………………………………………………………. 228
19.4 Debridement ………………………………………………………………………………. 229
19.5 De nitive Measures …………………………………………………………………….. 230
19.6 Timing to Reopen an Abdomen: Examples of Source-control Strategies … 230
19.7 Conclusions ……………………………………………………………………………….. 231
References …………………………………………………………………………………………….. 232
20 Immunoglobulins in Sepsis ……………………………………………………………………. 235
Giorgio Berlot, Claudio M. Vassallo and Nicola Busetto
20.1 Introduction ……………………………………………………………………………….. 235
20.2 Structures and Function of Immunoglobulins …………………………………. 236
20.3 Rationale for Using IvIg in Sepsis…………………………………………………. 238
20.4 Clinical Indications for IvIg in Sepsis ……………………………………………. 238
20.5 Conclusions ……………………………………………………………………………….. 240
References …………………………………………………………………………………………….. 240
21 Extracorporeal Endotoxin Removal in Sepsis ………………………………………… 243
Claudio Ronco, Dinna Cruz, Federico Nalesso and Pasquale Piccinni
21.1 Background………………………………………………………………………………… 243

21.2 Endotoxin as Therapeutic Target …………………………………………………… 243
21.3 Use of Polymyxin-B Based Haemoperfusion in Abdominal Septic Shock . 244
21.4 Endotoxin Measurement in Human Blood ……………………………………… 245
21.5 EUPHRATES …………………………………………………………………………….. 246
21.6 Conclusions ……………………………………………………………………………….. 247
References …………………………………………………………………………………………….. 247
Part IX Perioperative Medicine
22 Perioperative Medicine – An Introduction …………………………………………….. 251
Antonino Gullo, Chiara M. Celestre, Annalaura Paratore and Fortunato Stimoli
22.1 Introduction ……………………………………………………………………………….. 251
22.2 Coexisting Diseases …………………………………………………………………….. 253
22.3 Improving Outcome after Major Surgery ……………………………………….. 255
22.3.1 Perioperative Oxygen Transport ……………………………………………………. 255
22.3.2 Fluid Management ………………………………………………………………………. 255
22.3.3 Glucose Control ………………………………………………………………………….. 256
22.3.4 Infection Prevention and Treatment ………………………………………………. 256
22.3.5 Perioperative Bleeding Prevention and Treatment …………………………… 257
22.3.6 Neurological and Cognitive Dysfunction (Delirium) ……………………….. 258
22.4 Intraoperative Care ……………………………………………………………………… 259
22.5 Postoperative Care and Pain Management ……………………………………… 259
22.5.1 Neurological Complications …………………………………………………………. 260
22.5.2 Cardiovascular Complications………………………………………………………. 260
22.5.3 Pulmonary Complications ……………………………………………………………. 260
22.5.4 Postoperative Bleeding ………………………………………………………………… 260
22.6 Pain Management ……………………………………………………………………….. 260
22.7 Infants and Children; Elderly and Pregnant Patients ………………………… 262
22.7.1 Infants and Children ……………………………………………………………………. 262
22.7.2 Elderly Patients …………………………………………………………………………… 262
22.7.3 Pregnant Patients ………………………………………………………………………… 262
22.8 Good Medical Practice, Checklist and the Helsinki Declaration ……….. 263
22.9 Conclusions ……………………………………………………………………………….. 265
References …………………………………………………………………………………………….. 266
23 Neuraxial Analgesia for Caesarean and Vaginal Delivery and Childhood
Learning Disabilities …………………………………………………………………………….. 271
Juraj Sprung, Randall Flick and David Warner
23.1 Introduction ……………………………………………………………………………….. 271
23.2 Conclusions ……………………………………………………………………………….. 274
References …………………………………………………………………………………………….. 276
24 Off-label Drugs in Perioperative Medicine: Clonidine ……………………………. 279
Cesare Gregoretti, Paolo Pelosi

24.1 Introduction ……………………………………………………………………………….. 279
24.2 Pharmacokinetics and Pharmacodynamics of Alpha-2 and Imidazoline
Receptor Agonists and Effects on Different Organ Systems ……………… 279
24.3 Effects on Sedation ……………………………………………………………………… 281
24.4 Clonidine in the Treatment of Acute and Chronic Pain …………………….. 282
24.5 Clonidine in Neuraxial Blocks, Locoregional
and Intra-articular Anaesthesia ……………………………………………………… 283
24.6 Clonidine as Preanaesthetic Drug and Intraoperative
Anaesthetic/Analgesic-sparing Effect ……………………………………………. 284
24.7 Preventing Perioperative Haemodynamic Stress Response ………………. 284
24.8 Other Clinical Uses of Clonidine ………………………………………………….. 285
24.9 Conclusions ……………………………………………………………………………….. 285
References …………………………………………………………………………………………….. 285
Part X Spinal Cord Stimulation
25 Cost Effectiveness of Spinal Cord Stimulation in the Management of
Severe Angina ………………………………………………………………………………………. 295
Mats Börjesson, Clas Mannheimer
25.1 Refractory Angina Pectoris…………………………………………………………… 295
25.1.1 SCS in Angina Pectoris ……………………………………………………………….. 296
25.1.2 SCS Ef cacy in Refractory Angina Pectoris …………………………………… 296
25.1.3 SCS Cost-Effectiveness in Severe Angina Pectoris Patients ……………… 297
25.2 Conclusions ……………………………………………………………………………….. 298
References …………………………………………………………………………………………….. 298
Part XI Neurotrauma
26 Clinical Assessment and Diagnostic Procedures in Neurotrauma ……………. 303
Marco Zanello, Matteo Vincenzi and Marco Bandini
26.1 Introduction ……………………………………………………………………………….. 303
26.2 Clinical Assessment …………………………………………………………………….. 304
26.2.1 Severity and Early Prognostic Factors …………………………………………… 304
26.2.2 Diagnostic Procedures: Neuromonitoring ………………………………………. 308
26.3 Conclusions ……………………………………………………………………………….. 312
References …………………………………………………………………………………………….. 312
Part XII Disaster Medicine
27 Disaster Preparedness …………………………………………………………………………… 319
Francesco Della Corte, Pier Luigi Ingrassia
27.1 Introduction ……………………………………………………………………………….. 319
27.2 De nitions and Modern Background …………………………………………….. 320

27.3 A New Philosophy of Actions ………………………………………………………. 321
27.4 Disaster Classi cation …………………………………………………………………. 322
27.5 Disaster Management Phases ……………………………………………………….. 323
27.5.1 Preparedness ………………………………………………………………………………. 323
27.5.2 Response ……………………………………………………………………………………. 324
27.5.3 Recovery ……………………………………………………………………………………. 325
27.5.4 Mitigation ………………………………………………………………………………….. 325
27.6 Disaster Plan and Education …………………………………………………………. 325
27.7 Conclusions ……………………………………………………………………………….. 326
References …………………………………………………………………………………………….. 326
28 Medical Emergency Response in Toxicological Mass Casualty ……………….. 329
Pier Luigi Ingrassia, Luca Ragazzoni and Francesco Della Corte
28.1 Introduction ……………………………………………………………………………….. 329
28.2 Types of Incidents and Epidemiology ……………………………………………. 330
28.3 Medical Management ………………………………………………………………….. 331
28.3.1 Identifying the Event …………………………………………………………………… 332
28.3.2 Identi cation of Priorities: Triage …………………………………………………. 332
28.3.3 Decontamination and Evacuation ………………………………………………….. 334
28.3.4 Medical Treatment ………………………………………………………………………. 335
28.3.5 Psychological Care ……………………………………………………………………… 337
28.4 Conclusions ……………………………………………………………………………….. 338
References …………………………………………………………………………………………….. 338
Part XIII Quality of Care
29 Telemedicine to Improve Care in the Critically Ill …………………………………. 343
Gastón Murias, Bernat Sales Lluis Blanch
29.1 Introduction ……………………………………………………………………………….. 343
29.2 Costs in the Critical Care Setting ………………………………………………….. 344
29.3 Telemedicine ………………………………………………………………………………. 344
29.4 Integrated Telemedicine and E-Learning ……………………………………….. 344
29.5 Conclusions ……………………………………………………………………………….. 345
References …………………………………………………………………………………………….. 346
30 Professionalism, Quality of Care and Pay-for-Performance Services ……… 349
Antonino Gullo, Cristina Santonocito, Paolo Murabito and Marinella Astuto
30.1 Professionalism Promotes Health Care Systems ……………………………… 349
30.2 Patient Safety, Quality of Care and Evidence-Based Medicine …………. 351
30.3 De nition and the Reason for Measuring and Improving Performance 352
30.4 Pay for Performance: De nition and Examples of Impact ………………… 355

30.4.1 Conclusive Remarks and Looking to the Future ……………………………… 357
References …………………………………………………………………………………………….. 359
Subject Index ………………………………………………………………………………………………… 363

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